Mrs Jane M Little

Profession: Radiographer

Registration Number: RA27652

Interim Order: Imposed on 14 Dec 2015

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 16/01/2017 End: 17:00 18/01/2017

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

Panel: Conduct and Competence Committee
Outcome: Suspended

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Allegation

During the course of your employment as a Radiographer for Blackpool Teaching Hospitals NHS Foundation Trust,

 

1. On 15 May 2014, Patient 1 attended for a Multi Gated Acquisition

(MUGA) scan, and:

 

a. you did not scan Patient 1's heart

 

b, you did not record the reason for poor diagnostic images

 

2. On 8 October 2014, you injected Patient 2 with the wrong

radiopharmaceutical

 

3. On 12 February 2015, you did not follow the correct procedure for a Glomerular Filtration Rate (GFR) test in relation to Patient 3

 

4. On 28 January 2015, Patient 4 attended for an adenosine test and:

 

a. you did not ensure that the adenosine infusion had been correctly

inserted into the infusion pump, and;

 

b. you administered an unmeasured volume of adenosine

 

5. On 2 July 2015, during a clinical assessment of myocardial perfusion involving a stress test, you did not check the calibration factor set and/or attempt to calculate the dose accurately in the cases of:

a. Patient 6

b. Patient 7

c. Patient 8

d. Patient 9

 

6. Your actions as set out in paragraphs 1- 5:

 

a. Exposed patients to unnecessary radiation, and/or

 

b. Demonstrated unsafe clinical practice.

 

7. The matters as described in paragraphs 1 - 6 constitute misconduct and/or lack of competence.

 

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

Finding

Background:

1. The Registrant was employed as a Band 7 Radiographer at Blackpool Teaching Hospitals NHS Foundation Trust [“the Trust”]. At the time of the matters giving rise to the Allegation, the Registrant was the Deputy Nuclear Medicine Manager.

2. Between October 2014 and July 2015, a number of incidents occurred which gave rise to concerns about the Registrant’s ability to practise safely. Several patients treated by the Registrant, were either administered the wrong dosage of intravenous radiopharmaceutical drugs or the correct clinical procedures were not followed. It is alleged that the Registrant failed to carry out tasks appropriately, resulting in patients and others being exposed to unnecessary radiation. 

Decision on Facts:

3. The Panel heard oral evidence from two witnesses called on behalf of the HCPC. Witness VH was the Nuclear Medicine Manager and witness HD was a Band 6 Radiographer in the Nuclear Medicine Department at the Hospital.

4. The Panel considered that both the witnesses called on behalf of the HCPC gave credible and balanced evidence. The Panel found that VH had attempted to assist the Registrant by discussing each matter of concern with her following each incident. The Panel found that HD gave an open and honest account. The Panel found the Registrant’s evidence was at times inconsistent and sometimes evasive in that she showed reluctance to accept responsibility for her actions and attempted to shift responsibility onto her work colleagues.

5. The Panel had regard to all of the documentary evidence comprising of a main bundle including the witness statements and a bundle of exhibits. The Panel also received a bundle of documents from the Registrant. The Panel heard submissions from Ms Eales and the Registrant. The Panel received and accepted the advice of the Legal Assessor.

6. The Panel made the following findings of fact:

Particulars 1(i) and (ii) – Proved

7. The Panel accepted the Registrant’s admissions to these Particulars. The Panel also had regard to the incident report headed “Incident which occurred on the 8 October 2014”, in which it is recorded that the Registrant came in and announced that “she had done something really stupid”. The Registrant told VH that she had injected Myoview instead of HDP into a patient booked in for a bone scan. Further, in relation to Particular 1(a), the Panel accepted the evidence of witnesses VH and HD that the Trust’s policy clearly requires a second radiographer to check and sign the administration sheet. In relation to Particular 1(b), the Panel noted that Patient 2 had to be recalled to the hospital for checks and a further scan as a result of the Registrant’s error. This caused unnecessary delay in the patient’s care.

Particulars 2(i) and (ii) – Proved

8. The Panel had regard to the oral evidence of VH which was supported by the contents of her witness statement and VH’s letter to the Registrant following their meeting on 6 March 2015. It was clear that a blood test was not taken from the Patient prior to the administration of the radiopharmaceutical which was contrary to the policy and procedure for a GFR test. Further, no evidence of a completed administration sheet was provided. The Registrant accepted in her evidence that she did not take a pre tracer blood sample as per the protocol, nor did she complete the administration sheet for the GFR test.

