Miss Kelly Meaden

Profession: Radiographer

Registration Number: RA72520

Hearing Type: Final Hearing

Date and Time of hearing: 09:00 02/07/2018 End: 16:00 06/07/2018

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 at Portsmouth
Hospitals NHS Trust:

1. On 11 October 2015 you:

a) selected the wrong detector programme for a clavicle scan

b) selected the wrong detector programme for a thumb scan

2. On 9 December 2015, while performing a chest x-ray on a
4-month old child, exposed the patient to a higher level of radiation than
necessary.

3. On 25 January 2016, you electronically implanted incorrect anatomical
markers on rheumatology images of the patient's hands and feet so that left
and right images were transposed.

4. On 19 April 2016, you x-rayed the wrong humerus of a patient

5. On 21 June 2016, you x-rayed the incorrect femur of a patient

6. On 14 July 2016, whilst x-raying a bilateral shoulder, you selected the
wrong detector programme

7. On 26 August 2016 you:

a) x-rayed a patient without supervision, which was in contravention of what
had been agreed at a formal Capability meeting on 17 August 2016; and

b) selected the incorrect detector for the shoulder x-ray of that patient

8. The incidents at paragraphs 1, 2, 4, 5, 6 and/or 7b resulted in over
exposure for the patient and/or repeat imaging

9. The matters set out in paragraphs 1 – 8 constitute lack of competence
and/or misconduct.

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

Finding

Preliminary Matters


Service of Notice of Hearing

1. The Panel was informed by the Hearings Officer that notice of this hearing was sent to the Registrant’s registered address by letter dated 4 April 2018.

2. The Panel received and accepted the advice of the Legal Assessor. The Panel was satisfied that the service of the letter dated 4 April 2018 had satisfied compliance with the service requirements of the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 (the Rules).


Proceeding in absence

3. Ms Mitchell-Dunn for the HCPTS applied for the hearing to proceed in the Registrant’s absence. She submitted that this Hearing had been notified in April 2018. Ms Mitchell-Dunn submitted that it was in the public interest to proceed and that she had three witnesses present today (2 July 2018) .The Panel received and accepted the advice of the Legal Assessor who advised that the Panel’s discretion to proceed in the Registrant’s absence should only be exercised with the utmost care and caution. The Panel had regard to the guidance given in the HCPTS Practice Note, “Proceeding in the absence of the Registrant" dated March 2017 and to the House of Lords in R v Jones [2002] UKHL 5.

4. The Panel noted the history of this case and the communication received from the Registrant explaining her reason for her non-attendance, that she had university commitments, and also her detailed submissions in response to the allegations. There was no request for an adjournment from the Registrant.

5. The Panel considered the information received from Ms Mitchell-Dunn on behalf of the HCPTS and considered the Registrant’s written submissions. The Panel accepted the advice of the Legal Assessor.

6. Having taken account of the registrant’s interests and the interests of justice including the expeditious disposal of the case, the attendance of the witnesses and the possible deterioration in the recollection of events, most of which occurred almost two years ago, the Panel decided it was in the interests of justice to proceed with the Hearing in the absence of the Registrant.


Decision on application to amend Particulars

7. Ms Mitchell-Dunn applied to amend several of the particulars and numbering of the allegation. She applied to amend particulars 1(a), 1(b), 2, 3, 4, 5, 6, 7(a), 7(b) and 8 of the allegation.

8. Ms Mitchell-Dunn applied to amend the particulars of the allegation in the manner as set out above. She submitted that the amendments were necessary to clarify the case against the Registrant. The proposed amendments had been notified to the Registrant on 8 March 2017 and no observations or objections in respect of the proposed amendments have been received from the Registrant.

9. The Panel received and accepted the advice of the Legal Assessor that an amendment to the allegations could be made, provided no injustice was caused to the Registrant. The Panel noted that the Registrant had been made aware of the proposed amendments and had made no observations.

10. The Panel considered that the proposed amendments did not alter the nature of the case against the Registrant but merely clarified the allegations.

