Patricia E Beck

Profession: Physiotherapist

Registration Number: PH50302

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 01/03/2016 End: 17:00 01/03/2016

Location: 405 Kennington Road, London, SE11 4PT

Panel: Health Committee
Outcome: Not well founded

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Allegation

By reason of your physical and/or mental health, your fitness to practise as a Physiotherapist is impaired

Finding

Preliminary matters:

1. There was no application for these matters to be heard in private.

Background:

2. On 30 November 2015, a Panel of the Conduct and Competence Committee completed the factual stage of the case against Registrant. The above allegation was then referred to the Health Committee of the HCPC pursuant to Rule 4(1) of the Conduct and Competence Committee Rules.
Allegations found proved before the Panel of the Conduct and Competence Committee on 30 November 2015:

During the course of your practice as a Physiotherapist with the Central North West London Foundation Trust during the period of 1 April 2000 to 4 September 2012:

1.  On 4 September 2012, you undertook a treatment session with Patient A and:
(a) [NOT ADMITTED and NOT PROVED];
(b) You did not record your clinical reasoning for administering the treatment [ADMITTED and FOUND PROVED]
(c) [NOT ADMITTED and NOT PROVED];
(d)  You did not assess Patient A prior to commencing treatment and/or did not record an assessment [ADMITTED and FOUND PROVED IN PART];
(e)  [NOT ADMITTED and NOT PROVED].
2. During the period December 2011 - June 2012, you provided physiotherapy treatment to Patient A and:
(a)  You did not record a treatment plan for Patient A [ADMITTED and FOUND PROVED];
(b)  [NOT ADMITTED and NO CASE TO ANSWER]
(c) You did not communicate your treatment plan for Patient A to Patient A’s parents [ADMITTED and FOUND PROVED].
3. Subsequent to the events described in points 1 and 2 an audit of your caseload was undertaken, and it was found that you:
(a)  In the case of Patient G;
(i) Did not conduct and/or record a full assessment on the first visit to the child alone [ADMITTED and FOUND PROVED IN PART];
(ii) Did not validate records on RiO [NOT ADMITTED but FOUND PROVED];
(iii) Did not routinely record the treatment goals for Patient G [ADMITTED and FOUND PROVED];
(iv) Did not record a timeframe for Patient G’s goals [ADMITTED and FOUND PROVED];
(v) Did not record what the plans for the next treatment session would be [ADMITTED and FOUND PROVED];
(vi) Did not enter objective markers in case notes [ADMITTED and FOUND PROVED];
(vii) [NOT ADMITTED and NO CASE TO ANSWER]; and
(viii) Made two entries on RiO for the same visit on 3 July 2012 which were almost identical but entered an hour apart [ADMITTED and FOUND PROVED].
(b) In the case of Patient S;
(i) Did not conduct and/or record a full assessment on the initial visit [ADMITTED and FOUND PROVED IN PART];
(ii) Did not validate records on RiO [NOT ADMITTED but FOUND PROVED];
(iii) [NOT ADMITTED and NO CASE TO ANSWER];
(iv) In the case notes for a treatment session held on 24 April 2012, did not finish a sentence [ADMITTED and FOUND PROVED] ; and
(v) Did not enter objective markers in the case notes [ADMITTED and FOUND PROVED].
(c) Subsequent to the events described in points 1 and 2 an audit of your caseload was undertaken, and it found that you:
(i) [ADMITTED but NO CASE TO ANSWER]
(ii) – (xiv) [NOT ADMITTED and NO CASE TO ANSWER]
(d) In June 2012 prior to going on 6 weeks' annual leave, you did not provide a handover of your caseload, contrary to management instruction in that you provided this on or around 27 July 2012 [ADMITTED and FOUND PROVED].
4. [NOT ADMITTED and NO CASE TO ANSWER]
5. The matters set out in paragraphs 1-4 constitute misconduct and/or lack of competence.
6. By reason of your misconduct and/or lack of competence your fitness to practise is impaired.

3. The Registrant is a Physiotherapist whose expertise within her profession is in working with children with movement difficulties, particularly those with Cerebral Palsy. She qualified in 1992. At all material times, the Registrant was employed by the Central and North West London NHS Foundation Trust (“the Trust”). During the course of that employment, she underwent dyslexia assessment in 2009 and was diagnosed with dyslexia. She underwent an Access to Work assessment in 2011 after which she was provided with a laptop computer, a dictaphone and a computerised speech recognition system with the aim of facilitating the preparation and recording of notes.