9. The Panel was satisfied that the correct procedures for a GFR test were not followed. The Panel accepted that AL, who was another Radiographer present at the procedure, was there as an observer and not to carry it out. The Panel considered that as the Band 7 Radiographer and unit Deputy Manager, the Registrant should have taken control and ensured that the correct procedures were followed.

Particulars 3a) and 3b) – Proved

10. In relation to Particular 3a), the Panel accepted HD’s evidence that she was present in order to undertake an audit and was the second Radiographer, whilst the Registrant was acting as the stress leader. HD was therefore not responsible for ensuring the adenosine tubing had been correctly inserted into the infusion pump. The Panel also accepted HD’s evidence that she never assumed that responsibility which remained with the Registrant, who placed the bag onto the stand.

11. In relation to Particular 3b), the Panel noted that HD reported the incident immediately and in her oral evidence was able to give a vivid and consistent account of the temporary adverse reaction experienced by Patient 4. The Registrant also accepted in her own evidence that a small amount of adenosine could have been administered to Patient 4.

Particulars 4a) – 4d) – Proved

12. The Panel accepted the Registrant’s admissions to these Particulars. The Panel also noted that these facts are also supported by the documentary evidence in the form of the Trust’s incident reports. The Panel regarded the extent of the inaccurate doses to be immaterial as to whether or not the Registrant had checked the calibration factor settings or calculated the radiopharmaceutical doses.

Particulars 5(a)  and 5 (b) – Proved

13. The Registrant admitted these Particulars. The Panel was satisfied that by injecting a wrong radiopharmaceutical and incorrect dosages, the Registrant had exposed patients to unnecessary radiation. The Panel was also satisfied that the Registrant’s actions in relation to all matters found proved, demonstrated unsafe clinical practice.  The Panel found Particular 5a) proved in relation to paragraphs 1 and 4 only, as Particulars 2 and 3 did not relate to exposure to radiation. The Panel found Particular 5b) proved in relation to paragraphs 1-4.

Decision on Grounds:

14. The Panel was satisfied that the Registrant breached the following Standards of conduct, performance and ethics:

1 You must act in the best interests of service users


7   You must communicate properly and effectively with service users and other practitioners

And the following Standards of Proficiency for Radiographers:

1.1    know the limits of their practice and when to seek advice or refer to another professional
 
2.1    understand the need to act in the best interests of service users at all times
 
3.1   understand the need to maintain high standards of personal and professional conduct
 
4.1    be able to assess a professional situation, determine the nature and severity of the problem and call upon the required knowledge and experience to deal with the problem
 
4.4    recognise that they are personally responsible for and must be able to justify their decisions

8.1  be able to demonstrate effective and appropriate verbal and non-verbal skills in communicating information, advice, instruction and professional opinion to service users, colleagues and others
 
12.3  understand the principles of quality control and quality assurance as they apply to the practice of diagnostic or therapeutic radiography

13.2 understand the concept of leadership and its application to practice

14.20 be able to check that equipment is functioning accurately and within the specifications, and to take appropriate action in the case of faulty functioning and operation

15.2 be aware of applicable health and safety legislation, and any relevant safety policies and procedures in force at the workplace, such as incident reporting and be able to act in accordance with these

15. The Panel considered that the Registrant, as a Band 7 Deputy Manager, must have been aware of the required standards and knew that she had breached them. The Panel considered these to be serious breaches which amounted to misconduct but did not amount to lack of competence.

Decision on Impairment

16. The Panel was satisfied that the Registrant’s misconduct had put her patients at unwarranted risk of harm by exposing them and others to unnecessary radiation and by demonstrating unsafe practice. The Panel was also satisfied that the Registrant had brought her profession into disrepute and had breached fundamental tenets by failing to act in the best interests of her patients.

17. Whilst the Panel accepts that the Registrant has belatedly demonstrated some insight, it was not presented with appropriate evidence of remediation such as further courses or supervision. Additionally, the Panel found that the Registrant has failed to demonstrate sufficient insight into the substantial risks to service users, the public and the Service as a whole as a result of her disregard for the Trust’s policies and procedures, in the context of nuclear medicine.

18. Taking all matters into consideration, the Panel was satisfied that reasonable members of the public would be alarmed if the Registrant was allowed to continue to practise as a Radiographer unrestricted. The Panel concluded that public confidence in the profession and its Regulator would be undermined were a finding of impairment not made.

