Heather A Crawley
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Allegations (as amended at Final Hearing)
During the course of your employment as a Biomedical Scientist at Peterborough City Hospital:
1. While working on the blood culture bench during November 2012, you:
a. "mixed up" Gram stain results which resulted in an incorrect reporting of results
b. Incorrectly identified a Staphytect positive organism as coagulase - negative staphylococcus (CNST)
c. Reported a Trimethoprim resistant organism as sensitive
d. Used an incorrect methodology for inoculum for a API 20E
e. Used an incorrect antibiotic disk set for a Gram - positive rod
f. Reported a Staphylococcus aureus in blood culture when it was CNST
g. Reported Gram negative bacteria in the Gram film of a negative blood culture
h. Did not inform the consultant when a coliform was identified.
2. While working on the routine 24 hour read bench during November 2012, you:
a. Reported a CAP screen as negative, when it was a Streptococcus pneumoniae positive.
b. Did not identify a Haemophilus species in a specimen.
3. While working on the routine 24 hour read bench during December 2012 you did not inform the Consultant when a beta haemolyfic Group B streptococcus (BHSB) was identified from a significant site.
4. While working on the routine 24 hour read bench during January 2013, you:
a. incorrectly identified BHSB as present in a High Vaginal Swab (HVS), when it was Enterococcus faecalis (ENFA) in relation to specimen 2676,
b. incorrectly identified a penile swab as 3+MCO, 3+PYO and SBHSG when BHSG was ENFA in relation to specimen 2709,
c. incorrectly identified a skin swab from a neonate as scanty coliforms (pure) when it was not pure and should have been reported as UBF in relation to specimen 2728
d. incorrectly identified a throat swab from a neonate screening as 3BHSB and 2C0LI when coliform was not a target organism and was mixed in relation to specimen 2761
e. incorrectly identified skin flora with mixed coliform on an IQA sample when significant pathogens were present and a growth of ++ Staphylococcus aureus was found in relation to two specimens
f. did not report sensitivity to Pseudomonas aeruginosa in relation to specimen 7674
g. incorrectly identified skin flora only (diphtheroid) instead of Staphylococcus aureus in relation to specimen 7703
h. conducted a Staphytect Test on Branhamella Catarrhalis instead of catarrhalis disc testing in relation to specimen 7940
5. While working on the MRSA bench on 20 April 2013 you incorrectly identified and reported a sample as nose, throat and groin positive when it was not groin positive.
6. While working on the routine 24 hour read bench during May 2013, you:
a. were unable to detect Trichomonas vaginalis with 3+ white cells in a wet prep slide
b. incorrectly identified a specimen as no growth when 4 colonies of Staphylococcus aureus were present.
c. incorrectly identified a specimen as skin flora with 2 types of CNST however it was skin flora with Staphylococcus aureus
d. incorrectly identified a specimen as Group C strep and Staphylococcus aureus however it was Group D and C mixed with coliforms.
7. On 24 January 2013 you did not follow direct management instruction in that colleague A advised you to stay on the Routine Bench and not go to Specimen Reception and you worked in Specimen Reception.
8. You stated to colleague A that your Specialist Portfolio had been shredded by your previous employer.
9. Your statement at paragraph 8 above was incorrect.
10. While working on the MRSA bench on or around 15 April 2013, you did not record:
a. that a urine sample had been received
b. the results in relation to the urine sample
11. Your actions at paragraph 8 and 9 were dishonest.
12. The matters set out in paragraphs 1 – 10 constitute misconduct/lack of competence.
13. The matters set out in paragraph 11 constitute misconduct.
14. By reason of your misconduct and/or lack of competence your fitness to practise is impaired.
Application to amend allegations
1. Mr Claxton applied to amend the word ‘cell’ to the word ‘slide’ in particular 6. Mr Steer did not oppose the application. The amendment was not substantive in nature and the Panel acceded to the application.
2. At the end of his case Mr Claxton made an application to amend a number of the allegations. In relation to particular 5 he applied to amend the date from the 20 April 2013 to 19 April 2013. This amendment was not opposed by Mr Steer. The Panel finds that there was evidence supporting the amendment. The amendment corrected an incorrect date. The Panel find that it was not substantive but provided both clarification and accuracy and therefore acceded to the application.
