PUBLIC RECORD. Record of Determinations Medical Practitioners Tribunal. Dates: 28/02/ /03/2018

Transcription

1 PUBLIC RECORD Dates: 28/02/ /03/2018 Medical Practitioner s name: Dr Stefania COSTA ZACCARELLI GMC reference number: Primary medical qualification: Type of case New - Deficient professional performance State Exam 1992 Universita degli Studi di Modena e Reggio Emilia Outcome on impairment Impaired Summary of outcome Conditions, 36 months. Immediate order imposed Tribunal: Legally Qualified Chair Lay Tribunal Member: Medical Tribunal Member: Mr Rob Ward Mr Keith Moore Dr Nitesh Raithatha Tribunal Clerk: Ms Angela Carney Attendance and Representation: Medical Practitioner: Medical Practitioner s Representative: GMC Representative: Present and represented Mr Giles Colin, Counsel, instructed by the MDU Mr Tom Gilbart, Counsel Attendance of Press / Public The hearing was all heard in public. 1

2 DETERMINATION ON IMPAIRMENT 28/02/2018 Background 1. Dr Costa Zaccarelli was assessed as a Consultant Community Paediatrician. She qualified in 1992 with a Degree in Medicine and Surgery from the University of Modena in Italy. Dr Costa Zaccarelli gained a CCST in General Paediatrics in 1992 at the University of Modena and gained entry onto the GMC specialists register (paediatrics) in She subsequently worked in a series of Staff Grade roles in Community Paediatrics before being employed as a Consultant in Community Paediatrics in In March 2017 Dr Costa Zaccarelli underwent a GMC Performance Assessment following concerns raised about her clinical practice. 2. At the outset of the hearing Mr Giles Colin, on behalf of Dr Costa Zaccarelli, admitted all of the paragraphs of the allegation and the Tribunal found the allegation proved, as follows: 1. Between 8 and 10 March 2017 you underwent a General Medical Council assessment of the standard of your professional performance. Admitted and found proved 2. Your professional performance was unacceptable in the following areas: a. Maintaining Professional Performance; Admitted and found proved b. Assessment; Admitted and found proved c. Clinical Management; Admitted and found proved d. Relationship with Patients. Admitted and found proved 3. The Tribunal now has to decide in accordance with Rule 17(2)(k) of the Rules whether, on the basis of the facts which were admitted and found proved, as set out before, whether Dr Costa Zaccarelli s fitness to practise is impaired by reason of deficient professional performance. The Evidence 4. The Tribunal has taken into account the documentary evidence received during the facts stage of the hearing. The Tribunal was provided with a copy of the Performance Assessment report dated 28 April

3 5. There were no witnesses on behalf of the GMC or on behalf of Dr Costa Zaccarelli. Submissions 6. On behalf of the GMC, Mr Gilbart referred the Tribunal to the findings in the Performance Assessment report. He said that the report sets out those areas in relation to Good Medical Practice in which Dr Costa Zaccarelli s fitness to practice is impaired. He said that there is no challenge to the findings in the report and that it is an accurate and helpful assessment. Mr Gilbart pointed out that there is no evidence which shows that those difficulties have been remedied. Mr Gilbart submitted that the Tribunal could have been provided with evidence of Continuing Professional Development (CPD), testimonies from professional colleagues, undertakings and reflections from the doctor but said that that material is lacking. He submitted that in those circumstances Dr Costa Zaccarelli s fitness to practise is impaired. 7. Mr Colin, on behalf of Dr Costa Zaccarelli, did not challenge the GMC s submissions that Dr Costa Zaccarelli s fitness to practise was impaired in March 2017 or that it remains impaired today. The Relevant Legal Principles 8. The Tribunal reminded itself that at this stage of proceedings, there is no burden or standard of proof and the decision of impairment is a matter for the Tribunal s judgement alone. 9. In approaching the decision, the Tribunal was mindful of the two stage process to be adopted: first whether the facts as found proved amounted to deficient professional performance and then whether the finding of that deficient professional performance could lead to a finding of impairment. 10. The Tribunal must determine whether Dr Costa Zaccarelli s fitness to practise is impaired today, taking into account her performance at the time of the Performance Assessment and any relevant factors since then such as whether the matters are remediable, have been remedied and any likelihood of repetition. The Tribunal s Determination on Impairment Deficient Professional Performance 11. The Tribunal took account of the Performance Assessment report dated 28 April It noted that Dr Costa Zaccarelli s performance has been assessed under eight categories and with reference to the professional standards described in the GMC publication Good Medical Practice. The Assessment Team s overall assessment aligned each category finding to Good Medical Practice. The Assessment Team 3

