Miss Lisa Bond

Profession: Paramedic

Registration Number: PA40923

Hearing Type: Review Hearing

Date and Time of hearing: 10:00 31/08/2022 End: 17:00 31/08/2022

Location: This hearing is being held virtually.

Panel: Conduct and Competence Committee
Outcome: Interim Conditions of Practice

Please note that the decision can take up to 5 working days to be uploaded onto the HCPTS website. Please contact one of our Hearings Team Managers via tsteam@hcpts-uk.org or +44 (0)808 164 3084 if you require any further information.

 

Allegation

Whilst registered with the HCPC as a paramedic and employed at East Midlands Ambulance Service, on or around 11 June 2018:


1. You did not convey Patient A to hospital when it was clinically indicated.
2. Your actions at 1 put Patient A at risk in that potential life threatening condition(s) could not be ruled out outside a hospital setting.
3. You did not complete the Electronic Patient Report Form (ePRF) to an adequate standard in that:
a) you did not ensure it recorded:
i. an accurate summary of the history provided and/or the patient’s presentation;
ii. Any differential diagnoses and/or working diagnosis;
iii. Any information given to Patient A and/or his family about why he should be conveyed to hospital and/or your concerns about his presentation;
iv. Any advice to Patient A that he should be conveyed to hospital.
v. That Patient A’s refusal to be conveyed to hospital was against your advice; and/or
vi. If you had assessed Patient A’s capacity and/or how his capacity had been assessed.
b)Not proved;
4. The matters set out in paragraphs 1 - 3 constitute misconduct and/or
lack of competence
5. By reason of your misconduct and/or lack of competence your fitness to practise is impaired.

Finding

Background
 
1. The brief background to this Allegation, as recorded in the substantive hearing decision, was:

  • The Registrant is a Paramedic employed by East Midland Ambulance Service (EMAS) NHS Trust (the Trust) since 23 May 2016 when she was newly qualified. The Registrant had also undertaken her training practice with the Trust.

  • On 11 June 2018, the Registrant and Colleague A, an Emergency Care Assistant, attended Patient A’s home following a request from a Community First Responder for back up.

  • On 20 July 2018, Person E (YL) submitted a complaint regarding the Registrant and Colleague A to the Trust’s Patient Advice Liaison Service in  which she questioned why her father had not been conveyed to hospital on 11 June 2018. Amanda Davidson (AD) was appointed as the Incident Investigator.

  • On 27 February 2019, Person B (JW) submitted a Fitness to Practise referral to the HCPC.

 

2. Following further investigation by the HCPC the Registrant was required to attend a hearing to consider the Allegation set out above. That hearing was three years after the events that gave rise to the Allegation. At that Final Hearing the Final Hearing Panel found the matters alleged (with the exception of limb 2(b)) proven.


3. At the misconduct stage the Final Hearing Panel made, amongst others, the following observations:


‘The Panel has heard the reasons given by the Registrant for the decision to leave the Patient at home, namely that one of the daughters would be in attendance overnight and that advice was given to contact the GP in the morning. The Registrant’s conscious decision not to seek outside assistance from the wider multi-disciplinary team within the Trust or within primary care resulted in the decision-making and responsibility remaining with her.

The Registrant’s acknowledged poor record keeping has further exacerbated the situation. Her completion of the form does not provide an accurate description of the presentation of Patient A. Nor does it give a flowing narrative which identifies and tracks the clinician’s thought process. The risk of being perceived as sitting at a laptop at the expense of delivering patient care is appreciated by the Panel. However, the scant and incorrect information recorded on the ePRF, the lack of narrative   about the conflict of his being conveyed to hospital, together with his vulnerability in terms of truly understanding the risks of his decision, are  not of the standard or quantity expected. A fellow practitioner would not be able to fully appreciate the full situation which presented itself to the Registrant nor the information provided to her and be able to rely upon it.

The Panel has therefore concluded that there are multiple clinical and professional reasons why the Registrant’s treatment of Patient A resulted in an inappropriate working diagnosis and the subsequent incorrect treatment and management of his case.’

 

The Final Hearing Panel further added

 

‘……the Panel has concluded that the Registrant’s conduct had fallen far short of that required of a registered Paramedic. Whilst the Panel appreciates that this was an extremely challenging and complex situation with difficult communication issues, there remained some key elements of the Registrant’s practice which on this day fall far short of what is expected. Further, the poor record keeping has resulted in there being no clear and understandable narrative of what was happening, the thought processes involved, the communication with Patient A and his daughters and the resolution of the issues involved. Three crucial elements have not been addressed.