3. Mr Claxton made two further applications to amend the allegations. In relation to particular 1(e) he applied to insert the word ‘attempted’ before the word used. The proposed allegation would then read ‘Attempted to use an incorrect antibiotic disc, rather than ‘used an incorrect antibiotic disc’.
4. He also sought to amend particular 4(f). He applied to substitute the words ‘did not report sensitivity’ to ‘did not set up sensitivity’. Mr Steer objected to these amendments on the grounds that these were completely different allegations which he had not had the opportunity to cross-examine on. This meant that the case that Miss Crawley had to meet had been changed to suit the evidence.
5. The Panel finds that the amendment is substantive and not just one for clarification. Its purpose appeared to the Panel to plug a gap in the Council’s case and the amendment had the potential to cause prejudice to Miss Crawley. The Panel finds that it is in the interest of justice for the Registrant to know at the outset the case he/she needs to meet.
Half time submissions
6. At the close of the case for the Council, Mr Claxton offered no evidence on allegations 1(d), 2(b) and 10. Accordingly, the Panel find that these allegations are not proved.
7. Mr Steer made submissions of no case to answer in respect of particulars 1(e) and 4(f). Having heard the submissions of Mr Steer and Mr Claxton’s reply and having taken advice from the Legal Assessor, the Panel find that there was no evidence in relation to particular 1(e). The evidence taken at its highest was that Miss Crawley took an incorrect disc out of the tray. The Panel therefore finds that the Council has failed to discharge the burden of proof in respect of this allegation and finds there is no case to answer. Particular 1 (e) is therefore not proved.
8. In relation to particular 4(f) the Panel finds that there is a case to answer. The Panel heard evidence from Mrs R and Mr D that there were various stages in the reporting process. The Panel finds that there is a case to answer on this allegation.
9. The Registrant, Miss Crawley was employed as a Band 5 Biomedical Scientist in the Clinical Microbiology Department at Peterborough City Hospital between 1 October 2012 and 5 June 2013 as maternity cover. During this time she was managed by Senior Biomedical Scientists KR, AD and AS. In October/November 2012 a number of errors were highlighted in relation to Miss Crawley’s work. Miss Crawley did not pass her initial competency assessment in November 2012 and the team set up weekly meetings to try to assist her to manage her workload effectively. This involved supervising her work and appointing a mentor to work with her. By 21 January 2013 there were significant concerns over errors and AD instituted formal performance management meetings. On the 15 May 2013, KR made a referral to the Council in relation to Miss Crawley’s competency. Miss Crawley’s maternity leave contract came to an end in June 2013.
10. During her employment Miss Crawley advised KR and AD that her Specialist Portfolio had been shredded by her former employer, James Paget University Hospital. The Council contend that this statement was false and dishonest.
11. The Panel heard from the following HCPC witnesses:
a. KR (Witness 1) Senior Biomedical Scientist and Training Officer at Peterborough City Hospital. Witness 1 was the Registrant’s Line Manager.
b. AD (Witness 2), Senior Biomedical Scientist at Peterborough City Hospital. Witness 2 was the Registrant’s Line Manager.
c. FB (Witness 3), Biomedical Scientist at Peterborough City Hospital.
d. LH (Witness 4), former Lead Biomedical Scientist at James Paget University Hospital. Witness 4 was the Registrant’s Line Manager.
Decision on Facts
12. Before the hearing Miss Crawley admitted the particulars as set out: 1(a), 1(g), 2(a), 2(b), 4(a), 4(b), 4(c), 4(d), 4(e), 4(g), 6(a), 6(b), 6(c).
13. Miss Crawley put the Council to proof in relation to particulars 1(b), 1(f), and 6(d). In his closing submissions, Mr Steer accepted that Miss Crawley could not remember the particular incidents and did not put forward a positive case on her behalf in relation to these matters.
14. In relation to particular 1(b) the Panel find that this allegation is proved. The evidence supporting it is derived from KR's statement, her oral evidence and from Exhibit 7 which is a record of KR's observations of Miss Crawley’s work on 14 November 2012. Therefore, the Panel finds this particular proved.
