Ruth E Yorkston
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The following allegation was considered by a Panel of the Conduct and Competence Committee at the substantive hearing on 19 – 21 April 2016 and 18 – 19 April 2017
During the course of your employment as an Occupational Therapist for Tees, Esk and Wear Valleys NHS Foundation Trust between April 2010 and February 2012, you:
1) Did not demonstrate adequate clinical reasoning and/or skills in that you:
a) Were unable to demonstrate an adequate understanding of the MOHOST tool and/or its rating system.
b) Were unable to demonstrate an adequate understanding of the Mayers Lifestyle Questionnaire.
c) In relation to Case 1:
i) You did not specify height measurements in relation to a bath, toilet and/or bed; Not found proved
ii) You did not provide any/or adequate indication of whether the heights referred to at 1c)i) might pose a problem for the Service User post-surgery; Not found proved
iii) You did not contact the acute hospital about any help they could provide the Service User following her planned surgery. Not found proved
d) In relation to Case 3, on 25 October 2011 recorded a plan to visit the Service User for food shopping on 2 November 2011 but did not state why you had selected this activity in the notes.
e) In relation to Case 4, on or around 25 October 2011 you made an entry in the notes which was fragmented and/or did not make sense.
f) In relation to Case 5:
i) Your entry dated 19 October 2011 was unclear, in that it did not specify what further assessment was to be undertaken;
ii) On 1 November 2011, the information you recorded in relation to a cooking assessment of the Service User did not state how he managed the process and/or whether he was able to continue cooking for himself;
iii) Your entry relating to contact which took place on 9 November 2011 was unclear and/or fragmented.
g) In relation to Case 8:
i) Following a home visit on 25 November 2011 you noted that the Service User wanted to have his teeth removed but did not take any/any adequate steps to clarify whether this was a genuine need or a possible symptom of his mental health;
ii) Your plan, recorded following a home visit on 25 November 2011, did not adequately address the Service User’s needs.
h) In relation to an OT assessment you observed on 6 October 2011 you produced a reflective log but did not include all relevant information.
i) In relation to an OT assessment you observed on 19 October 2011 you produced a reflective log which did not include all relevant information.
2) Did not complete follow-up actions in that:
a) In relation to Case 1, you did not contact and/or did not adequately record your contact with the Service User's Care Coordinator as planned:
i) following a telephone conversation with the Service User on 3 November 2011;
ii) following a home visit to the Service User on 8 November 2011;
iii) until prompted in supervision on 17 November 2011.
b) In relation to Case 1, you did not make and/or record appropriate enquiries into the Service User’s potential vulnerability on:
i) 3 November 2011;
ii) 8 November 2011.
c) In relation to Case 2, having recorded a plan on 24 November 2011 to speak to the Service User’s Care Coordinator you:
i) did not contact and/or adequately record contacting the Care Coordinator in a timely manner;
ii) did not inform and/or record informing the Care Coordinator of a potential risk to the Service User, in that a person who answered the phone indicated that he “did not live there” or words to that effect.
d) In relation to Case 8, following information being provided to you during an assessment on 28 November 2011 as to the Service User’s incontinence, you did not make a referral to an incontinence nurse in a timely manner or at all.
3) Did not maintain adequate records in that:
a) In relation to Case 1, in an entry dated 8 November 2011, you:
i) referred to yourself both as ‘therapist’ and as ‘Occupational Therapist’;
ii) made reference to a telephone call but did not state when it occurred;
iii) your entries made on 3 November 2011 and 8 November 2011 were unclear such that they required subsequent amendments.
b) You made amendments to records after entries had been countersigned by your clinical supervisor, in that you:
i) In relation to Case 1, made amendments to an entry dated 17 November 2011;
ii) In relation to Case 5, made amendments to an entry dated 2 November 2011.
c) Did not record the following relevant information:
i) In relation to Case 1, a telephone conversation between you and the Service User which took place on 8 November 2011;
ii) In relation to Case 3, the outcome of the OCAIRs and/or Mayers Lifestyle Questionnaire completed on 25 October 2011 within the case entry;
iii) In relation to Case 8, your entry following the home visit on 25 November 2011 was blank in respect of Objective 3.