  • Correct identification and assessment of the clinical issues which would have resulted in a different treatment plan.
  • Poor verbal communication with all parties of the Registrant’s reasoning and logic in her decision-making process.
  • A wilful resistance by the Registrant to obtain assistance and independent support at the scene from a GP or remotely from the Trust’s Clinical Assessment team (CAT).

 

These elements have led to a failure to take the correct immediate action, an absence of an informed decision being discussed, resolved and documented, and resulted in a long period of indecision and anxiety for all those involved, including the Registrant.

The Panel has concluded that the Registrant’s conduct on that day amounts to serious misconduct.’

 

4. Having made that decision, the Final Hearing Panel moved on to consider the issue of impairment and in this regard made the following observations.


The Panel considered whether the elements the Panel has identified as practice failings when making its decision on misconduct were capable of remedy. Those practice issues were:

  • Lack of sound clinical assessment and analysis – her failure to correctly identify indicators which would have led her to a different outcome on a Patient Pathway analysis.
  • Poor communication skills – her failure to explain fully and to communicate effectively with those around her.
  • An inability to identify when it is appropriate to escalate a situation and engage with the multidisciplinary team. Her attitudinal approach was one of complete autonomy and disregarded the need to work in a collegiate way in the best interests of a patient.
  • Poor record keeping which meant that a fellow practitioner would be unable to establish the thought process taken by her to reach her decision.

 
5. The Final Hearing Panel considered that these issues could be remedied but that the evidence before it some three years later, was not sufficient to support a finding of no current impairment. The Final Hearing Panel noted:


‘the limitations of this information, in that it [the Final Hearing Panel] did not have before it any of the following, which would have provided evidence that the Registrant had fully and effectively addressed her practice failings.

  • A copy of Training Needs Analysis which had been undertaken by the Trust in 2018. This would have been evidence of what had informed the Trust’s steps of providing mentorship for a four-week period and one review of practice.

  • A statement or reference from the Paramedic who had undertaken her mentoring for four weeks.

  • A statement or reference from a Senior Clinician concerning her clinical practice and/ or knowledge.

  • Evidence of undertaking a report writing course or samples of her improved record keeping skills.

  • Details of the reflective practice which was recommended by the Trust.

  • Evidence of mediation being undertaken.

  • Evidence of any further learning, training and reflection undertaken in the past three years. Particularly training in relation to communication skills in difficult and challenging situations.
  • A piece of reflective writing prepared for this hearing in which she identified the basis of her failings and how they had been remedied. Such reflection could have addressed the issues of remorse, insight, and regret for the events of June 2018 and the  lesson learnt from those events in 2018.

 

The Panel has therefore concluded that whilst the Registrant has complied with the requirements of her employer, those requirements were not, in the  Panel’s view, sufficiently robust in evidencing how they had addressed the failings identified by this Panel.’


6. The Final Hearing Panel then moved on to make the decision that the Registrant’s fitness to practice was impaired on both the public and the personal components.


7. At the Sanction stage the Registrant gave further evidence and provided the Final Hearing Panel with evidence of voluntary study, which were:

  • ‘A ‘Top-up’ degree course with Coventry University. She is undertaking this course remotely part-time. She commenced this course in September 2018. Due to the COVID-19 pandemic the date for completion is now April 2022.

  • A confirmation that she had engaged in an online webinar on the subject of clinical examination completed in October 2020.

  • Poster advert for a multi-agency fire and ambulance CPD event in August 2020, which the Registrant stated that she attended.’

 

The Final Hearing Panel also observed that

 

‘The Registrant gave further clarification on the training she has undertaken and gave some limited reflection on how traumatic giving evidence in this hearing must have been for the family when reliving that day.’

 

8. At the sanction stage, the Final Hearing Panel noted the mitigating and aggravating factors which had led to their decision to impose a Conditions of Practice Order stating


The Panel in accepting that conditions are appropriate in this instance is satisfied that they will provide sufficient protection to the public by ensuring that the Registrant’s practice is supervised, monitored and remediated to the standard expected.

The Panel determined that a period of twelve months with production of information as identified in the Order, should be sufficient for the Registrant to demonstrate the level of learning and insight required. The Panel has chosen not to exercise its discretion to limit the Registrant’s ability to call for an early review.

