Ruth Vaughan

Profession: Speech and language therapist

Registration Number: SL32142

Hearing Type: Final Hearing

Date and Time of hearing: 09:00 30/07/2018 End: 16:00 01/08/2018

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 Speech and Language Therapist at,Bromley Healthcare from around August 2014 until around November 2015, you:

 1. In relation to Service User A:

 (a) On or around 26 August 2015:

 (i) did not choose the most appropriate assessments, in that you assessed Service User A’s spoken word comprehension;

 (ii) did not carry out formal assessments in a standardised and appropriate manner in that you failed to assess Service User A’s written word comprehension at a sentence level;

 (iii) did not provide Service User A with strategies to assist her word-finding skills after conducting a naming task;

 (iv) did not provide all appropriate feedback to the husband of Service User A.

 (b) On or around 4 September 2015, did not prepare the discharge report without significant support from colleagues.

 2. In relation to Service User C, or or around 8 September 2015, did not adequately assess whether Service User C was safe for discharge.

 3. In relation to Service User D:

 (a) On or around 14 September 2015:

 (i) did not discuss Service User D’s discharge with your supervisor;

 (ii) discharged Service User D when Service User D required further assessment.

 4. In relation to Service User E:

 (a) On or around 22 July 2015:

 (i) did not choose the most appropriate assessments;

 (ii) did not carry out a formal reading assessment or a structured informal assessment;

(iii) did not provide adequate feedback to Service User E.

 b) On or around 24 July 2015 you:

 (i) did not carry out formal assessments in a standardised and appropriate manner;

 (ii) did not adequately justify to Colleague HF clinical decisions relating to Service User E’s care;

 (iii) did complete an adequate Cog-Neuro Model Analysis;

 (iv) did not provide adequate feedback to Service User E;

 (v) did not obtain Service User E’s consent for the activity planned.

 5. In relation to Service User F, on or around 28 August 2015, you provided care to Service User F without reading Service User F’s medical notes.

 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.

 

Finding

Preliminary matters
Service
1. The Panel heard that notice in respect of this hearing was sent by first class post and email to the Registrant’s registered address on 3 May 2018 in accordance with Rules 3 and 6 of the Conduct and Competence Procedure Rules 2003.

2. The Panel determined that the notice had been served in accordance with the Rules.

Proceeding in the absence of the Registrant
3. Mr Dite, on behalf of the HCPC, invited the Panel to proceed in the absence of the Registrant. He drew the Panel’s attention to the Registrant’s email to the HCPC dated 11 July 2018:
“Due to my current circumstances, it is not possible for me to attend the hearing. I am very sorry about this and I appreciate the amount of work that has been put into this case. I would like the hearing to continue in my absence. I would also like to take responsibility for my actions, therefore if it is possible, I would like to submit a statement addressing the allegations.”        
                     
4. Mr Dite referred the Panel to an email response from the HCPC dated 13 July 2018 informing the Registrant of the options of attending via telephone or video link. The email stated “If you would like to explore this option, please let me know.” Mr Dite said that no reply to this offer was received.

5. Mr Dite referred the Panel to the guidance contained in the HCPTS Practice Note on ‘Proceeding in the Absence of the Registrant’ and submitted that it was appropriate for the Panel to exercise its discretion to proceed on the basis that the Registrant had chosen not to attend the hearing and had waived the right to appear. He pointed out that  not only had there had been no request from the Registrant for an adjournment, but she had specifically stated her wish that the hearing continue in her absence. Mr Dite informed the Panel that the Registrant had also submitted written representations for the Panel to consider when reaching its decisions in relation to the allegation. He submitted that the public interest in expeditious disposal of the allegation outweighed any disadvantage to the Registrant in proceeding in her absence.

6. The Panel heard and accepted the advice of the Legal Assessor who advised that it should have careful regard to the Registrant’s email of 11 July 2018, and ask itself three questions: 
a. Is the Registrant aware of today’s hearing?
b. Has the Registrant determined not to attend the hearing?
c. Is the Registrant content for the Panel to proceed in her absence?