4. On 4 September 2012 the Registrant undertook a treatment session with Patient A at the patient’s home address in the presence of A’s father. As a result of events which occurred during this session, the Trust carried out an investigation into aspects of the Registrant’s practice. The Registrant was subsequently dismissed by the Trust who referred her to the HCPC.

5. At the start of proceedings on 23 November 2015, the Registrant made admissions to 10 of the particulars. The evidence on most of the allegations was so unreliable and not credible that that Panel found there was no case to answer on four of the remaining particulars and six others were found not proved, despite the Registrant’s admissions to some of them.

6. The Panel on that occasion found that the particulars proved were either directly or indirectly linked to the Registrant’s dyslexia. It then, of its own volition, invited further submissions from the parties as to whether or not it should refer this matter to the Health Committee.

7. That Panel firstly considered whether a striking-off order was a possible outcome of the case taking all the circumstances into consideration. It determined that a striking-off order was not a possible outcome in this case. In coming to this conclusion, it took into consideration that “there were no remaining concerns regarding the Registrant’s clinical practice and that she appears to have good insight and understanding of the consequences of her condition insofar as they relate to her ability to maintain accurate and comprehensive records and otherwise manager her work. She appeared to be genuinely remorseful for any adverse effects.”

8. That Panel also took into account the following managerial failings on the part of management at the Trust in that whilst the Registrant was willing to work to develop her ability to manager her dyslexia:

• The opportunity for her to do so during the course of her employment at the Trust had been limited.

• No action appears to have been taken between the diagnosis of dyslexia in 2009 and the assessment for Access to Work support in July 2011.

• The measures recommended in the assessment of July 2011 took over a year to implement and it was not until the Registrant returned from leave on 4 September 2012 that all the features were in place.

• During the period September 2012 to January 2013, the Registrant was under considerable stress as a result of the ongoing Trust investigation.

• The medical expert’s opinion was that the work-related dyslexia training of five two-hour sessions fell significantly short of what was actually required.

9. That Panel also noted the medical expert’s opinion that with appropriate counselling and support, time and commitment from the Registrant, she was capable of developing effective techniques to manage her condition.

10. In light of all of the above, and its finding the remaining allegations were either directly or indirectly linked to the Registrant’s dyslexia. The Panel on 30 November 2015 determined that it was appropriate for this matter to be referred to the Health Committee.

The Hearing today:

11. The matter is now before this Panel of the Health Committee and the allegation before it is as follows:

Allegation:

By reason of your physical and/or mental health, your fitness to practise as a Physiotherapist is impaired in that you suffer from dyslexia ICD-10CMR48.0

12. It is accepted by Miss Beck that she suffers from dyslexia. Miss Beck does not accept that her fitness to practise is impaired by reason of dyslexia.

13. The representatives for both the HCPC and the Registrant accepted that both the background to the allegations before the Panel of Conduct and Competence Committee on 30 November 2015, and also that Panel’s determination on the facts of those allegations, form the factual basis upon which this Panel of the Health Committee is to determine whether or not the Registrant’s fitness to practise is impaired by reason of her dyslexia.

14. In his opening, Mr Walters submitted that there were three possible outcomes to today’s hearing, and that they were:

a. The Panel makes a finding that the Registrant’s fitness to practise is impaired by reason of her health condition and then goes on to dispose of the case by way of imposition of a sanction;

b. The Panel makes a finding that the Registrant’s fitness to practise is not impaired by reason of her health condition and remits the case back to the Conduct and Competence Committee; or

c. The Panel makes a finding that the Registrant’s fitness to practise is not impaired by reason of her health condition but considers that no further action is required in relation to the Registrant. If this were the case, then this Panel of the Health Committee will certify that it has dealt with the allegation and that no further action on the part of the Conduct and Competence Committee is required in relation to the allegation.

15. The Panel heard oral evidence from Professor McLoughlin as an expert witness, and the Registrant. The Panel found both witnesses to be credible, measured, honest and reliable.

16. Professor McLoughlin told the Panel that in his opinion the Registrant has “turned a corner since last November”. He said that now she is more positive, more relaxed and is responding well to input from Dr Kirwan.

17. Professor McLoughlin said that his position from the last hearing has not changed in that his opinion is that a period of a year would be a reasonable timeframe in which an improvement might be seen. He said that in the interim, what can be done includes providing opportunities for the Registrant and reducing her caseload. He stated that this does not automatically resolve the report writing difficulty.