 

9. The terms of the Conditions of Practice Order that was imposed, and which is the subject of review today, are:

  1. You must work with a senior clinician as your personal Supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice:

    a. Identification of clinical red flags within patient presentation and the formulation of differential diagnosis.

    b. Understanding the application of the Mental Capacity Act including informed consent and the process of obtaining  informed consent or the refusal thereof.

    c. Your referral of onward care of patients where they are not conveyed to hospital.

    d. Your practice in the area of clinical escalation within the Trust where you are faced with clinical concerns which compete with patient autonomy.

    e. Ensuring that your record keeping is accurate, comprehensive and comprehensible.

  2. You must maintain a record of every case where you have undertaken treatment but where the patient has not been conveyed or not been referred to another health care provider which must be signed by your personal supervisor, and you must

    a. provide a copy of these records to the HCPC on a three- monthly basis, the first report to be provided within three months of the Operative Date, or confirm that there have been no such cases during that period; and

    b. make those records available for inspection at all reasonable times by any person authorised to act on behalf of the HCPC.
     

  3. Within 6 months of the operative date satisfactorily complete a period of learning around the Mental Capacity Act and cases where informed consent must be gained prior to conveyance and treatment or refusal of such.
  4. You must maintain a reflective practice profile detailing your reflection on patient cases involving:

    a. Identification of clinical red flags within patient presentation and the formulation of differential diagnosis.

    b. Your referral of onward care of patients where they are not  conveyed to hospital.
  5. You must provide a copy of that profile to the HCPC on a three- monthly basis or confirm that there have been no such occasions in that period, the first profile or confirmation to be provided within three months of the Operative Date.

  6. You must provide a reflective piece of writing in relation to the events on 11 June 2018 and the impact of your actions on Patient A, his family members who were his carers.

 

Evidence placed before this reviewing Panel


10. The HCPC presented to the Panel within the larger bundle a  set of papers totalling 73 pages which relate to an incident that took place on 2 January 2022, and which has become the subject of a separate HCPC investigation. The referral was sent to the HCPC by a member of the family attended by the Registrant.

11. The Registrant had supplied in accordance with the terms of the conditions of practice the following:

 

  • Work diary for the period September 2021 to February 2022, and confirmation of the appointment of a supervisor, MF. This diary includes reference to the incident that is the subject of the referral which is within the HCPC papers placed before this Panel today.

  • Email in which the Registrant explained her inability to find a CPD course around capacity and so had prepared some self learning on this topic. She attached:

o   Self-learning note on capacity, and

o   Reflective account relating to the Registrant’s attendance at the incident (relating to Service User A), and

o   personal development plan
Work diary for period from February to April 2022.

  • Work diary for period May to July 2022.

 

12. The Registrant had provided, immediately before the hearing a copy of the statement of her appointed supervisor, Michelle Fields whichhad been supplied in support of the submission that the Registrant had complied with the terms of the Conditions and was, in the view of MF, no longer impaired.


Submissions


The HCPC


13. The HCPC stated that it was making this application for an early review in light of the fresh evidence of a further complaint that is currently being investigated by the HCPC. It was submitted that in view of this evidence the current conditions are no longer sufficient to ensure service user safety.


14. The HCPC presented a comprehensive overview of the case that had led to the imposition of the Conditions of Practice. Using the timeline for 11 June 2018, that had been established by the Final Hearing Panel, the HCPC noted that:

  • Patient A was an 87-year old Jamaican man who was profoundly deaf and blind in his right eye, with only 5% sight in his left eye. He had glaucoma, diverticulitis, stage 3 kidney disease, chronic obstructive pulmonary disease (COPD) and Hepatitis C. He had no medical history of suffering from seizures.

  • Around 1.45pm Person B, who had spent the afternoon with her father (Patient A) in the garden weeding, had left to go to the council refuse site whilst Patient A was left undertaking some work with his arm down a drain and his cap and jacket by his side on the ground. Patient A’s inhaler, which he used when he suffered an angina attack, was in his jacket pocket. It was thought the patient had taken little fluids.

  • Around 5.30pm Patient A rang Person B saying he thought he was having a heart attack, and Person B returned to his home to find her father rubbing his shoulder and leaning to one side.