11. Accordingly the Panel was satisfied that the amendments would not cause any prejudice to the Registrant and determined they should be allowed.


Background

12. Ms Kelly Meaden (the Registrant) was employed by Portsmouth Hospitals NHS Trust (‘the Trust”) in the Diagnostic Imaging, Radiology Day Care Unit, from 29 June 2015.The Registrant joined the department as a newly qualified Band 5  Radiographer.

13. The Registrant undertook a general rotation around the departments working alongside students and staff attending to patients. The Lead Interventional Radiographer was allocated as the Registrant’s supervisor and as such assessed the Registrant’s competency at the end of her induction. This induction is routine and is completed before signing off new members of staff as competent to begin night shifts. On 30 September 2015, at the end of the induction period, the Registrant was signed off by her superiors as competent to perform her role as a Band 5  Radiographer.

14. Concerns were raised following a number of DATIX (an electronic incident reporting system for risk management) incidents that had been reported by the Registrant. Following this a Performance improvement Plan was drafted in order to support the Registrant.


Admissions

15. There were no Admissions received.


Decision on facts

16. The Panel heard and accepted the advice of the Legal Assessor. It recognised that the burden of proving each individual particular rests always on the HCPC and that the HCPC will only be able to prove a particular if it satisfies the required standard of proof: the civil standard, whereby it is more likely than not that the alleged incident occurred.

17. The Panel heard oral evidence from:

• Witness 1, Lead Interventional  Radiographer.
• Witness 2, Deputy Superintendent  Radiographer and
• Witness 3, Superintendent  Radiographer

18. The Panel found witnesses 1, 2 and 3 to be honest, reliable and credible. Their overall levels of recollection were good, but on occasions conceded that they could not remember some details, due to the passage of time, although they were able to refresh their respective memories from the contemporaneous notes they made, or the records, where available.

19. Each of the witnesses gave positive comments about the Registrant’s attitude and hard work during the training and assessment process. In particular, they all said that they had hoped at the beginning of the process that the Registrant would benefit from the assessment and supervision. This led the Panel to conclude that their evidence was fair and balanced. When challenged, each was willing to reconsider their initial positions or maintain their line, as appropriate.

20. Particular 1: This related to taking a scan, having selected the wrong detector programme.

21. Particular 1(a) is found proved. The Panel accepted the DATIX completed by the Registrant which stated the incorrect detector programme (which resulted in a repeat radiation being required subjecting the patient to an additional radiation dose) was selected for a clavicle scan. The Registrant accepted responsibility for this in her written Reflections dated 11 October 2016. Witness 2 confirmed she had reviewed this incident.

22. Particular 1(b) is found proved. The Panel accepted the DATIX completed by the Registrant, which stated the incorrect detector programme (which resulted in a repeat radiation being required subjecting the patient to an additional radiation dose) was selected for a thumb scan. The Registrant accepted responsibility for this in her written Reflections dated 11 October 2016. Witness 2 confirmed she had reviewed this incident.

23. Particular 2 is found proved. The Panel accepted the DATIX completed by the Registrant in which she stated that whilst performing a chest x-ray on a paediatric patient, she exposed the patient to a higher level of radiation which would not normally be given to a child, due to the incorrect programme being selected. Witness 1 gave evidence that she met with the Registrant to discuss this incident and that she accepted responsibility for the incident.

24. Particular 3 is found proved. The Panel accepted the DATIX completed by the Registrant in which she accepted that she had electronically implanted the wrong markers on the hand and feet of a rheumatology patient, so that left and right images were transposed. Witness 2 confirmed that a radiologist had flagged the issue after which it had been corrected.

25. Particular 4 is found proved. The Panel accepted the DATIX completed by the Registrant in which she accepted that she had x-rayed the wrong humerus of a young child patient. Witness 2 confirmed that a Consultant had noted that a suspected lesion had disappeared in circumstances where this would not have been anticipated.  The patient had to be recalled and the x-ray was repeated 4 weeks later. 