4 found Dr Costa Zaccarelli s performance to be unacceptable in the following categories: Maintaining Professional Performance Assessment Clinical Management Relationships with Patients 12. The Assessment Team found Dr Costa Zaccarelli s performance to be acceptable in the following category: Working with Colleagues 13. The Assessment Report stated: 2.3 Dr Costa Zaccarelli s performance was found to be Acceptable in Working with Colleagues and Unacceptable in four of the assessment categories which are listed above. The Team were unable to obtain any medical records to review therefore it was decided that there was insufficient evidence on which to make a judgement in the category of Record Keeping. During the assessment, there was no evidence obtained in the categories of Operative/Technical skills and Safety and Quality so no judgement was made of her performance in these categories. Dr Costa Zaccarelli s score in the knowledge test was % which was below the standard set mark of 62.34%. There was evidence of repeated failure by Dr Costa Zaccarelli to assess patients in a structured manner, with a clear process for eliciting the history of presenting complaint and symptoms, past medical and developmental history. There was also evidence of repeated failure to develop a clear management plan that included a treatment plan agreed and understood by patients and their families. The Team was of the view that these failures represented a risk to patient safety. 2.4 The Team is of the opinion that Dr Costa Zaccarelli s performance is deficient but considers the doctor is fit to practise on a limited basis. 2.5 The Team is of the opinion that Dr Costa Zaccarelli: - Requires a period of Direct Supervision Should not work as a locum Should have a named Educational Supervisor to develop and implement a training programme in response to the deficiencies noted as a result of this assessment. 4

5 14. The Tribunal noted the submissions from Mr Gilbart that Dr Costa Zaccarelli s fitness to practise is impaired by reason of deficient professional performance. Further, this was conceded on behalf of Dr Costa Zaccarelli. 15. The Tribunal accepted the findings of the Performance Assessment Team. It noted that Dr Costa Zaccarelli s Knowledge Test score was significantly below the lower end of the reference group and that in eleven out of the thirteen of the objective structured clinical examination (OSCE) stations, Dr Costa Zaccarelli scored below the 25 th percentile. Therefore, the Tribunal concluded that Dr Costa Zaccarelli s performance fell so far short of the minimum standards of performance reasonably to be expected of a doctor at her level and experience, as to amount to deficient professional performance. 16. The Tribunal having found that the facts admitted and found proved amounted to deficient professional performance, went on to consider whether, as a result of her deficiencies Dr Costa Zaccarelli s fitness to practise is currently impaired. 17. The Tribunal noted that several assessment methods were used and all of these found Dr Costa Zaccarelli s performance to be unacceptable in a number of key areas. 18. The Tribunal is satisfied that at the time of the Performance Assessment, Dr Costa Zaccarelli s fitness to practise was impaired. The Tribunal noted the suggestion that at that time of the Performance Assessment Dr Costa Zaccarelli s was not addressing her shortcomings. 19. The Tribunal has received no evidence before it today that Dr Costa Zaccarelli s has addressed the deficiencies in her clinical performance as identified by the Performance Assessment in March The Tribunal bore in mind the patient safety concerns identified by the Performance Assessment. The Tribunal was mindful of the need to protect the public and to uphold proper standards and public confidence in the profession which would be undermined if a finding of impairment was not made in this case. The Tribunal has therefore determined that Dr Costa Zaccarelli s fitness to practice is impaired by reason of deficient professional performance. DETERMINATION ON SANCTION 01/03/ Having determined that Dr Costa Zaccarelli s fitness to practise is impaired by reason of her deficient professional performance, the Tribunal now has to decide in accordance with Rule 17(2)(n) of the Rules on the appropriate sanction, if any, to impose. 5