  • Person B tapped Patient A’s arm and she considered that he may have strained his arm when putting it down the drain and the Patient A thought so too.

  • Person B contacted her sister, Person E who was on holiday and after describing the situation to Person E, gave Patient A two sprays on his inhaler. Person B went into the kitchen and when she returned to the living room, her father was “fitting” and she therefore called 999. Person B observed her fathers’ eyes had gone red, he was shaking, his false teeth had come out and flown across the room with his glasses come off. She told the call handler that Patient A was having a seizure.

  • The Community First Response was recorded as arriving at Patient A’s home around 7pm, and a few minutes later the CFR had contact with control to request a Red (priority 2) backup.

  • Person B had called her sister Person D and she had then arrived at Patient A’s home.

  • Patient A’s breathing was laboured, and the CFR had given oxygen via a nasal cannula. Later, a double crew ambulance arrived at the scene and the Registrant and Colleague A took a handover from the CFR.

  • The Registrant proceeded to treat the Patient and take observations. The recorded respiratory rate of 16 breaths per minute (BPM), heart rate (HR) of 113 and blood pressure (BP of 79/53 was taken while the Registrant was seated. A second set of observations were taken. At some point, it was conveyed that the Registrant was intending to take Patient A to the hospital and at about this time, the Patient indicated something to the effect of “I’ve got no choice” or “I suppose I have to”. A third set of observations were taken, the CFR left the scene and the Registrant undertook an abdominal assessment of the Patient. Three sets of further observations were taken between 8:45pm and just after 9:00pm. Two of Patient A’s daughters then signed the “discharge at home” form.

  • The Registrant had made the decision not to contact the GP out of hours service in relation to her findings of abdominal pain and primary and secondary impressions of faint/dizziness and constipation. The Registrant had also made the decision not to contact the Trust Clinical Assessment Team to discuss Patient A’s presentation or his decision to refuse conveyance for further treatment. Prior to leaving the scene, the Registrant’s advice was to ring the GP in the morning.

 
15. The HCPC highlighted the elements the Final Hearing Panel had identified as informed, mislead, and influenced the Registrant decision-making processes.


16. The HCPC made reference to the documentation presented by the Registrant to demonstrate compliance with the terms of her conditions. The HCPC raised no specific concerns on those, but in cross examination of the Registrant, highlighted that reliance had been placed on the accuracy and completeness of those documents.  

17. The HCPC highlighted the details of a fresh referral which had been received. The HCPC identified the similarities of this case with that of the matter which had resulted in the restrictions on the Registrant’s registration. The HCPC identified the following salient factors as follows:

  • On 27 July 2022, the HCPC received a referral from a relative of Service User B. The referral reported a concern about the Registrant’s attendance at an incident on 2 January 2022.

  • The concern related to the Registrant and her crew mate who attended to assess Service User B who had been vomiting, had experienced excessive weight loss, was confused and off balance. The Registrant was reportedly also made aware that Service User B’s GP had prescribed anti-sickness tablets and paracetamol for headaches.

  • The complainant was concerned that the Registrant had made assumptions about Service User B after seeing empty lager cans in the room that the Service User was sleeping in, and asked questions regarding whether Service User B had been drinking those.

  • In response to those questions, the complainant and a relative had reportedly told the Registrant that Service User B had not consumed those drinks as he could not keep water down, he had a terrible headache, and was off balance, and had, over a short period of time, lost 4 stone in weight.

  • The referral reports that the Registrant was adamant from the beginning of the assessment that she was not taking Service User B to hospital and had advised the claimant to give him cooled lemonade with sugar added and to measure his vomits.

  • The referral states that a relative “pleaded with” the Registrant as this was not Service User B’s normal behaviour, and that Service User B was holding his head in pain throughout. The referral states that the Registrant made Service User B get up, walk downstairs (which he could barely do), so that she could check his observations.

  • The Registrant asked Service User B where he lived which he answered incorrectly.

  • The Registrant then gave Service User B two paracetamol which were vomited up, and the Registrant asked to see the vomit, before giving him another anti-sickness tablet.
     
  • Service User B was reported as being sleepy. The referral noted that the paramedic team left after a significant time with the advice to try Lucozade and yoghurts.

  • It is alleged that the crew had refused to take Service User B to hospital, as he had only had 1 anti-sickness tablet.