26. Particular 5 is found proved. The Panel accepted Witness 3’s evidence that the Registrant had reported to her that she had x-rayed the patient’s incorrect femur .Witness 3 also spoke to the completion of a DATIX in respect of this incident.

27. Particular 6 is found proved. The Panel accepted the DATIX completed by the Registrant in which she accepted that she had selected the wrong detector programme whilst x-raying a bilateral shoulder . Witness 3 also confirmed that the Registrant had reported this error to her .Witness 1 stated that as a result of the error, Witness 3 had an informal meeting with the Registrant.

28. Particular 7(a) is found proved. The Panel accepted Witness 3’s evidence that the Registrant would have been fully aware of the restrictions on her practice as Witness 3 had discussed it at length at the formal capability meeting on 17 August 2016. The Panel also accepted the Registrant’s account in her reflections as well as the account given by her supervising colleague that despite a restriction on the Registrant to have supervision, she had performed an x-ray on a patient without supervision.

29. Particular 7(b) is found proved. The Panel accepted the DATIX completed by the Registrant which stated the incorrect detector programme (which resulted in a repeat radiation being required subjecting the patient to an additional radiation dose) was selected for a shoulder X-ray. The Registrant accepted responsibility for this in her written reflections dated 11 October 2016. Witnesses 1 confirmed this incident having occurred and a subsequent discussion between Witness 3 and the Registrant.

30. Particular 8 related to the incidents at 1, 2, 4, 5, 6 and/or 7b resulting in over exposure for the patients and/or repeat imaging.

31. Particular 8 is found proved. The Panel accepted the evidence of the Witnesses and the DATIX completed by the Registrant in respect of these particulars where it was noted that the incidents resulted in over exposure and /or repeat imaging.


Decision on Grounds

32. The Panel next considered whether the matters found proved as set out above amounted to misconduct and/or lack of competence and, if so, whether by reason thereof, the Registrant's fitness to practise is currently impaired.

33. The Panel considered the submissions made by Ms Mitchell-Dunn on behalf of the HCPC. She submitted that the matters found proved demonstrated misconduct and or a lack of competence on the part of the Registrant. She submitted that the Registrant's fitness to practise is currently impaired.

34. The Panel heard and accepted the advice of the Legal Assessor. The Panel was aware that any findings of lack of competence and/or misconduct and impairment were matters for the independent judgement of the Panel.

35. The Panel was aware that consideration of impairment only arises in the event that the Panel judges that the facts found proved do amount to one or both of the statutory grounds and that what has to be determined is current impairment, that is looking forward from today.

36. The Panel determined that the Registrant’s practice has persistently fallen below the standard expected of a  Radiographer, over ten months, a reasonable period of time, and as judged against a fair sample of her work. The Panel accepted the evidence that the regularity of the Registrant’s reported errors far outweighed that of the other  Radiographers in the organisation. In the Panel’s judgement, the facts of the Particulars found proved, with the exclusion of Particular 7a amounted to a lack of competence on the Registrant’s part.

37. In relation to the facts found in both Particular 4 and Particular 7(a), and 7(b) the Panel found misconduct. The Panel determined that in relation to those Particulars the Registrant’s acts or omissions did fall short of what would be proper in the circumstances, as characterised by Lord Clyde’s definition of misconduct in the case of Roylance v GMC (No.2) (2000)1 AC 31.

38. In relation to Particular 4 the Panel found the Registrant’s behaviour to demonstrate a lack of competence and also misconduct.
The evidence was to the effect that the child patient was being x-rayed by the Registrant in respect of the monitoring of a lesion detected in her humerus which could potentially have been harmful. The Panel found that the Registrant x-rayed the wrong humerus of the child. This error resulted in the child requiring to be recalled for a further x-ray at a later date. This was only discovered when a Consultant was not satisfied that the lesion could have disappeared within this timeframe.

39. In relation to Particular 7(a) and 7(b) the Panel found there to be misconduct. The Panel determined that the Registrant’s behaviour in x-raying a patient on 26 August 2016 without supervision, in contravention of what had been agreed at a formal Capability meeting on 17 August 2016, was a sufficiently serious breach as to be misconduct.