18. In response to questions, Professor McLoughlin stated that, in principle, what he was describing was similar to a ‘phased return to work’ and the difference was the control the individual has over his/her caseload. He stated he has not changed his opinion that if the Registrant returned to work within a NHS situation, she is unlikely to cope with the pressures in that environment. He also stated that dyslexia was a genetic condition and the Registrant would have had the condition all her life and throughout her career. He told the Panel that he agreed with the Registrant’s evidence that she had long standing problems with time management, organisation, and paper work. Her regular sessions with the dyslexia coach were helping her to devise strategies so that she could manage the impact of her dyslexia.

19. The Registrant gave evidence on oath and she set out in detail, to the Panel, the coping mechanisms that she now has in place to deal with her difficulty in remembering to carry out tasks and the location of items. This included a demonstration of her use a daily journal and her iPad. She also demonstrated how it eliminated the various intermediary steps that she encountered with the “reasonable adjustments” implemented at the Trust. She stated that in the past she compensated for what must have been the impact of her dyslexia by taking extra time to complete the tasks and to look for the information required. However, the changes in her circumstances in 2009 to 2011 meant that she had less time to be able to compensate for her difficulties and this led to her poor standard of her record-keeping. She stated that she accepted her record-keeping at the time was deficient and that she was deeply embarrassed by the standard of her paperwork.

20. The Registrant stated that if allowed to return to practice now, unrestricted or otherwise, she would not go back immediately to autonomous practice in any event. She recognised that having not practised since 2013, she needs to ease herself back into working as a physiotherapist so as to rebuild her confidence in herself and to ensure that she is working at the standard expected of a competent physiotherapist. She is aware that she is currently not suited to working in a pressurised environment such as the NHS since she is still learning to work at speed with her coping mechanisms. She recognises that it is unrealistic for her to return to such an environment and that she has no intention of doing so in the short term, if at all.

21. The Registrant told the Panel that, in light of the above, she is currently in the final stage of complete a Personal Trainer qualification with the YMCA which has involved study over a number of months and submission of course work to a particular timetable. She also told the Panel that as a personal trainer she also deals with paperwork, and this helps her practice the coping processes which she has in place to manage her time.

22. The Registrant stated that she now realises that her dyslexia was exacerbated by the lack of support from her managers, and the hostility with which she was treated by Witness 3 (employed by Royal Free Hospital London) at work. She accepts that at the time she was unable to recognise the ‘triggers’ which exacerbated her dyslexia leading to her poor performance. She stated that now, through her sessions with Dr Kirwan and Professor McLoughlin, she is able to identify such triggers and bring coping strategies to bear.

23. The Registrant gave evidence to the Panel about the reaction of disbelief on the part of her manager, Witness 3, with regard to the diagnosis her dyslexia, and how the hostile manner in which Witness 3 had continued to treat her meant that the Registrant’s confidence was very poor by the time she left the Trust. The Registrant stated that even with the diagnosis of dyslexia at that time, she (the Registrant) did not fully understand what having dyslexia meant or the difference that the coping strategies, which she now employs, could make.

Submissions:

24. The Panel heard submissions from both Mr Walters on behalf of the HCPC and Miss Gallafent QC on behalf of the Rregistrant.

25. Mr Walters, on behalf of the HCPC, submitted that the first matter to be considered is whether the health condition is made out in evidence. He submitted this is established on the evidence of both the Registrant and Professor McLoughlin and that it is an agreed fact between the parties.

26. Mr Walters stated that the only issue in relation to the Registrant’s practice is her record-keeping. He submitted that record-keeping is a crucial aspect of being a Physiotherapist and the impact of poor record-keeping is to put patients at risk of harm.

27. Mr Walters submitted that the evidence is such that the Panel cannot be satisfied that the Registrant has remediated her shortcomings in her recordkeeping. He accepted that she was in the process of remediating her shortcomings but in the absence of full remediation, the Panel could not be satisfied that there would not be a repetition of these matters if faced with a similar situation as she faced in 2011. He submitted that in these circumstances, the Registrant’s fitness to practise is currently impaired by reason of her dyslexia.