d) In relation to case 7:
i) on or around 8 December 2011, did not record sufficient information to identify the level of risk arising from the Service User’s failure to take her medication;
ii) did not seek and/or record seeking advice from a consultant or other suitable professional in relation to the Service User missing her medication.
e) In relation to Case 8, on 25 November 2011 you conducted a home visit and did not conduct and/or record a Mental State Examination (MSE) despite being made aware that the Service User's father had halved his medication the night before your visit.
f) In relation to Case 8, your entry following the home visit on 25 November 2011 did not record sufficient information to enable an assessment to be made of the risk involved after being made aware that the Service User’s father had halved his medication.
4) Did not complete an adequate report in that, in relation to Case 3, the Occupational Therapy Functional Assessment report completed between 11 and 16 November 2011:
a) Contained unnecessary repetition;
b) Recorded information in the wrong sections;
c) Did not include observations on the Service User's abilities and/or functioning during the shopping trip.
5) Did not complete tasks in a timely manner in that:
a) In relation to Case 5, a cooking assessment took place on 1 November 2011 but your report was not completed until 24 November 2011;
b) In relation to Case 3:
i) You had not completed an entry on PARIS for a community assessment made on 2 November 2011 by 9 November 2011;
ii) You had not completed an Intervention Plan by 17 November 2011, despite having been instructed to complete this on 9 November 2011.
c) In relation to Case 7, on 14 December 2011 you had not recorded an assessment and/or completed an intervention plan when the original deadline for completion was 6 December 2011.
d) In relation to Case 8:
i) By 12 December 2011, you had not seen the Service User despite having planned to see him the week of 5 December 2011;
ii) By 12 December 2011, you had not completed an intervention plan when the original deadline for completion was 5 December 2011.
6) The matters set out in paragraphs 1 - 5 constitute misconduct and/or lack of competence.
7) By reason of your misconduct and/or lack of competence your fitness to practise is impaired.
At the substantive hearing the Panel found all of the particulars (above) proved with the exception of 1(c)(i) to (iii). The Panel found the proved particulars amounted to a lack of competence and the Registrant’s fitness to practice to be impaired. A Suspension Order for a period of 12 months was imposed as a Sanction.
Hearing the proceedings in private
1. At the outset of the interim order application, Ms Bass for the HCPC raised the issue of conducting part of the hearing in private. The Registrant applied for those parts of the hearing concerning her health to be conducted in private in order to protect her private life.
2. The Panel was referred to and followed the guidance set out in the HCPTS Practice Note on “Conducting Hearings in Private”. It also received and accepted legal advice.
3. The Panel decided that in order to safeguard the Registrant’s privacy, it was appropriate for those parts of this review hearing concerning the Registrant’s health to be heard in private.
4. The Registrant is an Occupational Therapist. She qualified in 1992 and worked for Tees, Esk and Wear Valleys NHS Foundation Trust (the Trust) as an Occupational Therapist from 2001 until 2012.
5. In 2008 concerns arose relating to her ability to perform her job adequately. These concerns persisted throughout 2008 and into 2009. In about November 2009 the Trust received an Occupational Health report, which outlined that the Registrant suffered from a health condition. In light of this health concern, it was decided to redeploy her to a different team. The team to which she was moved was the South Durham Psychosis Team, based at the Goodall Centre. She moved to this team on 1 April 2010.
6. On 27 July 2010, it was reported that there were continuing concerns about the Registrant’s competence, she was therefore removed from clinical practice on 05 August 2010 and placed within the inpatient Occupational Therapy Team to complete project work not involving patient contact. An investigation was initiated into the Registrant’s clinical practice.