6 The Evidence 2. The Tribunal has taken into account evidence received during the earlier stages of the hearing where relevant to reaching a decision on sanction. 3. The Tribunal received further evidence on behalf of the GMC including: Witness evidence from Dr A, Performance Assessment Team Leader and General Practitioner, in person Witness evidence from Dr D, Performance Team Medical Assessor and Consultant Community Paediatrician, by telephone 4. The Tribunal received no further evidence on behalf of Dr Costa Zaccarelli. Witnesses 5. The Tribunal found both Dr A and Dr D gave clear and coherent answers to its questions, which were consistent not only with the Performance Assessment Report but also with each other. Both answered specific questions from the Tribunal clearly to allow the Tribunal to take into account their professional opinions. 6. Dr D told the Tribunal that she had previously undertaken a Performance Assessment of a Consultant Paediatrician. She agreed with Dr A s assessment that the questions in the Knowledge Test were aimed at doctors around the ST2 level in paediatrics. She said that it would take approximately a further six years of training from ST2 level to reach consultant level, as a doctor is required to complete core training in paediatrics before specialising in community paediatrics. 7. Dr D told the Tribunal that the OSCE scenarios were chosen by two community paediatricians specifically to reflect scenarios a community consultant paediatrician would experience in their daily job. She said that, generally speaking, she would expect consultants to score more highly than juniors in the OSCEs. 8. In relation to the risk to patient safety, Dr D confirmed her opinion that Dr Costa Zaccarelli s performance was deficient and that she is fit to practice only on a limited basis. She said that Dr Costa Zaccarelli showed repeated evidence of her failures in being able to structure a consultation, make assessments, plan and speak to parents so that they could understand. 9. Dr D referred the Tribunal to the Assessment Team s recommendations that Dr Costa Zaccarelli: Requires a period of Direct Supervision Should not work as a locum Should have a named Educational Supervisor to develop and implement a training programme in response to the deficiencies noted as a result of this assessment 6

7 10. In relation to Dr Costa Zaccarelli s previous period of direct supervision of her clinical practice, Dr D said that from the Performance Assessment there is evidence that it was not as effective as would be hoped. However, she stated that although the Assessment Team saw deficiencies it also saw positives. She stated that a doctor s insight depends on opportunities to be coached and mentored and the doctor s willingness to take on board feedback. She said if that is the case with Dr Costa Zaccarelli then another period of direct supervision could be helpful but this depended on Dr Costa Zaccarelli s motivation to take on board feedback. She confirmed that Dr Costa Zaccarelli should be directly supervised at all times including written communication. She said that Dr Costa Zaccarelli s progress should be reviewed. At the review, if there was evidence of sufficient professional development, the direct supervision may be reduced or ended. 11. Dr D said the Assessment Team envisaged that a development plan should be in place for the direct supervision with review by an Educational Supervisor. The Educational Supervisor may decide whether another Performance Assessment was necessary, which would indicate if there were ongoing concerns with respect to any deficiencies. 12. Dr D stated that a period of direct supervision that was reflective would be most beneficial if Dr Costa Zaccarelli was willing to learn new skills. Dr D was able to give an example of Dr Costa Zaccarelli s insight and willingness to learn when Dr Costa Zaccarelli researched information regarding cot death overnight in readiness for Case Based Discussions the next day. Submissions 13. On behalf of the GMC, Mr Gilbart submitted that the appropriate sanction in this case is one of conditions. He referred the Tribunal to the Sanctions Guidance (February 2018) (The SG). Mr Gilbart observed that Dr Costa Zaccarelli admitted all the facts of the allegation at the outset of the hearing and conceded that her fitness to practice was impaired. He stated that the Tribunal should consider what remediation, if any, Dr Costa Zaccarelli has undertaken. 14. He submitted that it would be inadequate to take no action and referred the Tribunal to the Performance Assessment findings. He stated that the purpose of conditions is to help the doctor to remedy any deficiencies in their practice and that conditions might be most appropriate in cases involving issues around the doctor s performance. 15. Mr Gilbart reminded the Tribunal that the Performance Assessment report recommended direct supervision and submitted that direct supervision would be workable and would protect the public. In relation to locum work, he referred the Tribunal to the Performance Assessment and submitted that by restricting the doctor from undertaking locum work and short term contracts would be a further layer of protection for the public. He also stated that the Tribunal may consider directing a 7