19. For all these reasons, the Panel found that the Registrant’s fitness to practise is currently impaired by reason of her misconduct.

Decision on Sanction:

20. The Panel considered the submissions made by Ms Eales on behalf of the HCPC. The Panel received and accepted the advice of the Legal Assessor.

21. The Panel was mindful that the purpose of any sanction was not to punish the Registrant but to protect the public and maintain public confidence in the profession and the HCPC as its regulator, by the maintenance of proper standards of conduct and behaviour.

22. The Panel had regard to the Indicative Sanctions Policy. The Panel applied the principle of proportionality by weighing the Registrant’s interests with the public interest and by considering each available sanction in ascending order of seriousness.

23. The Panel had regard to paragraph 9 of the Indicative Sanctions Policy which states,
 "Even if a Panel has determined that fitness to practise is impaired, it is not obliged to impose a sanction. This is likely to be an exceptional outcome but, for example, may be appropriate in cases where a finding of impairment has been reached on the wider public interest grounds identified above but where the registrant has insight, has already taken remedial action and there is no risk of repetition".

24. In deciding whether to impose any sanction, the Panel had regard to paragraph 14 of the Indicative Sanctions Policy which states,
 "The degree of insight displayed by a registrant is central to a proper determination of whether fitness to practise is impaired and, if so, what sanction (if any) is required. The issues which the Panel need to consider include whether the registrant: 
• has admitted or recognised any wrongdoing;
• has genuinely recognised his or her failings;
• has taken or is taking any appropriate remedial action;
• is likely to repeat or compound that wrongdoing.”

25. Having carefully considered the above paragraphs of the Indicative Sanctions Policy, the Panel concluded that given its findings of misconduct, and current impairment, a sanction was required in the public interest, to mark the seriousness of the matter.

26. The Panel considered the fact that the Registrant’s misconduct adversely affected seven different patients over a 10 month period of time, to be an aggravating factor. The Panel regarded the Registrant’s previous practice as a Radiographer over a period of 26 years without incident and her engagement with these proceedings as mitigating factors.

27. The Panel considered the available sanctions in ascending order of seriousness and concluded that taking no action or a Caution Order would be not be appropriate to mark the findings of misconduct and impairment.

28. The Panel next considered conditions of practice. The Panel bore in mind its findings that the Registrant was aware of the required standards and knew that she had breached them. The Registrant’s misconduct arose as a result of her disregard for policies and procedures and not because she was unable to perform her duties properly.

29. Further, the Panel was not provided with any information as to the Registrant’s current professional circumstances or her ability to comply with any conditions. The Panel was of the view that before any conditions could be formulated, the Registrant had to provide evidence that she had adequately reflected on the role and importance of policies and procedures in safeguarding the interests of patients and the public.

30. For these reasons, the Panel concluded that at this stage, a conditions of practice order would not be an appropriate or proportionate sanction.

31. In considering a suspension order, the Panel had regard to the seriousness of the matters found proved and to the number of patients whom the Registrant put at unwarranted risk of harm. The Panel also took into account the length of time over which the Registrant has practised as a Radiographer and that this was her first disciplinary matter.

32. The Panel was of the view that a Suspension Order would afford an opportunity to the Registrant to demonstrate to a review Panel that she has gained insight into the damage caused to her profession by her misconduct and to produce a reflective piece as to the role and importance of policies and procedures used in Radiography to safeguard the interests of patients and the wider public.

33. Given the potential mitigation and the prospect of remediation, the Panel was of the view that a striking off order was not necessary at this stage and would be disproportionate.

34. For all of the above reasons, the Panel determined that the appropriate and proportionate sanction was a Suspension Order for a period of 6 months. The Panel considered that the review Panel would be assisted by evidence of how the Registrant has maintained her knowledge and skills as a Radiographer by providing her CPD portfolio as well as the reflective piece referred to above.

Order

ORDER: That the Registrar is directed to Suspend the name of Jane M Little from the Register for a period of 6 months.

The order imposed today will apply from 15 February 2017 (the operative date).

This order will be reviewed again before its expiry on 15 August 2017.

Notes

No notes available

Hearing History

History of Hearings for Mrs Jane M Little

Date Panel Hearing type Outcomes / Status
11/04/2018 Conduct and Competence Committee Review Hearing Struck off
17/07/2017 Conduct and Competence Committee Review Hearing Suspended
13/02/2017 Conduct and Competence Committee Interim Order Review Hearing has not yet been held
16/01/2017 Conduct and Competence Committee Final Hearing Suspended