Mr Samuel James Eldridge

Profession: Biomedical scientist

Registration Number: BS65026

Hearing Type: Final Hearing

Date and Time of hearing: 09:00 27/04/2016 End: 16:00 28/04/2016

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

Panel: Conduct and Competence Committee
Outcome: Struck off

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Allegation

(as amended at the Final Hearing)
During your employment as a Biomedical Scientist for Great Western Hospitals Foundation NHS Trust, you:


 

1. Recorded and/or attached incorrect patient information, including on the following occasions:


a) On or around 21 November 2014, you attached the results of a patient known to have leukaemia to a patient who did not have leukaemia;


b) On or around 9 October 2014, you booked a bone marrow patient under the incorrect demographics;


c) On or around 9 October 2014, you entered incorrect demographics on the system for Patient A;


d) On or around 10 July 2014, you attached the incorrect demographics to Patient B;


e) On or around 1 May 2014, you attached the incorrect demographics to Patient C;


f) On or around 28 November 2013, you changed a patient’s demographics incorrectly;


g) On or around 13 November 2013, you booked Patient D under the incorrect demographics.


2. Authorised incorrect results, including on the following occasions:


a) On or around 11 November 2014 for Patient E;


b) On or around 12 September 2014 for Patient F;


c) On or around 23 June 2014 for Patient G;


d) On or around 31 May 2014 for Patient H;


e) On or around 22 May 2014 for:


i. Patient I


ii. Patient J


iii. Patient L


f) On or around 3 March 2014 for Patient M.


3. On or around 18 March 2014, gave a clinician the incorrect results for Patient N.


4. Did not take appropriate action when samples returned abnormal results, including the following occasions:


a) On or around 9 September 2014 in relation to result which showed no coagulation;


 

b) On or around 2 July 2014 in relation to Patient O.


 

5. Did not follow the laboratory’s standard operating procedures, in that you:


a) Did not telephone results and/or log them as telephoned, including the following occasions:


i. On or around 11 September 2014 in relation to Patient P;


ii. On or around 21 August 2014 in relation to Patient Q;

 

iii. On or around 27 April 2014 in relation to Patient R;


iv. On or around 2 April 2014 in relation to Patient S;


v. On or around 20 February 2014 in relation to Patient T;


vi. On or around 20 February 2014 in relation to Patient U;


vii. On or around 14 February 2014 in relation to Patient V.


b) On or around 9 May 2014, did not refer to the standard operating procedure when performing a fibromagen test;


c) On or around 14 August 2013, in relation to Patient W:


i. did not highlight a low platelet count as being urgent;


ii. did not call and/or document making a call to the ward regarding the patient. 


6. On or around 20 March 2014, in relation to Patient X, did not perform manual coagulation for one or two of the samples when the results indicated that you should have done so;


7. On or around 30 January 2014, in relation to Patient Y, you performed manual coagulation when this was not the correct test.

8. The matters as described in paragraphs 1 – 7 constitute misconduct and/or lack of competence.


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

Finding

Preliminary Matters


Service


1. The Panel had sight of a letter dated 12 February 2016 sent to the Registrant at his registered address, as well as an email of the same date, giving notice of today’s hearing, and determined, in accordance with Rule 3 of the Health Professions Council Rules 2003 (“the Rules”), that service had been properly complied with.


Proceeding in absence


2. The Panel accepted the advice of the Legal Assessor, who took the Panel to the Practice Direction on Proceeding in the Absence of the Registrant, to Rule 11 and to the guidance given in the cases of Jones (2003) 1 AC 1 and Tait –v The Royal College of Veterinary Surgeons [2003] UKPC 34.


3. The Registrant had sent an email to the HCPC on 16 February 2016 stating: “To [whom] it may concern: I will not be attending this hearing. Regards Samuel Eldridge”.


4. In those circumstances the panel concluded that the Registrant had voluntarily absented herself from the proceedings. He had not attended, he had not made an application to adjourn and the Panel concluded that it was unlikely that he would attend if the hearing were to be adjourned. The Panel concluded that it was in the public interest for the matter to be heard expeditiously and for the Panel to proceed today in the absence of the Registrant.