8 further Performance Assessment and reminded the Tribunal of the Assessment Team s hope that Dr Costa Zaccarelli s performance would improve. Mr Gilbart provided the draft undertakings, which were not presented to the Tribunal for acceptance, and he suggested they would be a useful guide for drafting conditions. 16. Mr Gilbart stated that if the Tribunal takes the view that there is a lack of insight then it may consider a more serious sanction in order to protect the public. 17. On behalf of Dr Costa Zaccarelli, Mr Colin submitted that conditions are the appropriate sanction in this case. He said that conditions would give Dr Costa Zaccarelli the opportunity to improve her deficiencies and to develop her insight further. He accepted that the Performance Assessment demonstrated limited insight, but reminded the Tribunal of Dr D s assessment that, although there were deficiencies in Dr Costa Zaccarelli s practice, there were many positives. He said that Dr D also gave an example of insight and learning during the assessment when Dr Costa Zaccarelli tried to engage in feedback and learning. 18. Mr Colin referred the Tribunal to the undertakings in relation to Locum work and said that, in effect, if Dr Costa Zaccarelli was directly supervised she would also be supervised in any locum roles or fixed term positions. Mr Colin stated that Dr Costa Zaccarelli would expect the Educational Supervisor to advise on whether a further Performance Assessment was necessary. The Tribunal s Determination on Sanction 19. The decision as to the appropriate sanction to impose, if any, in this case is a matter for this Tribunal exercising its own judgement. In reaching its decision, the Tribunal has taken account of the SG. It has borne in mind that the purpose of the sanctions is not to be punitive, but to protect patients and the wider public interest, although they may have a punitive effect. 20. Throughout its deliberations, the Tribunal has applied the principle of proportionality, balancing Dr Costa Zaccarelli s interests with the public interest. It also bore in mind the overarching objectives, which includes to: a. protect and promote the health, safety and wellbeing of the public b. promote and maintain public confidence in the medical profession c. promote and maintain proper professional standards and conduct for the members of the profession The Tribunal s Decision 8