  • The referral notes that after this, Service User B deteriorated significantly, with the family attending ED for a third time, where he was sent to Hull Royal Hospital to have major brain surgery to relieve pressure from tumours in his brain. Service User B was subsequently diagnosed with multiple brain tumours and encephalitis two days after the attendance to the hospital.

  • The referral expresses a concern that the Registrant is not fit to practise, as she had not recognised a seriously ill patient, and a concern that the Registrant’s demeanour was ‘appalling’. The complainant also reported that the Registrant said it would be “kidnap” to take Service User B to hospital.

  • On 10 May 2022, the Registrant’s employer at EMAS provided a copy of Service User B’s PCRF.

  • On 23 June 2022 EMAS confirmed that they have not investigated this concern.|

  • On 7 June 2022, a relative of Service User B provided a further statement, which provided additional information about the incident and noted that the relative assisted the Service User downstairs by holding on.

  • On 21 July 2022, the HCPC notified the Registrant of the new concern that had been raised regarding her fitness to practise.

    In relation to the review of the Conditions of Practice Order, the HCPC stated that the incident was also referenced in the Registrant’s document “HCPC diary until February” using incident number 148030111, in the following terms:

    “49 yom – not eating and drinking much for 6/52, unsteady on feet, has covid, Pt been to ED on 29/30 December and given doxycycline. Chest infection and metoclopramide x3 daily. GP aware and said if any deterioration to call 999. Pts family worried so called, on arrival family demanding pt be given IV fluids and taken to ED for re-hydration. Family calmed down and explained we needed to assess pt and find the best treatment for him. Obs normal parameters – NEWS 0. Pt only been taking 1 metoclopramide and drink, pt drank 1 pint during approx. 45 mins and kept it down and also had some custard which also kept down. Pt managed to walk downstairs unaided. Explained to the family that ED is not the place for him and reassured them by calling ED and speak to sister in charge re bloods, Pts condition (no change) and what they would be able to do for him and agreed ED not for him. Offered advice about eating small amounts and confirmed this with Dr in control who also agreed with ongoing and needs to see own GP. Mental health/eating disorder reasons for ongoing issues. Advice left.”

 

18. The HCPC, having referred the Panel to this excerpt from the Registrant’s diary log relating to the fresh complaint, highlighted the differences between the complainant’s recollection of what had happened on 2 January 2022, and the diary log made by the Registrant. There were several discrepancies and conflicting evidence.

19. In relation to the new complaint that has been placed before the Panel, the HCPC maintained that this was relevant to the Panel’s considerations today in relation to current fitness to practise and the potential for repetition of the misconduct. The HCPC stated that this repetition within the initial period of the Conditions is of concern. The fact of a repetition in circumstances where Service User B was only two days later taken to hospital and diagnosed with multi brain tumours and encephalitis was of serious concern.

20. The HCPC submitted that the Panel should consider whether there is sufficient evidence to demonstrate that the Registrant has fully remediated or has demonstrate that all the concerns raised in the original finding of impairment have been sufficiently addressed.

21. The HCPC submitted that the new information from the recent referral requires serious and careful consideration in realtion to whether the Conditions of Practice Order are sufficiently addressing and remediating the concerns raised by the original finding. The HCPC submitted that the new information also indicates that since the final hearing, there remains a risk of repetition and potential harm to patients.

22. The HCPC submitted that the reputation of the profession and public confidence in the regulator may be at jeopardy if a finding of current impairment is not made today.  The HCPC submits that members of the public should have trust and confidence in the registered professions who treat them and have confidence that they are people of integrity and honesty, who can carry out their duties to professional standards.

23. On the basis of the information before it, the HCPC submitted that the Panel may consider that the Registrant has not yet discharged the persuasive burden referenced in Abrahaem and GMC.

24. Given these factors, the HCPC submitted that the evidence before today’s Panel is not sufficient to indicate that the Registrant’s fitness to practice is no longer impaired.

Registrant’s Representations

25. The Registrant’s Representative informed the Panel that the Registrant would not be answering any questions relating to the fresh referral, and that no adverse inference should be drawn from this. The Registrant’s Representative emphasised that the investigation of the recent referral was at a very early stage. There is at yet no case to answer and no weight should be placed on it for this review hearing.

26. When a complaint is received it is rightly taken very seriously and investigated. At present however there is no information from the Registrant on this case, which she has only recently been made aware of.