7. In July 2011, MB, Professional Head of Allied Health Professionals with the Trust, was asked to produce an action plan to support the Registrant’s clinical reasoning, practice, and record-keeping, with a view to returning her to supervised practice. The plan contained 12 objectives. The Registrant was to be based in the Darlington Psychosis Team (also known as the Woodland Road Team) for three months to receive support and build up her caseload to a maximum number of 15 cases. Other objectives were for her to provide clear evidence of understanding and applying Occupational Therapy processes and to use the Mayers Lifestyle Questionnaire (MLQ) tool and Model of Human Occupational Screening Tool (MOHOST). These tools were used by Occupational Therapists to identify a servicer user’s occupational needs and to understand their engagement in activities of daily living. Her placement was to be supervised by BL, Specialist Occupational Therapist. The Registrant was restricted to working on 5 or 6 cases and any work she did was to be supported by formal weekly supervision, and informal daily supervision by BL. The Registrant transferred to the Darlington Psychosis Team on 10 October 2011.
8. The Registrant’s duties involved recording her observations of service users on PARIS, the Trust’s electronic database for patient case records in the health care setting.
9. The action plan was formally reviewed in both November and December 2011. On 12 December the Registrant’s placement with the Darlington team was terminated owing to concerns about her practice and service user safety. The concerns were collectively referred to a Disciplinary hearing, which took place on 03 April 2012.
10. The Registrant self-referred the concerns about her practice to the HCPC in June 2012. That referral eventually resulted in these proceedings.
11. The substantive hearing took place over a number of days in 2016 and in 2017. At the outset, the Registrant admitted the following particulars of the Allegation : 1 (f)(i); 2 (b) (i), 2 (b) (ii), 2 (c) (i), 2 (c) (ii), 2 (d), 3 (a)(i), 3 (a)(ii), 3 (a)(iii), 3 (b)(i), 3 (b)(ii), 3 (c)(ii), 3 (c)(iii), 3 (d)(i), 4 (a), 4 (b), 4 (c), 5 (a), 5 (b)(i), 5 (b)(ii), 5 (c), 5 (d)(i) and 5 (d)(ii).
12. After determining the outstanding factual matters and concluding the Registrant’s fitness to practise was impaired by reason of her lack of competence, the substantive hearing panel purported to refer the case to the Health Committee pursuant to Rule 4 of the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003. However, it transpired that having already adjudicated on the Allegation, the substantive hearing panel no longer had the power to make such a referral, and the panel resumed to decide on sanction.
13. At the resumed substantive hearing, the panel decided that the appropriate and proportionate sanction was a 12-month suspension order. In imposing the order, that panel set out that the reviewing Panel might be assisted by the following:
• Details of how the Registrant has kept her skills and knowledge up to date during the period that she has not been working as an Occupational Therapist.
• Evidence of the learning the Registrant has acquired.
• Evidence to demonstrate that the Registrant has developed appropriate coping strategies to deal with her health condition.
14. In reaching its decision, the Panel has taken account of the HCPTS Practice Note “Finding that Fitness to Practise is Impaired”. It has had regard to the submissions made by Ms Bass for the HCPC and to those of the Registrant. It has received and accepted legal advice.
15. The Panel has taken into account the Registrant’s evidence, and all the information put before it, including the determinations of the substantive hearing panel and documentary information provided by the Registrant which included:
• Document “Information for the Review Panel”
• A GP’s letter dated 7 April 2018
• Character references from three people who know the Registrant in a private capacity
• A document described as “Brief Description of CPD Activity” which was more of a diary of events between 19/04/17 to 06/04/18
• The Registrant’s commentary on Professional Standards and use of Terminology
• Documents from Job Search and People Plus
• Description of Occupational Therapy 2-day show in Nov 2017
• Document setting out strategies to cope
• Document setting out learning and training in 2018
• Document setting out Registrant’s summary of “recent work/practice”.
16. The Panel was mindful that the purpose of a review hearing was to assess current fitness to practise. The Panel has looked for evidence of insight, remorse and targeted efforts by the Registrant to remedy her lack of competence. It appreciates that it is more difficult to demonstrate remediation when subject to a Suspension Order, particularly where the competency concerns raised cover a broad range of failings relating to clinical reasoning, report writing and recording information.