7. The Panel took the view that a proper reading of the email from the Registrant left no room for doubt that she is aware of the hearing, had determined not to attend and is content for the Panel to proceed in her absence. The Panel noted that one witness was in attendance and two more were scheduled to give evidence. In the Panel’s view the public interest would best be served by proceeding. For all these reasons, the Panel agreed to proceed with the hearing.

Application to amend Particulars 2 and 4(b)(iii)
8. Mr Dite applied to amend Particulars 2 and 4(b)(iii) in order to correct two typographical errors. He submitted that the amendments would cause no substantial change to the overall strength or nature of the allegation and would not prejudice the Registrant.

9. The Panel heard and accepted the advice of the Legal Assessor.

10. The Panel was satisfied that the proposed amendments would correct the typographical errors, would cause no substantial change to the overall strength or nature of the Allegation and would not prejudice  the Registrant. The Panel allowed the application.

Application to conduct parts of the hearing in private
11. Mr Dite referred the Panel to the HCPTS Practice Note on ‘Conducting Hearings in Private’ and to Rule 10 (1) (a) of the Conduct and Competence Procedure Rules 2003.

12. He submitted that those parts of the hearing in which reference would be made to the health of the Registrant should be held in private session. He said this would be appropriate in order to protect the private life of the Registrant.

13. The Panel heard and accepted the advice of the Legal Assessor.

14. The Panel had careful regard to the provisions of the Practice Note  on ‘Conducting Hearings in Private’ and to Rule 10 (1) (a) of the Conduct and Competence Procedure Rules 2003 which provides:
At any hearing the proceedings shall be held in public unless the Committee is satisfied that, in the interests of justice or for the protection of the private life of the registrant,…or of any patient or client, the public should be excluded from all or part of the hearing.

15. The Panel was satisfied that, for the protection of the private life of the Registrant, the public should be excluded from those parts of the hearing in which her health is discussed.

Application to receive the evidence of HF by video link
16. Mr Dite applied to the Panel for a ruling under Article 32 (3) of the Health and Social Work Professions Order 2001, that the evidence of HF be heard by way of video link.

17. Mr Dite informed the Panel that at a preliminary hearing a different panel had agreed that the evidence of SB, who is resident in South Africa, should be heard by video link, but that panel had not considered the question of HF’s evidence. He informed the Panel that HF was unable to attend the hearing to give evidence in person as she was nursing her 6 month old baby and suitable childcare arrangements could not be made to allow her attendance in person. However, she was available to give evidence by way of video link. He submitted that, in the circumstances, it would be  fair and reasonable to permit her to give evidence by way of video link. He said the Panel would still have the opportunity to observe her demeanour in giving her evidence and the Registrant would not be disadvantaged by such a course.

18. The Panel accepted the advice of the Legal Assessor.

19. The Panel was satisfied that efforts had been made to secure the attendance of the witness in person but that, for the reasons set out by the Presenting Officer, suitable arrangements could not be devised. In the Panel’s view it would not be in the interests of justice for the evidence of the witness to be excluded because she was unable to attend in person. The Panel considered that, if the witness were to give evidence by way of video link, it would still have the opportunity to judge her demeanour when answering questions from the Presenting Officer and from the Panel itself. Further, in the Panel’s judgment, there would be no disadvantage to the Registrant.

20. For the reasons set out above, the Panel  determined to hear the evidence of HF by video link.

Background 
21. The Registrant was employed as a Band 5 Speech and Language Therapist at Bromley Healthcare from 26 August 2014 to 10 November 2015. This was her first clinical post since qualifying.

22. The position was a “rotational” post and initially the Registrant was based in the community. On 11 May 2015 she rotated into the acute service based at the Princess Royal University Hospital (PRUH).

23. LE, Head of Speech and Language Therapy, was the Registrant’s manager throughout her time at Bromley. However she also had a direct clinical supervisor in each of her rotational posts.