Application to amend


5. Ms Acker applied to amend the allegation. The Registrant had been given notice of the proposed amendments in advance of the date of hearing. He had not submitted any objection to them.


6. The Panel concluded that the proposed amendments were based on an accurate and fair reflection of the evidence and did not cause undue prejudice to the Registrant. The Panel considered that it was in the interests of justice to allow the application.


Proceeding in private


7. Ms Acker’s applied for some of the evidence to be heard in private to maintain the private life of the Registrant.  The evidence concerned background circumstances in his private life and matters pertaining to his health. The Panel received advice from the Legal Assessor and granted the application.


Witnesses


8. The Panel heard from the following live witness:
- Witness 1 – Lead Biomedical Scientist at Great Western Hospitals NHS Foundation Trust, who managed the Registrant over the entire period of his employment with the Hospital.


Background


9. On 20 November 2012 the Registrant was employed as a Band 5 Biomedical Scientist (BMS) for the Great Western Hospitals NHS Foundation Trust (“the Hospital”). He worked in the haematology department, working in blood transfusion and blood grouping, dealing with inpatients and outpatients and General Practitioner (GP) referrals. This was his first job as a BMS.

10. The Panel heard that the Registrant was placed on a Performance Plan on 20 May 2013 due to concerns raised by other practitioners that he had authorised abnormal results and had not checked patient demographics. 


11. A second Performance Plan was initiated on 1 October 2013 and the Registrant was issued with a “Must Do” list. It was suggested that he had not been following the Standard Operating Procedures (“SOPs”), which provided a step by step guide on how to perform various tasks within the haematology department.  The “Must Do” list was added to over time as further errors in his practise were identified. 


12. On 24 October 2013 a Capability Hearing for Performance was held and the Registrant was issued with a First Written Warning on the basis that he had continued to authorise results erroneously, enter patient demographics incorrectly and had failed to follow SOPs.


13. On 29 October 2013 a third Performance Plan was put in place for three months.


14. A number of concerns were then raised about the Registrant’s practise which Witness 1 began to log as they occurred.


15. On 10 February 2014 a further Performance Plan was issued due to concerns held by Witness 1 about the number of errors logged.


16. On 19 March 2014 an incident was reported in relation to Patient N which forms the basis of Particular 3. It was alleged that a consultant haematologist had requested results relating to Patient N and the Registrant had provided incorrect results.


17. On 11 June 2014 a further Performance Management meeting was held and the Registrant was issued with a First Written Warning as part of a Second Capability Process.


18. On 6 November 2014 a hearing was held to consider the Registrant’s progress and he was issued with a Final Written Warning.

19. On 20 November 2014 the Registrant commenced a Performance Improvement Plan.


20. On 21 November 2014 an incident occurred that led to concerns being raised about the Registrant authorising the wrong results for a patient. This forms the basis for Particular 1(a).


21. On 22 January 2015 a Stage 3 Formal Meeting was held and a reconvened hearing was held on 27 January 2015.


22. The incidents set out in the Particulars in the allegation were all alleged to have taken place between the time of the First Performance Plan on 20 May 2013 and the Stage 3 Formal Meeting on 27 January 2015.


Decision on Facts


23. In reaching its decision the Panel accepted the advice of the Legal Assessor. It understood that the HCPC bore the burden of proving the case on the balance of probabilities. It was aware of the evidential significance of the fact that some of the evidence had been presented by means of hearsay. It drew no adverse inference from the fact that the Registrant had chosen not to attend the hearing. It took into account of the fact that the Registrant was a person of good character.


24. The Panel found Witness 1 to be both credible and reliable. It was evident Witness 1 had taken time and effort to support the Registrant with the aim of improving his performance. It was also evident that she had made contemporaneous notes and a log of events and that where she could not remember or be sure she said so and did not speculate. There is also evidence that she recorded improvements in the Registrant’s performance when that occurred.