15. There was evidence supporting particular 1(f) from KR and in exhibit 36 and the Panel find this particular proved.
16. Regarding particular 6(d), the evidence in support of this particular is derived from KR’s evidence and her written statement and from Exhibit 28, which contains the full discussion between KR, AD and Miss Crawley following a competency check on Miss Crawley’s work. The Panel finds this particular proved.
17. The Panel found the witnesses called by the Council to be reliable, credible and balanced witnesses.
18. Miss Crawley denied the following particulars:
Particular 1(c) – Proved
19. This particular arises from Miss Crawley’s competency assessment on 13 November 2012. KR was observing Miss Crawley’s work at the time. It was KR's evidence that Miss Crawley should have reported that the organism was resistant to Trimethoprim. The Panel accepts KR's evidence that Miss Crawley had begun to enter an incorrect result on the computer and had she not intervened there was a real risk that inappropriate treatment would have been given. Her observations were contemporaneously recorded during the competency assessment and are contained in Exhibit 7. The Panel finds that Miss Crawley had begun to record her finding on the computer and that this amounts to reporting. The Panel finds reporting includes the inputting of information onto the computer. This particular is proved.
Particular 1(h) –Proved
20. The Panel accepts that this particular arises from the mixing up of Gram stains from two separate patients which formed the basis for the admissions in particulars 1(a) and (g). This particular concerns the failure to telephone through the positive coliform result to the consultant. Although Miss Crawley has accepted responsibility for mixing up the Gram stains from two different patients, she has been inconsistent over her actions in the aftermath. In her written statement, which is dated 16 March 2016, she states that a previously reported bacteria as not seen had grown a coliform and she asked AD to telephone the results through to the consultant. This is inconsistent with the oral evidence that she gave at the hearing. During her oral evidence, Miss Crawley stated that she did not notice the incorrect result until the Saturday morning. As soon as she saw the error she went over to AD and explained that she had inconsistent results and that she thought she might have mixed the results up. She stated that she was distraught as this was a mistake which was not easy to rectify without repeating the test and was beyond her capabilities. It was her evidence that AD told her to leave the plates to one side for him to sort out. She said that this conversation took place at approximately 8.30am and it had not been dealt with when she left her shift at midday. This key aspect of her oral evidence was not contained in her written statement.
21. AD could not remember the Saturday in question but he was clear that it was never his practice to take responsibility for somebody else’s work and that he would have shown Miss Crawley what to do rather than have done her work for her.
22. Miss Crawley told the Panel that she left work at midday. The Panel note that on Miss Crawley’s own account, this was a potentially very serious error and that if what she said is true she left work without checking that this error had been rectified, which in itself, would have been irresponsible.
23. Both KR and AD made it clear that it is always the responsibility of the Biomedical Scientist carrying out the test to report any positive findings to the consultant. The system described by Miss Crawley would have been unworkable and the Panel finds that it was Miss Crawley’s responsibility to inform the consultant that she had found a coliform.
24. The inconsistency in Miss Crawley’s account undermines its reliability and the Panel prefers the evidence of AD on this point. The particular is proved.
Particular 3 – Proved
25. The Panel accepts AS's evidence that whilst working on the 24 hour bench in December 2012, Miss Crawley failed to inform the consultant when a beta haemolyfic Group B streptococcus (BHSB) was identified. The Panel accepts the evidence of AD that it is the duty of the Biomedical Scientist who obtains a positive test result to inform the consultant.
26. The Panel does not accept the evidence of Miss Crawley that the positive results were put on a clip and phoned through together. The evidence of KR and AD was clear on the procedure in place at the laboratory. It had been set up to avoid confusion and to ensure accuracy and places the responsibility on the Biomedical Scientist who obtains the result to communicate it to the consultant in charge of the patient. There would be no reason to get anybody else to do it. This incident was discussed in Miss Crawley’s weekly development meeting on the 21 December 2012. The Panel accepts AD's evidence that the ‘arrow’ in his note next to the word ‘phone’ in his handwritten notes was to jog his memory to discuss it with Miss Crawley. The Panel notes that Miss Crawley accepted as accurate the typewritten notes of the meeting of the 21 December 2012, at her next weekly development meeting.