9 No Action 21. In coming to its decision as to the appropriate sanction, if any, to impose in Dr Costa Zaccarelli s case, the Tribunal first considered whether to conclude the case by taking no action. 22. The Tribunal considered that there are no exceptional circumstances in this case. The Tribunal determined that in view of the Tribunal s findings on impairment and the patient safety concerns, it would be neither sufficient, proportionate nor in the public interest, to conclude this case by taking no action. Conditions 23. The Tribunal next considered whether it would be sufficient to impose conditions on Dr Costa Zaccarelli s registration. It has borne in mind that any conditions imposed would need to be appropriate, proportionate, workable and measurable. 24. The Tribunal was concerned that Dr Costa Zaccarelli has not provided it with any evidence of insight into her deficient professional performance. However, it noted that Dr Costa Zaccarelli admitted all of the facts at the outset of the hearing and conceded that her fitness to practise was impaired. The Tribunal considered that this demonstrated that Dr Costa Zaccarelli has some level of insight. 25. The Tribunal took account of the Performance Assessment Team s recommendation that Dr Costa Zaccarelli is fit to practise on a limited basis and it was the Assessment Team s hope that she would be able to remediate her deficiencies, within a directly supervised setting and with the support of an Educational Supervisor. 26. The Tribunal has concluded that it is appropriate, necessary and proportionate to impose conditions on Dr Costa Zaccarelli registration. The Tribunal was concerned at the breadth of the deficiencies in Dr Costa Zaccarelli s clinical practice identified in the Performance Assessment and the wide gulf between the standard demonstrated and that expected of a reasonably competent consultant community paediatrician. The Tribunal therefore concluded that it is necessary to impose conditions on Dr Costa Zaccarelli registration for the maximum period of 36 months. This is necessary to protect patients. The Tribunal considered the period of 36 months would allow Dr Costa Zaccarelli to gain insight, find employment, work through her personal development plan with supervision and support, build her knowledge and skills to address her deficiencies, and undertake a Performance Assessment before a review hearing is held. 27. The following conditions relate to Dr Costa Zaccarelli s employment and will be published: 9

10 1. She must notify the GMC within seven calendar days of the date these conditions become effective: a. of the details of her current post, including her job title, job location and responsible officer (or their nominated deputy) information b. of the contact details of her employer and/or contracting body, including her direct line manager c. of any organisation where she has practising privileges and/or admitting rights d. of any training programmes she is in e. of the contact details of any locum agency she is registered with 2. She must notify the GMC: a. of any post she accepts, before starting it b. if any formal disciplinary proceedings against her are started by her employer and/or contracting body, within seven calendar days of being formally notified of such proceedings c. if she applies for a post outside the UK. 3. She must allow the GMC to exchange information with any person involved in monitoring her compliance with her conditions. 4. a. She must have a workplace reporter approved by her responsible officer (or their nominated deputy) and must inform the GMC of these arrangements. b. She must not start/restart work until her responsible officer (or their nominated deputy) has approved her workplace reporter and this approval has been forwarded to the GMC. 5. a. She must design a personal development plan (PDP), approved by her responsible officer (or their nominated deputy), with specific aims to address the deficiencies in the following areas of her practice. Maintaining professional performance Relationships with patients Clinical Management Assessment 10

11 b. She must give the GMC a copy of her approved PDP within three months of these conditions becoming effective. c. She must give the GMC a copy of her approved PDP on request. d. She must meet with her responsible officer (or their nominated deputy), as required, to discuss her achievements against the aims of her PDP. 6. a. She must have an educational supervisor approved by her responsible officer (or their nominated deputy) and must inform the GMC of these arrangements b. She must not start/restart work until her responsible officer (or their nominated deputy) has approved her educational supervisor and this approval has been forwarded to the GMC c. She must provide quarterly reports from her educational supervisor to the GMC 7. She must undertake an assessment of her performance, on a date given by the GMC, unless notified by the GMC that this assessment is not necessary. 8. She must share her performance assessment report dated 28 April 2017 with: a. her employer and/or contracting body b. her responsible officer (or their nominated deputy) c. her immediate line manager at her place of work, at least one working day before starting work (for current and new posts, including locum posts) d. any prospective employer and/or contracting body, at the time of application e. The responsible officer of any organisation where she has, or has applied for practising privileges and/or admitting rights, at the time of application f. her workplace reporter, educational supervisor and clinical supervisor 11