27. The conflict in the information recorded by the Registrant may well be at variance with the statements provided by the complainant as the diary log of cases the Registrant has provided was produced for an entirely different purpose of demonstrating the action taken in cases where there had been no conveyance to hospital as required by her current conditions. It will be appreciated that the referral was produced following a particularly sensitive event. The fact that the Registrant recorded speaking to a doctor and nurse which was not noted by the complainant, may reflect those sensitive circumstances. Further, the ePRF was reviewed by EMAS who have confirmed that a good systematic approach had been adopted by the Registrant. EMAS had chosen not to investigate the complaint.

28. At this stage of the HCPC investigation the Registrant has had no opportunity to put forward her representations on this matter and, as stated, there has been no internal investigation. It would therefore be improper and unfair to put weight on this evidence which are unrelated to this review and no need to answer, in the course of these proceedings, a complaint that has been untested. Other professional involved in the review of the ePRF considered her actions unimpeachable.

29. Turning to the current order it was submitted that the Registrant has complied with the conditions and her supervisor’s (MF) evidence supports that position. It was submitted that the Registrant has not only shown compliance but demonstrated personal commitment to fulfilling those. She has clearly taken to heart the findings previously made. The Registrant has not only complied with the Order, she has also demonstrated insight and remorse. This being the case, the current order should come to its natural end in October.

30. The Registrant’s Representative directed the Panel to several entries in the Registrant’s diary where the Registrant had a full understanding of ‘red flags’, impact of not taking patients to hostpial and the potential outcomes that could result from not conveying a patient to hospital. These entries support her understanding of informed consent and capacity. She has fully demonstrated her understanding of the underlying principles of communication and good record keeping.

31. The Panel should place no weight on the Registrant’s lack of response to the new complaint. She has today been open and honest with the Panel which should not be underestimated given the pressures and stresses of this hearing arena. She has reflected and adopted new practices, acknowledging that she had been overly confident when newly qualified. She now fully appreciates the findings which were made against her last year. The Registrant has matured in her decision-making and there is evidence she has taken steps to further her knowledge. She has been able to identify that these conditions have helped her personally and helped to improve her practice. The Panel should therefore allow the order to come to an end in October.

Oral evidence

32. The Registrant gave evidence in realtion to the steps and processes she has adopted to implement and comply with the current order. The personal development plan had been devised between her previous clinical supervisor (MF) and the Registrant.

33. The Final Hearing Panel’s findings has been helpful to her practice. It has been helpful in making her focus on identifying ‘red flags’, and to allow her reflection processes to develop and allow her to identify sources of support and seek further guidance from fellow clinicians.

34. The diary log prepared by the Registrant in response to condition 2, identified all cases where she had made a decision not to convey a service user to hospital and the reasons why that decision had been appropriate.

35. In relation to condition 3, which required the attendance on a course relating to the Mental Capacity Act, the Registrant stated that she had not been able to find a CPD day course that did not clash with her work commitments. She had instead gathered the information herself and sent her learning on this to MF. Reflecting on this learning has helped the Registrant to adapt her practice to ensure that the patient knows, as well as the family, what the potential outcomes can be if the patient is not taken to hospital. The Registrant stated that she now adopts a more thorough approach to making a decision and has improved her communication skills.

36. The Registrant had produced a personal reflective profile in relation to condition 4. In this she gave several examples of incidents where there had been a positive outcome. For instance, in February there was a case of a 42-year-old man with cancer and an end-of-life care plan in place. He and his wife did not wish him to be constantly removed to hospital when his situation changed. After an intervention the Registrant had arranged for him to obtain, at home, appropriate medication and a ‘respect form’ put in place so that he would not again be rushed to hospital. He had subsequently died at home with his wife.

37. In relation to Condition 5 the Registrant stated that she considered she had complied with this provision, albeit that her first profile had been sent late as she had been unclear where to send the documentation.

38. In relation to condition 6 the Registrant stated that undertaking a reflection on the impact of her decision had on Service User A and his family had resulted in her appreciating that the family had not been able to grieve properly, and she had deprived the patient of the ability to attend and get appropriate care. The Registrant acknowledged that the records of the incident were not good, She accepted that she had let herself and her colleagues down. She stated that she was young, complacent and had now learnt from her mistakes.

39. The Registrant stated that she had taken further steps to improve her skills and knowledge by re-enrolling in her university course (which had been interrupted by COVID) and the degree course would be completed in November. She continued to read her professional papers and she reflected on her practice constantly: she tried to be proactive and continually improve her knowledge.