17. The Panel considered that it was to her credit that the Registrant was still engaging with the regulatory process. The Panel noted the steps taken by the Registrant to address the concerns about her practice. The Panel concluded that the Registrant has gained some limited insight over the last 12 months and she has undertaken some Continuing Professional Development (CPD) but took the view that this was limited and not targeted to address the concerns as to her competence. She has provided testimonial evidence which clearly demonstrates her caring nature, but these do not alter the risk posed by her lack of competence. She has not practised as an Occupational Therapist since late 2011, some 7 years ago. In light of this, the Panel takes the view that there is still the risk of harm to service users.
18. With regard to the wider public interest, the Panel has decided that while there is evidence before it which shows that the Registrant has some developing insight and has taken some limited steps to remedy her lack of competence, it must make a finding that impairment remains in this case. It is satisfied that confidence in the Occupational Therapy profession would be undermined if no such finding were made today. A reasonable person aware of the circumstances of this case would expect a finding of impairment to be made where, as here, clinical concerns were yet to be remedied, so that proper professional standards in the Occupational Therapy profession are upheld.
19. In these circumstances, the Panel has determined that the Registrant’s fitness to practise remains impaired.
20. The Panel then considered what the appropriate and proportionate sanction was in this case. It was referred to and took account of the HCPTS Indicative Sanctions Policy and received and accepted legal advice.
21. The Panel considered its powers under Article 30 (1) of the Health and Social Work Professions Order 2001 and the available sanctions in ascending order of seriousness. It had in mind that the purpose of a sanction was not to punish the Registrant but to protect the public. It decided that to take no action in this case would not be appropriate or proportionate given the lack of competence. To take no action would not manage the competency risks identified in this case and the Panel was satisfied that to ensure the public was properly protected, it had to impose a sanction.
22. The Panel took the view that this was clearly not a case in which a Mediation Order would be appropriate. It also concluded that a Caution Order was not appropriate. Although there was evidence of limited insight and reflection, this was still far from being fully developed. There was evidence that the Registrant had taken some steps to remedy her lack of competence, for example attendance at the Occupational Therapy Show workshops, and reading around the issues of dementia. However, it took the view that CPD needs to address the Registrant’s deficiencies in clinical practice, as found in the substantive hearing: recording of information, report writing and clinical reasoning. As the Registrant is still some way off achieving full remediation, the Panel concluded that there remained a real risk of recurrence and it would not be appropriate to impose a Caution Order which would, in effect, mean that the Registrant could practise without restriction. The matters that led to the finding of lack of competence could not be described as either relatively minor or at the lower end of the scale.
23. The Panel also took the view that a Conditions of Practice Order was not appropriate at this time in this case. The evidence was that the Registrant was doing some voluntary work but was otherwise not in paid employment. The Registrant has not practiced as an Occupational Therapist for around 7 years and has not demonstrated that she had kept her skills and knowledge sufficiently up to date. Neither has her insight developed sufficiently to the stage where the Panel could at this time, devise conditions that would address the clinical concerns raised which were appropriate, workable and measurable.
24. The Panel recognised the difficulty in making progress towards remedying shortcomings when under a Suspension Order. It suggests that the Registrant might explore the following areas to get herself into a position where a Conditions of Practice Order might be the appropriate order, for example:
• finding an Occupational Therapist (OT) mentor from a university or NHS Trust to help her address her shortcomings e.g. through case studies;
• taking an OT Assistant role which might be a practical route back to connecting with her profession, even though it would involve a reduction in pay and status from an OT role.
25. In the circumstances, the Panel concluded that the appropriate and proportionate order was a Suspension Order for 12 months. The Panel considered that the Registrant would require an order of that length as she had a lot of ground to make up so far as insight and targeted remediation were concerned.
26. The Panel cannot bind the next reviewing panel but considers that it might be assisted by the following:
• A testimonial from any OT mentor the Registrant may find to assist her address her shortcomings.
• Details of how the Registrant has kept her skills and knowledge up to date during the period that she has not been working as an Occupational Therapist, including proof of any CPD activity.
• Any further evidence to demonstrate that the Registrant has continued to develop appropriate coping strategies to deal with her health condition.
The Registrar is directed to suspend the registration of Miss Ruth Yorkston for a further period of 12 months on the expiry of the existing order.
This order will be reviewed again before its expiry on 17 May 2019.