40. Throughout the capability process, the Registrant appears to have done her best .She has proactively engaged in the attempts to bring her skills and competency up to the required standard through training, shadowing peers, mentoring by senior colleagues and learning through observation and preparing self help guides. All the evidence indicated that she was enthusiastic and keen, with very strong technical ability in producing good radiographic images.

41. The Panel recognised themes emerging from the facts found proved, which pointed to a lack of competence and misconduct at a level at which the Registrant could not independently work safely and effectively in her profession. Therefore, the Panel found that the statutory ground of lack of competence is established in respect of charges 1, 2, 3, 4, 5, 6, 7(b) and 8 the statutory ground of misconduct is established in respect of charges 4 , 7(a) and 7(b).

42. In this case, the lack of competence and misconduct is sufficiently serious to lead the Panel to a consideration of whether or not the Registrant’s fitness to practise is currently impaired.

43. The Panel found that in relation to Particulars 1, 2, 3 and 8 the Registrant is in breach of the following Standards of conduct, performance and ethics (published 2012) for registrants of the HCPC:

• Standard 1 - You must act in the best interests of service users.

44. The Panel found that in relation to Particulars 4, 5, 6, 7 and 8 the Registrant is in breach of the following Standards of conduct, performance and ethics (published 2016) for registrants of the HCPC:

• Standard 6.1 - You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.

• Standard 6.2 - You must not do anything, or allow someone else to do anything, which could put the health or safety of a service user, carer or colleague at unacceptable risk

45. The Panel also finds that the Registrant is in breach of the following Standards of proficiency for  Radiographers (published 2013):

• Standard 2.1 - understand the need to act in the best interests of service users at times

• Standard 2.8 – be able to exercise a professional duty of care

• Standard 4.2 - be able to make reasoned decisions to initiate, continue, modify or cease radiotherapy treatment or diagnostic imaging examinations and record the decisions and reasoning appropriately

• Standard 14.1 - be able to conduct appropriate diagnostic or monitoring procedures, treatment, therapy or other actions safely and accurately

• Standard 14.5 – be able to understand or arrange investigations as appropriate

• Standard 14.6 – be able to undertake and record a thorough, sensitive and detailed clinical assessment, selecting and using appropriate techniques and equipment

• Standard 14.7 – be able to gather appropriate information

• Standard 14.8 - be able to use physical, graphical, verbal and electronic methods to collect and analyse information from a range of sources including service user’s clinical history, diagnostic images and reports, pathological tests and results, dose recording and treatment verification systems

• Standard 14.9 – be able to interrogate and process data and information gathered accurately in order to conduct the imaging procedure or radiotherapy most appropriate to the service users needs

• Standard 14.18 - be able to operate radiotherapy or diagnostic imaging equipment safely and accurately

• Standard 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.

• Standard 14.29 – be able to use to best effect the processing and related technology supporting imaging systems

• Standard 15.1 - understand the need to maintain the safety of both service users and those involved in their care.


Decision on Impairment

46. Having determined that the Registrant's actions amounted to lack of competence in respect of Particulars 1, 2, 3, 4, 5, 6 ,7(b) and 8 and misconduct in respect of Particular 4, 7(a) and 7(b) found proved, the Panel went on to consider whether her fitness to practise was currently impaired as a consequence of that lack of competence and /or misconduct.

47. The Panel had regard to the HCPC's Practice Note on impairment, and in particular the two aspects of impairment, namely the ‘personal component’ and the ‘public component’, and the case of CHRE v NMC and Grant [2011] EWHC 927 (Admin).

48. The Panel was of the view that the Registrant’s actions and omissions placed patients and service users at risk of harm through her scanning and x-ray errors and breach of the basis of her supervision at a time she was under a Capability programme.