40. In relation to the further referral, she had been notified on 2 May 2022, immediately before she was due to go on holiday. As soon as this notification had arrived the Registrant had contacted her Regional Supervisor, who then informed the Registrant’s Lead Operational Manager and in turn the Registrant’s Station Manager. The Registrant had chosen to inform people before she went on holiday, as she thought it appropriate to do so.

41. MF gave evidence in her role as the Registrant’s Supervisor and Support, as required by the current Order, a role she had assumed whilst she was employed as the Registrant’s Clinical Manager. Following an organisational restructuring, MF’s role changed and so whilst she has continued in the Supervisor/Support role she is no longer in a managerial role for the Registrant. The fresh complaint has therefore been dealt with by another clinician, but MF had been made aware of this complaint in June 2022.

42. MF confirmed that the Registrant had openly, freely and often discussed the case which gave rise to the conditions of practice being imposed on her. MF told the Panel that she could not recall any situations where the Registrant had reported to her a case where the Registrant considered that she had badly handled the situation.

43. MF had met the Registrant on a fairly regular basis but due to the distance between their working sites this had only been face to face on two or three occasions. In relation to the diary log of cases which extended to about 250 incidents attended where there had been a decision not to convey to hospital, MF stated that she had checked the accuracy of the entries on a random basis and had checked about 15 entries.

44. In response to a further question MF had confirmed that closer and more extensive supervision of the Registrant may be difficult given that the Registrant was stationed in a rural, remote station and senior clinicians were not normally in residence and attended on a need to basis.

Legal Advice

45. The Legal Assessor reminded the Panel that today’s hearing was an early review under Article 30(2) and its purpose was to conduct a comprehensive review of the Registrant’s practice as of today, to determine whether the evidence at this time supports the position that:

  • The Registrant is fit to return to unrestricted practice as submitted by the Registrant’s Representative; or

  • whether the current or varied restrictions on her practice remain sufficient to protect the public and service users, or

  • whether those restrictions should be varied to require further oversight of the Registrant’s practice as submitted by the HCPC.

46. The Legal Assessor reminded the Panel that its role was not to conduct a rehearing of the Allegations, nor was it to go behind the previous findings. Similarly, the Panel is not to make any findings of fact in relation to the further referral which has, as yet not been before the Investigating Committee. She advised that in carrying out this assessment, the Panel must exercise its own independent judgment and should consider and determine the weight to place upon all the fresh evidence it had before it.

47. The Legal Assessor reminded the Panel that it should first consider whether there has been compliance with the current conditions and whether in doing so the Registrant has demonstrated that she has successfully remedied her previous failings.

48. The Legal Assessor advised the Panel that if it determined that the Registrant’s fitness to practise remained impaired, then the Panel must go on to consider what restriction should be imposed that would maintain public confidence in the profession and ensure service-user safety. She also advised the Panel that it should bear in mind the principles of fairness and proportionality and have regard to the Sanctions Policy document issued by the HCPTS. She reminded the Panel that any order that it makes under Article 30 should not be punitive in purpose, and that it should be the least restrictive order that would suffice to protect the public and/or would otherwise be in the public interest.

Panel Decision

49. The Panel accepted the advice of the Legal Assessor. The Panel noted it powers today are to:

  • confirm the Order;

  • extend the period of the order;

  • vary the order;

  • revoke the order; or

  • replace it with another order which it was able to do at the final hearing stage.

 

50. The Panel has also, as advised, had regard to the HCPTS’s Practice Note on Fitness to Practise Impairment and the Sanctions Policy. The Panel noted that there was a persuasive burden on the Registrant as set out in the case of Ebraheam v GMC [citation to follow]. In this regard the Panel first considered whether the Registrant has complied with the terms of her conditions of practice and took into consideration all the documentation before it, the submissions of the parties and the oral evidence from the Registrant and her Supervisor.

51. The Panel considered closely the information it had received from the Registrant. It noted the progress she had made in her practice, her learning and her professional knowledge. There was evidence that the Registrant had taken seriously the issue of complying with the conditions and in improving her learning. The Panel accepted that there had been compliance with most of the conditions. After careful examination however there remained in the Panel’s view, areas where there was insufficient evidence to support a finding that there had been full remediation. This being the case, the Panel has concluded that the Registrant’s fitness to practise remains impaired.