Particular 4(f) – Not Proved
27. The Panel finds that one cannot report on something that has not been done. It would therefore have been impossible to report a sensitivity.
Particular 4(h) – Proved
28. The Panel accepts the evidence of KR that this was picked up and noted as part of the 48 hour Competency check following Miss Crawley’s 24 hour reads on 26 January 2013. During that check it was noted that Miss Crawley had used a Staphytect Test instead of Catarrhalis disc on Branhamella catarrhalis.
29. The Panel does not accept Miss Crawley’s explanation that the cocktail stick she had put on the card used for the Staphytect Test was simply there while she went to the fridge to get the appropriate test. The incident is contemporaneously recorded in the note of the Competency check at ‘Issue 3’ in Exhibit 25.
Particular 5 – Proved
30. This particular arises from a factual dispute between FB and Miss Crawley. Having assessed the evidence, the Panel accepts the evidence of FB who worked regularly on the MRSA bench. We accept her assessment that Miss Crawley incorrectly identified a sample as positive for MRSA in the nose, throat and groin area, when it was not groin positive. FB reported this incident to KR by email on 24 April 2013. The Panel attaches little weight to the photographic evidence produced by Miss Crawley. On Miss Crawley’s own account the plate, which was the subject of the photograph, was retrieved from the autoclave bin. Despite Miss Crawley’s assertion that the plate was intact the plate could have been compromised. It was at least four days old when Miss Crawley retrieved it. In addition the photograph was of such poor quality that the Panel could not form a view as to the colour of the dots. The disc was apparently not shown to anybody at the time and the Panel therefore finds that the particular is proved.
Particular 7 – Proved
31. There is no dispute that Miss Crawley was at Specimen Reception on the 24 January 2013. She accepted this in her witness statement and during her oral evidence. The key issue was whether she was told to stay on the Routine Bench and whether this was an instruction or merely advice. The Panel accepts the evidence of KR that Miss Crawley was told to stay on the Routine Bench and had been told not to work in Specimen Reception. Although the Panel accepts that it was sometimes the practice to help out at Specimen Reception, Miss Crawley had specifically asked where she should work and had been told, in terms, by KR that she should remain at the Routine Bench. The Panel notes from KR's witness statement that she went to Specimen Reception and at 2.35pm told Miss Crawley to return to the Routine Bench but she did not return to the Routine Bench until 3.20pm, almost one hour later. The particular is proved.
Particular 8 – Proved
32. The Panel finds that Miss Crawley did tell KR that her portfolio had been shredded by her previous employer. The Panel accepts KR's evidence on this point because she acted upon the information by contacting James Paget University Hospital.
Particular 9 – Not Proved
33. The Panel finds that the statement which forms particular 8 was, in a sense correct as Miss Crawley’s first portfolio had indeed been placed in the shredding bin at James Paget Hospital and had therefore, been shredded at her previous employers. The Panel finds that Miss Crawley had not explained the full details clearly to KR but that she did not intend to make an incorrect statement.
Particular 11 – Not Proved.
34. In light of the Panel’s findings in particulars 8 and 9 above, the Panel is not satisfied that Miss Crawley was dishonest and therefore finds that this particular is not proved.
Decision on Grounds
35. In reaching our decision on misconduct and impairment the Panel heard submissions from Mr Claxton who stated
(i) That the omissions were so serious that they amounted to misconduct;
(ii) That in the alternative they represented a sample of work over a sufficiently long time span to show patterns that amounted to lack of competence.
36. Mr Steer who appeared for Miss Crawley submitted that the mistakes had to be considered in their proper context. The most serious incident had occurred at the beginning of the period of employment and Miss Crawley had identified it. Secondly, once Miss Crawley was moved from the blood bench to the 24 hour bench her results were provisional results and subject to further routine checks at 48 hours. He argued that this mitigated the risks to service users. He argued that Miss Crawley’s performance was improving. He reminded the Panel of the high threshold for a finding of misconduct and argued that this was not a case where the sample of work could safely lead to a finding of lack of competence. He reminded the Panel that they could not aggregate a number of incidents of non-serious incidents to make a finding of lack of competence or misconduct.