12 9. She must get the approval of the GMC before starting work in a non- NHS post or setting. 10. a. She must be directly supervised in all of her posts by a clinical supervisor, as defined in the Glossary for undertakings and conditions. Her clinical supervisor must be approved by her responsible officer (or their nominated deputy) and she must inform the GMC of these arrangements. b. She must not start/restart work until her responsible officer (or their nominated deputy) has approved her clinical supervisor and this approval has been forwarded to the GMC. 11. She must not work in any locum post of less than three months duration or fixed term contract of less than three months duration. 12. She must have a mentor who is approved by her responsible officer (or their nominated deputy). 13. She must inform the following persons of the conditions listed at 1 to 12 above. a. her employer and/or contracting body b. her responsible officer (or their nominated deputy) c. her immediate line manager at her place of work, at least 24 hours before starting work (for current and new posts including locum posts) d. any prospective employer and/or contracting body, at the time of application e. The responsible officer of any organisation where she has, or has applied for, practising privileges and/or admitting rights, at the time of application f. any locum agency or out-of-hours service she is registered with 28. The Tribunal considered that it would not be beneficial to Dr Costa Zaccarelli s clinical practice to allow her to undertake locum posts or short term contracts of less than three months because effective supervision required continuity. The Tribunal is mindful that Dr Costa Zaccarelli s clinical progress should be monitored and reviewed, and that she will need support in order for her to remediate her deficiencies. 12

13 29. The Tribunal bore in mind that Dr Costa Zaccarelli demonstrated a number of significant failings in her professional performance. The Tribunal is satisfied that it is necessary to direct a Performance Assessment (unless notified by the GMC that this assessment is not necessary) to ensure any reviewing Tribunal has clear, objective and tested evidence of Dr Costa Zaccarelli s level of performance. 30. The Tribunal considered that having a mentor will be beneficial to Dr Costa Zaccarelli and may encourage reflection into her clinical practice whilst providing the necessary support with the remediation of her deficiencies. Suspension 31. The Tribunal recognised the seriousness of Dr Costa Zaccarelli s deficient professional performance, which was significant. Nevertheless, the Tribunal is satisfied that the direct supervision and constant review of her clinical practice is sufficient to protect patients. The Tribunal bore in mind that should Dr Costa Zaccarelli fail to demonstrate insight into her deficiencies and to improve her clinical practice, that suspension would be open to the Tribunal reviewing her case. Review 32. The Tribunal determined to direct a review of Dr Costa Zaccarelli s case. A review hearing will convene shortly before the end of the period of conditional registration, unless an early review is sought. The Tribunal wishes to clarify that at the review hearing, the onus will be on Dr Costa Zaccarelli to demonstrate how she has developed full insight and remediated her deficient professional performance. It therefore may assist the reviewing Tribunal if the following is provided by Dr Costa Zaccarelli: A reflective statement which demonstrates she has developed full insight into her deficient professional performance Report(s) from her Educational Supervisor Report(s) from her Clinical Supervisor/Workplace Reporter Performance Assessment Report Evidence of Continuing Professional Development Any other information that she considers will assist the review Tribunal DETERMINATION ON IMMEDIATE ORDER 01/03/ Having determined to impose conditions on Dr Costa Zaccarelli s registration, the Tribunal has considered, in accordance with Rule 17(2)(o) of the Rules, whether her registration should be subject to an immediate order. Submissions 2. On behalf of the GMC, Mr Gilbart submitted that an immediate order is necessary to reflect the concerns in the Tribunal s determination and send a message to the public 13

14 and the profession. Mr Gilbart submitted that there would be no prejudice to Dr Costa Zaccarelli as there has been an indication that she is not opposed to an immediate order application, and she is not employed at present. 3. On behalf of Dr Costa Zaccarelli, Mr Colin stated that he has no submissions on an immediate order. The Tribunal s Determination 4. The Tribunal bore in mind paragraph 173 of the Sanctions Guidance (February 2018), which states: 173. An immediate order might be particularly appropriate in cases where the doctor poses a risk to patient safety. For example, where they have provided poor clinical care or abused a doctor s special position of trust, or where immediate action must be taken to protect public confidence in the medical profession. 5. Having considered the submissions, and in the light of all the circumstances of the case, in particular, the Tribunal s finding of deficient professional performance and the patient safety concerns, the Tribunal is satisfied that it is necessary for Dr Costa Zaccarelli s registration to be subject to conditions as follows: 1. She must notify the GMC within seven calendar days of the date these conditions become effective: a. of the details of her current post, including her job title, job location and responsible officer (or their nominated deputy) information b. of the contact details of her employer and/or contracting body, including her direct line manager c. of any organisation where she has practising privileges and/or admitting rights d. of any training programmes she is in e. of the contact details of any locum agency she is registered with 2. She must notify the GMC: a. of any post she accepts, before starting it b. if any formal disciplinary proceedings against her are started by her employer and/or contracting body, within seven calendar days of being formally notified of such proceedings 14