49. Although the Registrant had a well-structured programme of training and support, over a long period of time, from October 2015 to August 2016, she was unable to reach the standard necessary for independent, safe practice. She continued to have DATIX incidents and demonstrated repeated errors in making final checks of the equipment to ensure the correct programmes were in place and correct parts of the body were being x-rayed or scanned. This resulted in inaccuracies and in turn over-exposure of x-rays to patients and repeat imaging. The Registrant appeared to be unable to apply her good technical knowledge practically and appeared unable to improve her practice, despite support. Her professional failings were such that they would have brought the profession into disrepute.

50. The Panel found that the Registrant’s lack of competence and misconduct also amounted to a breach of the fundamental tenets of her profession, as represented by the Standards identified under the statutory grounds above.

51. The Panel therefore finds that the Registrant was impaired by reason of her lack of competence and misconduct at the time of the allegations.

52. There was evidence before the Panel to indicate that the Registrant had been very proactive and had substantially reflected on her practice and adjusted her methodology of working. However she has still to demonstrate that through these steps she has achieved sufficient insight to result in a more effective way of working. It was noted that the Registrant had shown a serious lack of insight by working unsupervised although it was specifically provided her work was to be supervised. The Panel took into account the Registrant’s written Reflections in which she analyses the DATIX incidents and the difficulties that preceded her termination of employment .The Registrant indicated in her written reflections that she will need further support before she is a confident, competent professional.

53. Given that the standard of her practice had not responded sufficiently to the training and support she was given at the time to achieve independent safe practice, there remains a real risk of repetition.

54. The circumstances of this case engage three of the four criteria identified by Dame Janet Smith in her 5th Shipman report and subsequently approved by Mrs Justice Cox in the case of Grant. The Registrant has in the past placed and is liable in the future to place patients at unwarranted risk of harm; has in the past brought and is liable in the future to bring the profession into disrepute and has in the past breached and is liable in the future to breach fundamental tenets of the profession.

55. The Panel considered whether the Registrant may be able to remediate her practice. Whilst the Panel was of the view that her practice was capable of remediation in theory, there is no evidence that the Registrant has remediated her lack of competence and misconduct.

56. The Panel recognised that the Registrant displayed a positive attitude throughout the training and capability process. However, given the lack of insight ,remediation and real risk of repetition, the Panel finds that the Registrant’s fitness to practise is currently impaired.

57. A finding of impairment is also necessary, in the Panel’s view, to protect patients and service users; to uphold professional standards and to maintain public confidence in both the profession and the regulatory process.


Decision on Sanction


58. Having determined that the Registrant’s fitness to practise is currently impaired by reason of her lack of competence, the Panel next went on to consider whether it was impaired to a degree which required action to be taken on her registration by way of the imposition of a sanction.Ms Mitchell-Dunn submitted  that the Registrant posed a risk to public safety and that the Panel required to consider the protection of the public, the reputation of the profession and the wider public interest.She addressed the Panel on the aggressive and mitigating factors and the possible disposals indicating that suspension may be appropriate in all the circumstances of this case.


59. The Panel accepted the advice of the Legal Assessor and it exercised its independent judgement. The Panel had regard to the Indicative Sanctions Policy. The Panel was aware that the purpose of a sanction is not to be punitive but to protect members of the public and to safeguard the public interest, which includes upholding professional standards, together with maintaining public confidence in the profession and the regulatory process.

60. The Panel first identified what it considered to be the principal mitigating and aggravating factors in this case.


Mitigating factors:


61. The Registrant’s recent qualification as a Registrant and her lack of confidence and experience;

62. The Registrant’s proactive role in seeking opportunities to shadow to improve her performance and her openness and transparency in notifying prospective places of work of her disciplinary and incident reporting history.

63. The Registrant’s positive attitude and engagement throughout the re-training and capability process;

64. The detailed Reflection statements prepared by the Registrant into both the incidents and her reactions,and identifying her deficiencies.


• The witnesses were consistent in describing the Registrant as an enthusiastic,hardworking,  caring and open clinician who always sought to do her best for the patients in her care.