24. At first, the Registrant’s time at PRUH was split between the stroke unit and the rest of the acute wards. However, as of 8 June 2015, the Registrant was placed full time on the stroke unit in order to give her role more stability. Concerns had been raised about the Registrant’s performance.

25. After she started to be based on the stroke unit full time, HF, Specialist Speech and Language Therapist, became the Registrant’s supervisor.

26. The Registrant was sent on a dysphagia course for a week on 22 June 2015. On her return, because of some concerns that had been raised by a previous supervisor, it was decided that the Registrant would be provided with more frequent supervision by HF.

27. On 2 July 2015 the Registrant reported a personal health issue. It was decided that she should take some time off work, a referral was made to Occupational Health, and she was advised to see her GP.

28. The Registrant returned to work on 20 July 2015 and had a phased return to work, with reduced hours, until 31 July 2015.

29. Concerns continued to be raised regarding the Registrant’s clinical knowledge and ability to manage a case load independently.

30. On 11 September 2015 the Registrant was informed that she would be placed on an informal capability process. The Registrant requested that her clinical supervisor be changed.

31. On 14 September 2015 SB, a Band 7 Speech and Language Therapist on the stroke unit who had previously been providing the Registrant with support and supervision in addition to HF, was formally appointed as the Registrant’s supervisor.

32. On 9 November 2015, the Registrant was invited to a formal capability hearing. The Registrant handed in her letter of resignation the following day and the hearing did not go ahead. The matter was subsequently referred to the HCPC.

Decision on facts
33. In considering the Particulars, the Panel applied the principles that the burden of proving the facts is on the HCPC, that the Registrant is not required to prove anything and that any fact alleged is only to be found proved if the Panel is satisfied on the balance of probabilities that it is correct.

34. In reaching its decisions, the Panel had careful regard to all the evidence put before it and to the submissions of Mr Dite on behalf of the HCPC as well as the written representations of the Registrant.

35. The Panel heard oral evidence from the following witnesses:
• LE, the Registrant’s line manager. The Panel found her to be a clear, consistent and credible witness who was both experienced and knowledgeable. The Panel found her evidence was fair to the Registrant, giving credit where she could and avoiding the making of assumptions when she was not sure;
• HF, the Registrant’s first clinical supervisor. The Panel found her to be a credible and consistent witness with a good recollection of events who gave detailed and balanced answers to questions put to her. She provided good rationale for her answers and was able to respond helpfully to points raised in the Registrant’s written representations of which she had no prior notice.
• SB, the Registrant’s second clinical supervisor. The Panel found her to be an honest witness with a limited recollection of some details but with good recall of key issues and a clear desire to be scrupulously fair in her responses to the questions put to her.

36. The documentary evidence before the Panel included:
• Witness statements of LE, HF and SB
• Fitness to Practice Concern Form dated 17 November 2015
• Management Statement of Case dated 7 October 2015 with appendices
• Notes and emails between LE, HF and SB re concerns and supervisions
• Letter dated 9 July 2015 from Royal Marsden Occupation Health Department to LE re recommendations for Registrant’s working patterns
• Notes of meeting on 20 July 2015 between LE, SB and the Registrant
• Supervision Session and Supervision Preparation Notes
• Discharge summary regarding unnamed patient (later identified as Service User A)
• Letter dated 17 September 2015 from Royal Marsden Occupational Health Department to LE regarding the Registrant
• Email dated 6 October 2015 from the Registrant to LE
• Email chain between the Registrant and LE re impact of health matters on the Registrant’s work
• Letter dated 9 November 2015 from Bromley Healthcare to the Registrant re Capability Hearing
• Letter of resignation from the Registrant to LE
• Supportive Statement re the Registrant from SB
• Medical Records of Service Users A, C, E & F
• The Registrant’s written representations to the Panel

37. The Panel accepted the advice of the Legal Assessor.

Particular 1(a)(i) – found proved
 In relation to Service User A:
  a) On or around 26 August 2015:
i) did not choose the most appropriate assessments, in that you  assessed Service User A’s spoken word comprehension;
38. HF told the Panel that the Registrant had appropriately chosen to use the Comprehensive Aphasia Test Assessment (CAT Ax) for her session with Service User A on 25 August at which she was present. She said the CAT Ax has multiple sub assessments and the key is to pick the subtests appropriate for the individual patient. On this occasion, the Registrant had started out by assessing spoken word comprehension at a single word level, which was inappropriate as Service User A was able to have a conversation, so was obviously able to understand words spoken to her at a conversational level. HF stated that there was no indication that there was any requirement to assess Service User A’s spoken word comprehension at single word level.