15 c. if she applies for a post outside the UK. 3. She must allow the GMC to exchange information with any person involved in monitoring her compliance with her conditions. 4. a. She must have a workplace reporter approved by her responsible officer (or their nominated deputy) and must inform the GMC of these arrangements. b. She must not start/restart work until her responsible officer (or their nominated deputy) has approved her workplace reporter and this approval has been forwarded to the GMC. 5. a. She must design a personal development plan (PDP), approved by her responsible officer (or their nominated deputy), with specific aims to address the deficiencies in the following areas of her practice. Maintaining professional performance Relationships with patients Clinical Management Assessment b. She must give the GMC a copy of her approved PDP within three months of these conditions becoming effective. c. She must give the GMC a copy of her approved PDP on request. d. She must meet with her responsible officer (or their nominated deputy), as required, to discuss her achievements against the aims of her PDP. 6. a. She must have an educational supervisor approved by her responsible officer (or their nominated deputy) and must inform the GMC of these arrangements b. She must not start/restart work until her responsible officer (or their nominated deputy) has approved her educational supervisor and this approval has been forwarded to the GMC c. Her educational supervisor must provide quarterly reports to the GMC 7. She must undertake an assessment of her performance, on a date given by the GMC, unless notified by the GMC that this assessment is not necessary. 15

16 8. She must share her performance assessment report dated 28 April 2017 with: a. her employer and/or contracting body b. her responsible officer (or their nominated deputy) c. her immediate line manager at her place of work, at least one working day before starting work (for current and new posts, including locum posts) d. any prospective employer and/or contracting body, at the time of application e. The responsible officer of any organisation where she has, or has applied for practising privileges and/or admitting rights, at the time of application f. her workplace reporter, educational supervisor and clinical supervisor 9. She must get the approval of the GMC before starting work in a non- NHS post or setting. 10. a. She must be directly supervised in all of her posts by a clinical supervisor, as defined in the Glossary for undertakings and conditions. Her clinical supervisor must be approved by her responsible officer (or their nominated deputy) and she must inform the GMC of these arrangements. b. She must not start/restart work until her responsible officer (or their nominated deputy) has approved her clinical supervisor and this approval has been forwarded to the GMC. 11. She must not work in any locum post of less than three months duration or fixed term contract of less than three months duration. 12. She must have a mentor who is approved by her responsible officer (or their nominated deputy). 13. She must inform the following persons of the conditions listed at 1 to 12 above. a. her employer and/or contracting body b. her responsible officer (or their nominated deputy) 16

17 c. her immediate line manager at her place of work, at least 24 hours before starting work (for current and new posts including locum posts) d. any prospective employer and/or contracting body, at the time of application e. The responsible officer of any organisation where she has, or has applied for, practising privileges and/or admitting rights, at the time of application f. any locum agency or out-of-hours service she is registered with 6. This means that Dr Costa Zaccarelli s registration will be subject to conditions from today. The substantive direction, as already announced, will take effect 28 days from today, unless an appeal is made in the interim. If an appeal is made, the immediate order will remain in force until the appeal has concluded 7. The interim order currently imposed on Dr Costa Zaccarelli s registration will be revoked when the immediate order takes effect. CASE CONCLUDED Confirmed Date 01 March 2018 Mr Rob Ward, Chair 17