25. The Panel found the facts proved in their entirety on the following basis:


PARTICULAR 1
Particular 1(a)


26. The Panel accepted the evidence of Witness 1. She told the panel that she had been informed by a member of staff that on 21 November 2014 the Registrant had authorised a result which indicated the presence of leukaemia. The result was sent out to the patient’s GP. It transpired that the Registrant had sent out a result that related to a different patient; the GP’s patient did not have leukaemia.


27. The Panel heard and accepted that the Registrant had not informed anyone of the abnormal result, which he should have been done prior to authorising the result, in accordance with the abnormal results procedure. The Panel heard that when Witness 1 questioned the Registrant he did not recall asking anyone to check the sample. When asked what the correct protocol was, he was able to relay the information from the SOP, thereby suggesting that he was aware of what he was expected to do in these circumstances.


28. In addition to Witness 1’s evidence the Panel accepted as reliable the contemporaneous written record of a meeting between Witness 1 and the Registrant on 24 November 2014 when this matter was discussed. The Registrant signed the record which records his failing in this instance. The Panel also relied upon a “Summary Report (Performance)” which refers to this event as a “serious error”.


Particular 1(b)


29. The Panel accepted the evidence of Witness 1 that on 14 October 2014 the Registrant had booked a bone marrow request for a patient onto the wrong patient’s records, as evidenced by a reflective learning record compiled by the Registrant in which he records his “error”.


Particular 1(c)


30. The Panel accepted the evidence of Witness 1, based on her “Event Chronology Log”, that on 9 October 2014 the Registrant had entered an incorrect unit number when attaching blood results to Patient A’s computerised results, with the result that a different patient’s results were saved to Patient A’s records. The Panel has also relied upon the extract of Patient A’s record.


Particular 1(d)


31. The Panel accepted the evidence of Witness 1, based on her “Event Chronology Log”, that on 10 July 2014 the Registrant entered an incorrect patient ID number when booking in a result for Patient B, meaning that the results were attached to the wrong patient sample. The chronology records that in discussion the Registrant “was able to quote the correct protocol yet has not followed it. [He] now understands that protocols cannot be deviated from…”.


Particular 1(e)


32. The Panel accepted the evidence of Witness 1, based on her “Event Chronology Log”, that on 1 May 2014 the Registrant selected the wrong patient when inputting a data onto the system for Patient C.
Particular 1(f)


33. The Panel accepted the evidence of Witness 1, based on the Registrant’s contemporaneous reflective learning record signed 30 November 2013, that he had changed the patient demographics of one patient to another patient. It was unclear from the record what information he had changed. In his reflective learning record he describes his initial “error” which he then sought to correct but did so “incorrectly”. He wrote that he needs to be “more methodical” and “focused” in his work.

Particular 1(g)


34. The Panel accepted the evidence of Witness 1 that on 13 November 2013 the Registrant had booked Patient D under the incorrect demographics by using the wrong NHS number. The Panel heard that he identified this mistake, reported it to Witness 1 directly, and then submitted a reflective learning log and an incident report sheet. The Incident Report sheet records that the patient was “booked in under incorrect demographics”. In his reflective learning record the Registrant refers to his “mistake” and that in future he “must carefully check” the data and his recording of it. The Panel also relied upon an extract of the Patient’s record which shows that wrong demographics were entered.


PARTICULAR 2
Particular 2(a)


35. The Panel accepted the evidence of Witness 1, provided by her “Event Chronology Log”, that on 11 November 2014 the Registrant authorised results for Patient E which incorrectly showed an abnormal result. The Registrant then approved the result, and released it onto the computer system, meaning that it could be viewed by hospital staff and could be given to or seen by clinicians. The chronology records that this incident was discussed with the Registrant who was reminded of the need to keep up to date with instructions which were issued to staff at unit meetings and repeated on a board in the clinical area.


Particular 2(b)


36. The Panel accepted the evidence of Witness 1, provided by her “Event Chronology Log”, that on 12 September 2014 the Registrant authorised an incorrect result for Patient F. The Registrant recorded an Activated Partial Thromboplastin Time (APPT) test, which measures the time taken for blood to coagulate, of 18.6. The normal range for an APPT test is from 19.0 – 30.6. The result that the Registrant authorised, but then deleted, was therefore outside the normal range.