28. Miss Gallafent, on behalf of the Registrant, drew the Panel’s attention to the following authorities:

a. Meadow v GMC [2006] EWCA Civ 1390
b. Cohen v GMC [2008] EWHC 581 (Admin)

29. Miss Gallafent also drew the Panel’s attention to the Practice Note issued by the HCPC entitled Finding that Fitness to Practice is “Impaired”. She submitted that the Panel should take into consideration that the circumstances which led to this matter being referred to the HCPC were a combination of unique situations which did not apply today. She submitted that the unique situations included:

a. The Registrant had very young children at the time and this limited the amount of time the Registrant could allocate to dealing with the shortcomings in her record-keeping;

b. There was the death of a close family member which added to the stress that the Registrant was under and which exacerbated the effects of her dyslexia;

c. The Registrant did not understand the full implications of having dyslexia and she did not have coping strategies she could deploy;

d. The ongoing poor management by her line manager, who had reacted to the assessment of dyslexia with continued ‘disbelief’ and who believed that the Registrant was someone who “should be sat on from on high”;

e. The fact that recommendations for reasonable adjustments were not implemented until 14 months later and when the Trust’s investigation was near conclusion;

f. The fact that the Registrant was not given a reasonable time to become acquainted with working with the adjustments in that she was suspended shortly after the recommendations of reasonable adjustments were fully implemented.

30. Miss Gallafent submitted that the risk of harm from poor record-keeping in this context is limited. She pointed out that the finding of the previous Panel was that no harm had resulted because the Registrant would give an oral handover where required. Miss Gallafent further submitted that the risk of harm is limited because the practice of physiotherapy is such that each practitioner, when starting each session, must carry out their own assessment of the patient before commencing therapy. She submitted that the practice of physiotherapy is different from the practice of medicine and/or nursing where subsequent practitioners are heavily dependent upon the patient notes and the recording therein of what treatment had been administered prior. She pointed out the previous Panel found, when dismissing particular 1(c), that “the registrant was an autonomous practitioner and would have been responsible for forming her own view about the suitable treatment for Patient A on the day of her visit. She would not be constrained by any treatment plan prepared previously by herself or another practitioner.” In essence responsibility for any subsequent treatment lay with the physiotherapist administering that treatment.

31. In relation to remediation, Miss Gallafent submitted that the decision in Cohen should not be read as requiring any shortcomings to be remedied in full by the time a Panel came to consider the issue of impairment. She submitted that the Panel should consider whether the shortcomings were capable of being remedied when considering impairment. Whether or not the shortcomings have been remedied or are in the process of being remedied is a consideration to be taken into account when considering the risk of repetition of the circumstances leading up to these matters being referred to the HCPC.

Decision on Impairment

32. The Panel accepted the advice of the Legal Assessor. In particular, he advised that the background facts, and findings of the previous Panel of the Conduct and Competence Committee were integral to this Panel’s consideration of the Registrant’s fitness to practise. This is because they form the basis upon which the HCPC today brings the allegation of impairment due to health.

33. The Panel reminded itself of the decision in Cohen and considered that it applied in this case in that the task of the Panel today is:

a. to take account of the fact that the Registrant has dyslexia and the causes and stressors that led to these matters being referred to the HCPC; and then

b. to consider in the light of all the other relevant factors known and presented to the Panel today whether the Registrant’s fitness to practice is impaired by reason of her dyslexia.

34. The Panel is also aware that when carrying out the task outlined above, some of the highly relevant factors are:

a. Whether the shortcoming in the Registrant’s record-keeping due to dyslexia is easily remediable by means of reasonable adjustments or coping mechanisms and/or processes;

b. Whether reasonable adjustments have been put in place and/or the Registrant has taken remedial steps such that the shortcomings have been or are, realistically, in the process of being remediated; and

c. Whether the shortcomings are highly unlikely to be repeated if the same or similar circumstances were encountered by the Registrant in the future.

35. The Panel first considered the circumstances leading up to these matters being referred to the HCPC. The Panel determined that the poor line-management of the Registrant by Witness 3 significantly contributed to the stress imposed upon the Registrant. In particular it noted the following:

a. The decision of the Panel that dealt with the facts of this case. That Panel heard the evidence of Witness 1, 2 and 3. In its decision it stated “Evidence was called by the HCPC from witnesses 2, 3 and 1. The Panel considered that witnesses 2 and 1 were credible and reliable witnesses. Neither was directly involved in the events of 4 September 2012, nor with the clinical supervision of the Registrant at the time...”

b. The responses of Witness 3 during an interview conducted when the matter was being investigated by the Trust:

i. When Witness 3 was asked how she felt when she found out the Registrant had an identifiable condition that explained the difficulties she was having, Witness 3’s response was, “Disbelieving, I have never met anyone who can develop this midlife. All of her career she will have needed to fill out paperwork.”

ii. When Witness 3 was asked whether she thought there was anything more she could have done to support the Registrant, she replied, “Personally no. This was someone who needed sitting on from a great height....”