38. The Panel took advice from the Legal Assessor.
39. The Panel’s judgment is that this is not a case of lack of competence. This is a case of misconduct. Miss Crawley had eighteen months post registration experience and would have been expected to have the competencies to carry out the duties of a Band 5 Biomedical Scientist. Furthermore, she took a job where she was expected to’ “hit the ground running”. Having considered the Standards of Proficiency for Biomedical Scientists, the Panel finds that Miss Crawley fell short of the Standards of Proficiency set out in the HCPC Standards of Proficiency in that she did not meet - 2a.1; 2a.2 2a.4: 2b.4 & 2b. 5.
Particulars 1(a), 1(g), 1(h)
40. The Panel finds that the mixing of Gram stain results in particular 1(a) amounts to misconduct because it was a serious error. The error could have resulted in the wrong patient receiving treatment and the correct patient not receiving treatment for a serious condition. The consequences of the omission are set out in particular 1(g). Miss Crawley’s failure to take responsibility for the mistakes and to inform the Consultant (particular 1(h)) meant that the Consultant was not notified when a coliform had been identified. The Consultant should have been notified immediately. The Panel finds that each of the errors of themselves are so serious as to amount to misconduct.
Particulars 1(b); 1 (c) and 1 (f),
41. The Panel accepts the evidence of KR and AD that errors on the blood culture bench are always serious because they have the potential to delay urgent treatment or result in the wrong treatment. Each error of itself is so serious as to amount to misconduct.
Particular 2, 3 and 4
42. These particulars all relate to mistakes made by Miss Crawley on the 24 hour read bench. Particular 2 relates to errors in November; particular 3 to an error in December and particular 4 to errors in January. The Panel does not accept Mr Steer’s submission that errors on the 24 hour bench are less serious because they can be checked at 48 hours on the 48 hour bench when they are re-read. The Panel accepts the evidence of KR and of AD that results at 24 hours, although described as interim results, were often requested, so that treatment could be commenced. Moreover it is at this stage that the Biomedical Scientist sets up sensitivity testing to ensure that within 48 hours the most efficient treatment can be offered. The fact that these were being checked at 48 hours does not reduce the serious nature of the mistakes. At every stage a Biomedical Scientist has the professional obligation to be wholly accurate because of the possible consequences of inaccurate or delayed results.
43. Particular 2(a) relates to a failure to detect Streptoccoccus Pneumoniae positive. Pneumonia is a serious condition and the error had potentially serious consequences, and the error amounts to serious misconduct.
44. In relation to Particular 3, the Panel were told by KR that a Beta Haemolyfic Group B Streptococcus is potentially serious in pregnant women as it is a potential source of meningitis in neonates. This was a serious error because the failure to inform the Consultant of its presence could have led to a delay in the treatment of a neonate. The omission amounts to misconduct. The Panel heard evidence from KR and AD that it is the duty of the Biomedical Scientist, conducting the testing to relay his/her results to the Consultant in charge of the patient immediately.
45 In relation to particular 4 the principles set out in paragraph 42 above, apply, and the Panel find that each of the errors amounts to misconduct.
46. The consequences of saying that the swab contained MRSA in the groin as well as in the nose and throat amounted to negligence rather than misconduct or incompetence.
47. The Panel refers to paragraph 42 above. The particulars contained in 6 (a)-(d) all relate to errors made by Miss Crawley on the 24 hour bench. Whilst, the condition in particular 6(a) may not have been of the most serious, the course of treatment would have altered. The findings in particular 6 (b), (c) and (d) were all serious and basic errors and resulted in KR's decision to refer Miss Crawley to the HCPC. The Panel finds that they amount to misconduct.
Particulars 7 & 8
48. The Panel finds that particulars 7 and 8 are neither misconduct nor incompetence.
49. In the Panel’s view, the serious misconduct found is conduct which brings the profession into disrepute and thus affects public confidence in the profession. In short the Panel finds that the conduct falls seriously short of the HCPC’s “Standards of Conduct, Performance and Ethics”.