37. The relevant SOP states that when an abnormal result from an APPT test is shown the sample should be checked for a clot. If clotting factors have been activated then the test might show that the blood has coagulated in a shorter time. The result should be repeated before being authorised. Patient F’s record revealed that the Registrant authorised the result and then deleted it, meaning that the result was then removed from the system, and could not be checked. Witness 1 discussed this event with the Registrant who was able to correctly explain the relevant protocol.

Particular 2(c)


38. The Panel accepted the evidence of Witness 1, as recorded on her “Event Chronology Log”, that on 23 June 2014 the Registrant authorised an incorrect result for Patient G. The record read: ‘PTR auth [authorised] when patient clearly had been on warfarin for some time with INR at beginning of month’. The Panel heard that PTR is a blood clotting test used to monitor patients taking certain medications. It was clear from Patient G’s records that the patient had been taking warfarin. The Registrant used the wrong test and authorised a result which could not have been right because the patient was on warfarin. The Panel has also relied upon a record of a disciplinary interview conducted with the Registrant on 6 November 2014 in which the Registrant is recorded as saying “it said in the notes [Patient G] was on warfarin but I missed this”.


Particular 2(d)


39. The Panel accepted the evidence of Witness 1 that the Registrant had authorised an abnormal result on 31 May 2014. The Registrant had authorised a haemoglobin count (Hb) of 181 for Patient H. Patient H was a maternity patient. Witness 1 gave evidence that it would be extremely unlikely for a pregnant lady to have a haemoglobin count this high. Witness 1 re-ran the test on 2 June 2014 and the result was 125 (normal value). The Panel accepted the evidence of Witness 1 that the Registrant should have re-run the test given the unexpectedly high reading. The Panel has relied upon an extract of the patient’s record showing both results. The Panel has also relied upon a formal incident report and the Registrant’s own reflective learning record in which he describes how he “must take great care” in future and to work “carefully”.

 
Particular 2(e)


40. The Panel accepted the evidence of Witness 1, based on records made by a colleague, that on 22 May 2014 the Registrant authorised incorrect results for Patient’s I, J and L.  A colleague working in the hospital, a BMS Band 6, had identified these errors after re-running the tests that the Registrant had completed and he then recorded his (the Band 6’s) findings on an incident details sheet. The Panel heard that a normal white blood count ranges from 4 to 11. The Registrant had authorized a result of 59.3 for Patient I; when re-tested the result was 4.9. The Registrant had authorized a result of 136.9 for Patient J; when re-tested the result was 14.3. The Registrant had authorized a result of 45.8 for Patient L; when re-tested the result was 5.2. The Panel heard that a reading of above 30 was an indication that the patient might be suffering from leukaemia, and that had the Registrant’s results not been checked the patients could have caused emotional stress and worry to the patients concerned. The Band 6 records that “problems” had been previously experienced with the Registrant’s work. In his reflective learning log the Registrant acknowledges the errors relating to Patients I, J and L. The Panel also relied upon extracts of the records for Patients I, J and L. The Panel also noted that an additional entry was made to the “Must Do” list arising from this incident.


Particular 2(f)


41. The Panel accepted the evidence of Witness 1, based on her “Event Chronology Log” that on 3 March 2014 the Registrant authorised an incorrect result for Patient M. The Registrant authorised a mean corpuscular haemoglobin concentration level (MCHC) of 36.6. The normal range is 31.5 to 36. The Panel heard that it was recorded in the “Must Do” list that a MCHC lower than 30 or greater than 36 must be discussed with an experienced BMS. The Panel also relied upon an extract of the patient’s record.

PARTICULAR 3


42. The Panel accepted the evidence of Witness 1 that on 19 March 2014 the Registrant provided a Consultant Haematologist who was working at the hospital with incorrect haemoglobin results for Patient N.