52. This Panel noted that at the Final Hearing that panel made clear references to the failure of communication between the Registrant, the Service User and the Service User’s family. These included:
“a total breakdown of understanding and communication”
“…the clinical failings and poor communication had contributed to that level of risk”.

53. The remaining concerns about the Registrant’s practice arise from her reflective practice and her communications skills

54. The Panel noted that the Registrant’s reflective profile contained examples where there had been a positive outcome. It noted that there was little relating to how things could have been done better or differently. The Panel had concerns that whilst the Registrant had grasped the principles of review of her work, she had not appreciated the need for critical professional reflection of her practice. She was unable to identify cases where results could have been achieved in a different way. The log of cases did not demonstrate full reflection on her practice and the Personal Reflective Profile failed to demonstrate an understanding of the role of reflective practice in improving one’s actions and decision-making processes. A lack of true reflection on events could result in the same mistakes being repeated. In this limited regard the Panel took into account the details of the new referral, which in some instances echoed the circumstances of the previous referral. This included references to communication difficulties with the family of the service user.

55. The Panel noted that the documentation prepared and presented to this Panel relating to conditions 2 and 4 reflected a limited  interpretation of what was required to comply with those conditions.  

56. The diary log of cases where there had been a decision not to transfer service users to hospital had set out the steps that had been taken by the Registrant. In the Panel’s view this failed to set out the clinical decision-making process, reflection on what could have been done better and the learning points that flowed from this process. The Panel noted that this diary of logged cases had not been robustly quality tested, with MF stating that she had randomly checked about 15 of the 250 cases listed. There had not therefore been the opportunity to fully explore further whether alternative courses of action could have been adopted to reach the same or a better result.

57. The Reflective Personal Profile did not demonstrate a full insight into the extent of the Regsitrant’s previous failings and had not, albeit at this very late stage, demonstrated an apology for her previous actions. There therefore remained a lack of true remorse. The Registrant expresses ‘sadness’, ‘upset’ and identifies how things could have been done differently but does not demonstrate a profound understanding of the factors that led to this incident.

58. The Panel considered that the remaining areas of concern can be addressed and successfully remedied by the Registrant. Those remaining concerns about her practice could, in the Panel’s view, be better addressed by a smaller, focused set of conditions. Those conditions are set out below.

59. The Panel has considered the length of time that those conditions should be in place and concluded that twelve months was sufficient time for the Registrant to develop the requisite level of skill and understanding in those areas of her practice that remain of concern. The Panel chose not to restrict the Registrant’s ability to return to a Panel of the Conduct and Competence Committee and seek an early review but considered that there would need to be robust and full evidence to support such an early review.

Order

ORDER: The Registrar is directed to vary the Conditions of Practice Order against the registration of Miss Lisa Bond for a further period of 12 months on the expiry of the existing Order. The conditions are:

1. You must meet monthly (either in-person or virtually) with a senior clinician as your mentor to continue to develop your clinical practice by presenting your reflective learning from:

 

a. A minimum of five incidents that you have attended and from which you have identified specific areas for improvement.

 

And

 

b.    Where possible, cases relating to communication difficulties or conflict with service users and/or other parties should be included.

 

2. You must maintain a written log of these meetings which outlines the incidents discussed, outcomes and learning derived from these reflections.

 

3. These logs must be submitted to the HCPC fourteen days prior to the next review hearing in this case.

 

4. You must inform the following parties that your registration is subject to these conditions:

 

c.    any organisation or person employing or contracting with you to undertake professional work;

 

b.    any agency you are registered with or apply to be registered with (at the time of application); and

 

c.    any prospective employer (at the time of your application).

 

4. Any condition requiring you to provide any information to the HCPC is to be met by you sending the information to the offices of the HCPC, marked for the attention of the relevant Case Manager.

 

5. Within 6 months of the operative date be able to satisfactorily demonstrate your learning regarding communication and conflict management in healthcare settings. This can be through completing a written piece of work or attending formal training.

Notes

The Order imposed today will apply from 17th October 2022 and be reviewed by 17 January 2023.

Hearing History

History of Hearings for Miss Lisa Bond

Date Panel Hearing type Outcomes / Status
31/08/2022 Conduct and Competence Committee Review Hearing Interim Conditions of Practice
13/09/2021 Conduct and Competence Committee Final Hearing Conditions of Practice
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