Decision on Impairment
50. Whether or not Miss Crawley’s fitness to practise is currently impaired is a question for the Panel alone. The Panel paid due regard to the evidence of Miss Crawley and to the submissions of Mr Steer and reminded itself of the HCPC’s Practice Note entitled “Finding that Fitness to Practise is Impaired”. It also accepted the advice of the Legal Assessor.
51. The Panel accepts that the errors although serious are remediable. However, the Panel does not accept that they have been remedied. AD gave evidence that Miss Crawley’s performance was erratic. The Panel does not accept Mr Steer’s submission that there had been a significant improvement. The reason that Miss Crawley was placed without direct supervision, on the 24 hour bench was because AD was concerned that direct supervision might be damaging Miss Crawley’s confidence and preventing improvement. However, the Panel notes that there was at least one other biomedical scientist in the room, who she could consult. All Miss Crawley’s work was being checked at the 48 hour stage, to try to ensure that patients did not suffer harm. The Panel does not accept that Miss Crawley was about to be signed off as ‘competent’.
52. Miss Crawley herself has said that she does not feel confident to work as a Biomedical Scientist, having been out of practice for almost three years. She accepted that she would need considerable retraining. The Panel therefore finds that there is a high risk of repetition.
53. The Panel has had regard to the public interest in the wider sense that is the maintenance of public confidence in the profession and the upholding of proper standards of conduct and behaviour and whether or not the conduct is likely to be repeated.
54. Whilst Miss Crawley has now shown some insight, by admitting a number of the allegations and accepting that her errors could have caused patient harm, the Panel finds that Miss Crawley has yet to develop full insight. For example, how her repeated errors impacted on service users, her colleagues and the efficiency of the laboratory. In light of the factors set out above the Panel finds Miss Crawley’s fitness to practise to be currently to be impaired.
Decision on Sanction
55. In considering sanction the Panel paid careful regard to the submissions of Mr Claxton and Mr Steer. The Panel had regard to the HCPC’s Indicative Sanction Policy and accepted the advice of the Legal Assessor that it should apply the principle of proportionality, weighing the interests of the public with Miss Crawley’s. The public interest includes not only the protection of patients but also the maintenance of public confidence in the profession and the declaring and upholding of proper standards of conduct and behaviour.
56. It was conceded by Mr Steer that a Caution Order would not be appropriate in light of the misconduct found because it would not restrict Miss Crawley’s practice.
57. The Panel finds that Miss Crawley’s failings are capable of being remedied. However, they have not yet been remedied and this lack of remediation is compounded by Miss Crawley not having practised as a Biomedical Scientist, in any capacity, for almost three years.
58. Miss Crawley has told the Panel that she does not yet feel ready to return to practice and is unsure whether she will ever to do so. The Panel accepts that she has shown a willingness to learn and improve but under the particular circumstances of this case, the Panel feels it is unable to formulate conditions which would be workable and which would, at this stage, ensure that she is able to practise safely and effectively.
59. Miss Crawley’s failings were serious and continuing. The Panel finds that she has only limited insight and that there is a risk of repetition. Miss Crawley said that she may wish to return to practice in the future, possibly in an academic or less stressful environment. She accepted that she would need considerable further training and support to update her professional practice. The Panel finds she is not safe to practise at present, even with conditions, but could involve herself in retraining and education or work in a related field which does not require registration. The Panel has therefore decided to impose a Suspension Order for a period of 12 months to allow her to reflect on what she wishes to do in the future and how she can now remedy her failings. It will give her the opportunity to develop full insight into the reasons for, and the consequences of, her misconduct.
60. The Panel considered a Striking Off Order but considered this would be disproportionate in light of its findings that the misconduct is remediable. A Suspension Order would protect the public, uphold public confidence in the profession and in the HCPC as the regulatory body.
The order imposed today will apply from 20 May 2016.
This order will be reviewed again before its expiry on 20 May 2017.
History of Hearings for Heather A Crawley
|Date||Panel||Hearing type||Outcomes / Status|
|08/05/2017||Conduct and Competence Committee||Review Hearing||Voluntary Removal agreed|
|18/04/2016||Conduct and Competence Committee||Final Hearing||Suspended|