43. The incident had been reported to Witness 1 by the Consultant Haematologist who had telephoned the Registrant to request haemoglobin results for Patient N, and later reported that the Registrant provided the results relating to September 2013, instead of 19 March 2014. The Consultant had asked the Registrant to check the date as, from previous experience with the Registrant, he was concerned that it might be wrong. The Registrant confirmed that it was the correct result for the date requested. The Consultant then discharged the patient on the basis of this (incorrect) result. The Consultant then checked the result and identified that he had been provided with the results for September 2013, which were 121, rather than 19 March 2014, which were 118. The Consultant had to then recall the patient and apologise for the error. 

44. As a result of this complaint, Witness 1 discussed the matter with the Registrant at a meeting on 19 March 2014. The Registrant provided a reflective log explaining that the reason why he had given the incorrect result was because he had been reading the result from the patient records dated September 2013, rather that the result on the computer system from that day, 19 March 2014. In his reflective learning record the Registrant accepts that he gave the incorrect result and that his “error” was due to a “lack of focus and not checking details”. He went on to write “Errors such as this are highly dangerous and unprofessional as they can effect a patient negatively”. He further wrote that to “prevent error such as this from happening again I must make every effort to focus on the details…and not rush or lose focus” to “maintain a high level of patient care”.


PARTICULAR 4
Particular 4(a)


45. The Panel accepted the evidence of Witness 1, based on her “Event Chronology Log”, that the Registrant had failed to take appropriate action on 9 September 2014 when a paediatric coagulation sample returned an abnormal result. The sample provided a normal PTR result but no coagulation for APPT, which the Panel heard was very unusual. The Panel heard and accepted that the Registrant should have recorded the fact that he had received a paediatric sample with abnormal coagulation, in accordance with the process change note that had been distributed, but had failed to do so. The chronology records that the incident was discussed with the Registrant during which he admitted to gaps in his knowledge. This matter was also referred to in a disciplinary interview on 6 November 2014.


Particular 4(b)


46. The Panel accepted the evidence of Witness 1, based on her “Event Chronology Log”, that on 2 July 2014 the Registrant did not follow the correct procedure when a sample for Patient O returned an abnormal result.  Patient O had had an upper gastrointestinal (GI) bleed. The Registrant tested a blood sample for platelet count which produced a result of 34, which was low in that Patient O had had a platelet count tested on 29 June 2014 with a result of 192, and a test earlier in the day on 2 July 2014 with a result of 229. The Panel heard that the normal range for a platelet count is between 150 and 450. The Panel found that the Registrant should have checked to ensure that the result he had obtained was accurate. The Panel also heard that the Registrant attempted to telephone through the result, but failed and subsequently deleted it. He then requested a blood film. He did not wait for the blood film to be analysed by someone with the appropriate skill, which he should have done. The chronology records that this incident was discussed with the Registrant. In the course of this incident he had asked a member of reception staff for their assistance. During the discussion he was advised that he should not have asked for this assistance as the reception staff aren’t qualified to provide the assistance sought. 


PARTICULAR 5
Particular 5(a)
Sub-particular 5(a)(I)


47. The Panel heard and accepted from Witness 1 that when the results of a sample showed a haemoglobin level of less than 80, this result must be phoned into the accident and emergency department as the patient may require a blood transfusion. This was documented in the Registrant’s “Must Do” list.

48. The Panel accepted from Witness 1’s “Event Chronology Log” that on 11 September 2014 the Registrant did not make a note in the relevant log of any phone call in relation to Patient P and that this was discussed with the Registrant. The haemoglobin result that the Registrant had obtained was 6.6 which was double the previous recording, and was abnormal, and this should have been phoned in and logged. The Panel also relied upon the patient records.


Sub-particular 5(a)(ii)

49. The Panel accepted from Witness 1’s “Event Chronology Log” that on 27 April 2014 the Registrant did not phone in a haemoglobin result of 71 for Patient Q who was a patient on the maternity ward. He had then gone on to authorise the result. He had recorded the fact that he had tried to call the maternity ward on three occasions, but had then given up, rather than persisting until he got through, which he should have done. The chronology records that this was discussed with the Registrant. The Panel also relied upon the patient record that confirms he did try to telephone through the results 3 times.