 

Aggravating factors:

65. The risks to patients caused by the deficiencies in the Registrant’s practice including breaching the terms of a condition of a Capability programme supervision requirement;

66. The seriousness and wide ranging nature of the Registrant’s lack of competence over a protracted period of time;

67. That the Registrant’s practice had failed to improve to an adequate and safe standard following referral to occupational health, reviews  with Supervisors and an extensive capability and  a peer supervised programme;

68. The absence of adequate insight by the Registrant into her own lack of competence at the   time of the incidents, implications for patient safety and the consequences for the reputation of the profession;

69. The Registrant is a clinician who made many basic, fundamental errors, most of which could have been addressed by remembering to give her procedures a final detailed check.

70. The Registrant’s limited engagement with the regulator.

71. The Panel next approached the ladder of sanctions, beginning with the least restrictive. The Panel does not consider that the options of taking no further action, mediation or the imposition of a Caution Order to be appropriate or proportionate in the circumstances of this case. These sanctions would not provide the necessary levels of public protection, nor would they reflect the seriousness and wide-ranging nature of the Registrant’s lack of competence. The issues are not of a minor or isolated nature, and the Panel has identified a real risk of repetition.

72. The Panel moved on to consider the imposition of a Conditions of Practice Order. The Indicative Sanctions Policy suggests that this sanction may be appropriate where the issues are capable of correction and there is no persistent or general failure which would prevent the Registrant from doing so. In this case, the Panel is of the view that remediation is theoretically possible. However, the wide-ranging nature of the Registrant’s lack of capability and her inability to respond appropriately to the extensive re-training already given, leaves the Panel unable to conclude that correction is a realistic prospect at this time.

73. Furthermore, the Panel does not consider that it would be possible to formulate workable conditions that would provide the necessary level of public protection. At this time, any conditions would have to be so extensive, that they would effectively amount to a suspension by another name ,as supervision at that level could not be accommodated in a working hospital .

74. The imposition of conditions requires the conditions to be workable therefore, the Panel concludes that a Conditions of Practice Order is neither appropriate nor proportionate in this case.

75. The Panel next considered a Suspension Order. The Indicative Sanctions Policy suggests that a Suspension Order may be appropriate where a lesser sanction would provide insufficient public protection. The Panel considers that this is the case here. The Panel has taken into account the serious consequences for the Registrant in imposing a Suspension Order, but is of the opinion that the need to protect the public, mark the seriousness of the Registrant’s lack of competence and maintain public confidence in the profession, outweigh the Registrant’s own interests in the circumstances of the case.

76. The Panel is of the opinion that the Suspension Order might also facilitate the Registrant’s eventual return to practice. This is because it will provide her with an opportunity for reflection during which she might achieve adequate insight and take measures, within the confines of a Suspension Order, to address deficiencies in her practice.

77. The Panel did consider whether a Striking ff Order was appropriate but decided that in all the circumstances of this case and the willingness of the Registrant to improve her practice a striking off Order would be disproportionate.

78. The Panel has considered carefully the appropriate period of a Suspension Order, concluding that 12 months is the minimum practical period for the Registrant to address the issues identified above. The Panel notes that the Registrant would be free to seek an early review should her circumstances change. Accordingly the Panel directs that the Registrant should be suspended for a period of 12 months.

79. This order will be reviewed prior to its expiry. The panel conducting that review may be assisted by the following:

• The Registrant’s attendance at the review hearing;

• Evidence of any relevant training activities ,relevant shadowing and/or professional development (able to be completed within the confines of a Suspension Order) undertaken by the Registrant;

• Evidence of reflection, such as a reflective piece, demonstrating insight into the Registrant’s lack of competence and the associated consequences for patients and her profession;

• Any other evidence that the Registrant considers might be helpful to the review panel

 

Order

ORDER: That the Registrar is directed to suspend the registration of Miss Kelly Meaden for a period of 12 months from the date this order comes into effect. 

Notes

The Panel imposed an Interim Suspension Order for a period of 18 months to cover the appeal period. 

Hearing History

History of Hearings for Miss Kelly Meaden

Date Panel Hearing type Outcomes / Status
02/07/2018 Conduct and Competence Committee Final Hearing Suspended