36. The Panel determined the Registrant was not given any reasonable opportunity to demonstrate that she was able, with reasonable adjustments, to practise competently as a Physiotherapist, despite her dyslexia. It further determined that the following factors were such that the prevailing situation at that time meant that the Registrant would fail and through no fault of her own:

a. The failure of the Trust to implement the reasonable adjustments recommended by the Access to Work Assessment report in 2011. The Panel considers that 14 months is an unreasonably long time for the Trust to comply with its statutory duty.

b. The expert opinion of Professor McLoughlin that even when the equipment recommended by the 2011 report was finally put in place, the training the Registrant received as to the use of the technology was insufficient.

c. By the time the reasonable adjustments were put in place, the Trust investigation was already nearing conclusion. The adjustments were finally in place in September 2012 and the Registrant was suspended in January 2013.

d. The failure of the Registrant’s line manager to take seriously the dyslexia assessment in 2009. The Panel determined that Witness 3’s hostile attitude towards the Registrant was evidenced by the Registrant’s testimony and was corroborated by Witness 3’s own comments recorded in the Trust’s investigatory interview. The Registrant’s evidence is that Witness 3 objected to an Access to Work Assessment taking place which may, or may not, explain why it was not until July 2011 that the report was produced.

37. The Panel reminded itself that dyslexia is a recognised condition under the Equality Act 2010 and employers are under a duty, once put on notice of the condition, to ensure that a person suffering from dyslexia is not treated unfavourably and is offered reasonable adjustments or support.

38. The facts of this case are such that there is no evidence before the Panel that Miss Beck would not be able to carry out her role as a Physiotherapist competently if she were employed by a reasonable employer, who having been put on notice of her condition, would ensure that she was not treated unfavourably and that she was offered reasonable adjustments or support.

39. The Panel also determined that the circumstances in which the Registrant found herself with regard to her employment were so unsupportive that it would not be fair nor just to consider whether her fitness to practise, or for that matter, any other Registrant’s fitness to practise, would be impaired if faced with similar circumstances again. 

40. The Panel took into consideration the fact that dyslexia is a genetic condition and that the Registrant must have had dyslexia all her life and her career. It also took into account the Registrant’s long employment history with no referrals of any kind.

41. The above alone would justify a finding that the Registrant’s fitness to practise was not impaired. However, the Panel did not base its findings on the above alone.

42. The Panel considered that the Registrant has shown significant insight into her condition, the effect of stress on her and the limitations her condition imposes on her practice currently. This is supported by the finding of the previous Panel, which also heard her on oath, that the Registrant “has good insight and understanding of the consequences of her condition insofar as they related to her ability to maintain accurate and comprehensive records and otherwise manage her work.”

43. The Panel is satisfied that the Registrant recognises that she currently is not suited to working in a pressurised environment. She has outlined to the Panel her plans for the future which takes that into account. The Panel found the Registrant to be honest, sincere and realistic in her self-assessment of her condition, her abilities and her plans for the future. This is in line with, and supported by, the expert’s evidence. She has demonstrated that she understands the importance of continuing professional development and of accurate record-keeping. The Panel accepts her testimony that she will not go into an NHS environment or any other stressful environment in the short term, if at all.  She has put coping mechanisms in place to assist her with her dyslexia which are working and which are constantly being refined with the assistance of Dr Kirwan, who is a specialist dyslexia coach.

44. The Panel is aware that good record-keeping is the bedrock of any profession. However there is no evidence before the Panel that the Registrant is liable to breach this requirement if she were employed by a reasonable employer.

45. The Panel recognises, as did the previous Panel, that the practice of physiotherapists is such that each practitioner is autonomous. Whilst they should have regard to the notes of the previous practitioner, where appropriate, they are not bound by such notes. They are however, required to carry out their own assessment of a patient on the day itself before beginning treatment and apply the appropriate treatment, based on their own assessment. The notes of the previous practitioner, whilst they may be of assistance, are not of primary importance.

46. Taking into consideration all of the above, the Panel determined that public confidence in the profession and in the regulatory process would not be undermined by a finding of no impairment. It follows that the Panel determines that the Registrant’s fitness to practise is not currently impaired.

47. The Panel finds that the allegation is not well founded.

48. Pursuant to Rule 4(3) of the Conduct and Competence Committee Rules, this Panel of the Health Committee certifies that it has dealt with the allegation referred to it, and that no further action by the Conduct and Competence Committee is required in relation to the allegation remaining before that Committee.

 

 

Order

The Panel decided that the case was not well founded at the impairment stage of the process.

Notes

This was a Health Committee hearing held at the HCPC on the 01 March 2016.

Hearing History

History of Hearings for Patricia E Beck

Date Panel Hearing type Outcomes / Status
01/03/2016 Health Committee Final Hearing Not well founded