Sub-particular 5(a)(iii)


50. The Panel accepted from Witness 1’s “Event Chronology Log” that on 27 April 2014 the Registrant failed to log any phone call for Patient R who had a haemoglobin count of 71, which should have been phoned through. The Panel also relied upon the patient record that showed no telephone call being made.


Sub-particular 5(a)(iv)


51. The Panel accepted from Witness 1’s “Event Chronology Log” that on 2 April 2014 the Registrant failed to log any phone call for Patient S who had a haemoglobin count of 71, which should have been phoned through. The chronology records that this incident was discussed with the Registrant who was reminded of the relevant protocol and which also records that Patient S was in A&E with a GI bleed.


Sub-particular 5(a)(v)


52. The Panel accepted from Witness 1’s “Event Chronology Log” and evidence that on 20 February 2014 the Registrant did not phone in a result for Patient T, who had an INR greater than 10, which was abnormal in that the therapeutic range is between 2.5 and 3.5. The Registrant had recorded in Patient T’s notes that he had attempted to phone in the result but that attempt had failed. The Panel accepted the evidence of Witness 1 that he should have tried the out of hours number. The fact that he did not do so indicated that he did not understand the clinical significance of the result. The chronology records that this incident was discussed with the Registrant. The Panel also relied upon the patient records which records that the Registrant had attempted to telephone through the result. The Panel also relied upon evidence of a relevant update to the “Must Do” list.

Sub-particular 5(a)(vi)


53. The Panel accepted from Witness 1’s “Event Chronology Log” and evidence that on 20 February 2014 the Registrant did not phone in a result for Patient U, who had an INR greater than 10. He had recorded the fact that he had tried to phone the results through but had failed to follow this through as he should. The chronology records that this incident was discussed with the Registrant. The Panel also relied upon the patient records which records that the Registrant had attempted to telephone through the result. The Panel also relied upon evidence of a relevant update to the “Must Do” list (as with the incident involving Patient T immediately above).

Sub-particular 5(a)(vii)

54. The Panel accepted from Witness 1’s “Event Chronology Log” that on 14 February 2014, the Registrant did not phone in an INR result that was greater than 10 for Patient V, when he should have done so.

55. The Panel heard from Witness 1 that she discussed this incident with the Registrant and explained the significance of his error. It was after this conversation that he made the same error in relation to Patients T and U referred to above.

Particular 5(b)


56. The Panel accepted the evidence of Witness 1 that on 9 May 2014 the Registrant was reported to have been seen undertaking a fibrinogen standard curve, which is used as part of a clotting test, without having a copy of the SOP with him to use as a reference, contrary to the recommendation set out in the SOP. The Panel also relied upon a contemporaneous note of a meeting between Witness 1 and the Registrant on 22 May 2014 signed by both of them. In this note it is recorded that this incident was discussed. The Registrant is recorded as agreeing that he had not used the SOP. When asked why he had not done so he is recorded as saying that he “felt he was capable”. Witness 1’s evidence was that with this particular test even experienced BNS’ would have the SOP with them. At this meeting she instructed him to refer to it on future occasions.


Particular 5(c)
Particular 5(c)(I)


57. The Panel accepted the evidence of Witness 1 that she was made aware that the Registrant had carried out a platelet count test for Patient W who had come into the accident and emergency department on 14 August 2013. The patient record revealed that Patient W had a very low platelet count of 49. The Panel heard that the normal range for a platelet count is 150 to 400, and that this result was a significant cause for concern. The patient could have been suffering from thrombotic thrombocytopenic purpura (TTP), which can be life threatening. The Panel heard that there was no evidence on the file for Patient W to show that the test was marked as urgent. The Panel also relied upon an incident report for this event and a reflective learning record written by the Registrant in which he records that he had learnt from the experience of this incident. 


Particular 5(c)(ii)


58. The Panel accepted the evidence of Witness 1 that there was no evidence in relation to Patient W to show that the result referred to above was telephoned or logged as telephoned. Again, the Panel relied upon the incident report and reflective learning record referred to immediately above.

PARTICULAR 6


59. The Panel accepted from Witness 1’s “Event Chronology Log” that on 20 March 2014 the Registrant performed manual coagulation tests on one sample for Patient X, which produced no clotting results, when he should have tested three samples, and that this was discussed with the Registrant.


PARTICULAR 7

60. The Panel accepted the evidence of Witness 1 from her review of Patient Y’s records.  Patient Y was treated in the accident and emergency department on 30 January 2014 with a bleeding head wound. The Registrant recorded that Patient Y was ‘on warfarin’. The appropriate test for a patient on warfarin would be to perform INR and not a clotting screen (PT and APTT), which is a manual coagulation. The Registrant performed manual coagulation on the second sample. The Panel relied upon an incident report and also on the Registrant’s own reflective learning record in which he records his “error” and also that he “should have checked the history”.


Decision on grounds


61. The Panel accepted the advice of the Legal Assessor who took the Panel to the cases of Roylance v General Medical Council No 2 [2001] 1 AC and Calhaem v General Medical Council [2007] EWHC. The Panel was aware that a finding of misconduct and/or lack of competence is for the Panel’s professional judgement.


62. The Panel approached its task in the way put forward by Ms Acker on behalf of the HCPC who had asked the Panel to consider first whether all or any of the facts amounted to misconduct. If misconduct was found, the Panel was not asked to consider the question of lack of competence.

63. As set out in this determination, the Registrant had failed to record or had attached incorrect patient information, had authorised incorrect results, had failed to take appropriate action when samples returned abnormal results, and had failed to follow laboratory standard operating procedures.

64. The Panel also notes that in the contemporaneous records of meetings held with the Registrant to discuss his errors he was advised and accepted that he should not “chat” as he “can’t chat and work”. In addition, that he “must slow down, not talk and work, keep his focus”. During one meeting on 22 May 2014 the major concerns identified included the Registrant “Thinking [his] ability is greater than it is”. The Panel also took account of Witness 1’s evidence that the Registrant could perform satisfactorily but was inconsistent and that she had also recorded that there was “improvement with less failure to follow protocol and less lack of attention” at times.


65. However there was evidence that the Registrant knew what to do, and at times performed satisfactorily, but that whatever improvements there may have been they were not sustained and the inconsistencies in his practise as identified by Witness 1 were continued over the whole period with which the Panel is concerned.


66. It was the judgement of the Panel that this behaviour fell seriously below the standards expected of a Band 5 BMS in the circumstances and that this amounted to misconduct.


67. In reaching this conclusion, the Panel considered that the following ‘Standards of Conduct, Performance and Ethics’ were breached:
- 1, 2, 5, 6, 7, 8 and 10.


68. In addition, the Panel had regard to the ‘Standards of Proficiency for Biomedical Scientists’, applicable at the time of the allegations, and considered that the following standards were breached:
- 1a.5, 1a.6, 1a.8, 1b.2, 1b.3, 2a.1, 2a.2, 2a.3, 2a.4, 2b.2, 2b.4, 2b.5, and 3a.1.


69. The Panel did not consider whether the Registrant’s actions amounted to lack of competence in light of its findings on misconduct, in accordance with the way in which Ms Acker had put her case on behalf of the HCPC.

70. In addition, the Panel has taken into account the fact that there were repeated errors, across a range of procedures, over an extended period of time, involving multiple patients. The Panel also concludes that these errors to some extent harmed (as in Patient N) or could have harmed patients by way of treatment that was delayed or incorrect unless other professionals intervened. The Panel took into account the support and assistance given to the Registrant.  The Panel noted that one of the particularly serious allegations (Particular 3) involving the misreporting a test in result indicative of leukaemia occurred last in time of all the particulars alleged, even after the Registrant had been supported, assisted and indeed warned.  

 
Decision on impairment


71. The Panel accepted the advice of the legal assessor who addressed the Panel on the meaning of impairment and referred to the case of Grant (Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (20 Paula Grant [2011] [EWHC 927]).


72. The Panel found that in failing to record, in attaching incorrect patient information, in authorising incorrect results, in failing to take appropriate action when samples returned abnormal results, and in failing to follow laboratory’s standard operating procedures the Registrant had put patients at risk.


73. Further the Panel concluded that this repeated behaviour posed a risk to the reputation of the profession and of the HCPC as its regulator, as members of the public would rightly expect better standards from a member of the profession. The Panel also concluded that this repeated behaviour risked undermining the standards expected of Biomedical Scientists.


74. The Panel has not received any communication from the Registrant regarding his current circumstances, or any evidence of remediation or developments in his insight.


75. Accordingly Panel found the Registrant’s fitness to practise to be currently impaired by reason of his misconduct.

Sanction


76. In considering what sanction, if any, to impose, the Panel accepted the advice of the Legal Assessor and referred to the Indicative Sanctions Policy.

77. The Panel bore in mind that its purpose was not to be punitive, but to protect the public interest. It understood that it must act proportionately, balancing the interests of the Registrant with those of the public. It considered the range of available sanctions in ascending order of seriousness, starting with the option of taking no action.


78. The Panel found, by way of mitigation, that the Registrant had no previous findings against his name, and that this had been his first job as a BMS.

79. The Panel found, by way of aggravating factors, in addition his failings impacted adversely on other professionals and involved multiple patients that the misconduct amounted to serious failings that had posed an obvious risk to service users and had continued over a substantial period of time.


80. The Panel concluded that the Registrant had shown some insights and remorse. Contemporaneous notes of meetings and his own reflective learning records record his understanding of his errors and there potential consequences. However, the Panel is clear that whatever insight he did have and however willing he may have been, his efforts to perform consistently to the required standard did not translate into sustained improvements to his practise.  This remained the case even over the lengthy period with which the panel is concerned during which he was supported and assisted in various ways.


81. The Panel has therefore concluded that the evidence shows that the Registrant is unable to resolve or remedy his failings.


82. In view of the seriousness of the case, to take no further action or to impose a caution order would not be sufficient to protect the public, maintain confidence in the profession and maintain confidence in the regulatory process.


83. The Panel concluded that Conditions of Practice would be inappropriate as the risk of recurrence was too high and the Panel has no evidence that the Registrant would be willing now to abide by any conditions the Panel might seek to impose. In any event the Panel concluded that it is not realistic to impose conditions in this case given the wide range of failings identified in his practise.


84. The Panel gave careful consideration to a Suspension Order. The difficulty that the Panel faced was that that Registrant had not provided any evidence of remediation, and the misconduct stretched over a long period of time. In all the circumstances the Panel concluded that the risk of repetition of misconduct in this case was high and that the Registrant’s conduct was too serious for such a sanction.


85. In those circumstances the Panel concluded that a Striking-off Order was the only appropriate order. Such an order was necessary due to the seriousness of the misconduct, the lack of adequate remediation, as set out above, and the consequent risk of repetition. The Panel had no confidence that the Registrant would not repeat his misconduct. His actions had had the potential to cause serious harm to service users and this outweighed any interest of the Registrant to pursue a career as a Biomedical Scientist. The Panel understood that a striking off order was the most serious of all sanctions. However, it was the judgment of the Panel that this was the appropriate sanction in all the circumstances of the case for the protection of the public and otherwise in the public interest.

Order

Order: That the Registrar is directed to strike the name of Mr Samuel James
Eldridge from the Register on the date this Order comes into effect.

The Order imposed today will apply from 26 May 2016.

Notes

The Panel makes an Interim Suspension Order under Article 31(2) of the Health and Social Work Professions Order 2001, the same being necessary to protect members of the public and being otherwise in the public interest.  This order will expire: (if no appeal is made against the Panel’s decision and Order) upon the expiry of the period during which such an appeal could be made; (if an appeal is made against the Panel’s decision and Order) the final determination of that appeal, subject to a maximum period of 18 months.

Hearing History

History of Hearings for Mr Samuel James Eldridge

Date Panel Hearing type Outcomes / Status
27/04/2016 Conduct and Competence Committee Final Hearing Struck off
26/02/2016 Conduct and Competence Committee Interim Order Review Interim Suspension
10/09/2015 Investigating committee Interim Order Application Interim Suspension