39. In her written representations to the Panel, the Registrant stated: “I did not choose the most appropriate assessment. The assessment  selection was based on the patient's performance in a previous session, however, it was clear during the assessment that it was unnecessary to start at Word Level.” 

Particular 1(a)(ii) – found proved
 In relation to Service User A:
  a) On or around 26 August 2015:
ii) did not carry out formal assessments in a standardised and   appropriate manner in that you failed to assess Service User A’s  written word comprehension at a sentence level;
40. HF told the Panel that the Registrant had carried out a written comprehension test at word level when Service User A’s ability to follow written commands would suggest that she was already reading above the word level. HF stated that it would have been more appropriate to assess at sentence level and then step down to word level if she was unable to progress with this.  She stated that the Registrant’s failure demonstrated a poor understanding of how to adapt the test.

41. In her written representations to the Panel, the Registrant stated:
“I did not assess the patient's written word comprehension at sentence level during this session. I believe it was because the session had already exceeded the 45 minutes allocated. I do not recall HF stating that it was essential this assessment was carried out during this session.”

42. HF told the Panel that the assessment was led by the Registrant while her own role was to observe rather than to direct. She said that one of the reasons the session had taken so long was that the Registrant had carried out unnecessary assessments and allowed Service User A to talk for too long on a topic unrelated to the assessment.

Particular 1(a)(iii) – found proved
 In relation to Service User A:
  a) On or around 26 August 2015:
iii) did not provide Service User A with strategies to assist her word- finding skills after conducting a naming task;
43. HF told the Panel that the Registrant had carried out a confrontational naming task with Service User A, but had failed to use the task to provide her with strategies such as gesture / circumlocution / trial writing, to help her word finding skills. This failure had left Service User A with anxiety over her inability to find the correct words.

44. In her written representations to the Panel, the Registrant stated:
“It is true that I did not provide the patient with strategies to assist her word finding skills during the assessment. At the time, I was focused on assessing the patient, however, I should have used every opportunity possible to educate the patient about the strategies she could use to overcome her difficulties.”

Particular 1(a)(iv) – found proved
 In relation to Service User A:
  a) On or around 26 August 2015:
iv) did not provide all appropriate feedback to the husband of   Service User A.

45. HF stated that during the session with Service User A her husband had demonstrated a misunderstanding of his wife’s condition as an issue with memory. She said that, as Service User A’s main conversation partner at home, it was important he understood her condition so that he could support her communication skills appropriately. However, the Registrant  failed to correct the husband’s misunderstanding and did not take the opportunity to provide him with information and feedback. She said that provision of this type of feedback is central to the role of Speech and Language Therapist.

46. In her written representations to the Panel, the Registrant stated:
“I did not provide appropriate feedback to the patient's husband. I recall during the session he mentioned his wife was experiencing 'memory difficulties'. I responded by saying the occupational therapist would carry out further cognitive assessments. However, as HF pointed out, it was likely he was not able to differentiate between language and memory and what he was describing was in fact a language difficulty. This is an excellent observation to make and it was my duty to provide the patient and her husband with better information the nature of cognitive difficulties.“

Particular 1(b) – found proved
 In relation to Service User A:
  b) On or around 4 September 2015, did not prepare the discharge  report without significant support from colleagues.
47. HF told the Panel that the Registrant had been asked to produce a discharge report which she would then review. Instead, the Registrant had produced a draft discharge report which contained grammatical errors, inconsistent use of terminology and insufficient detail. Further, the report indicated that the Service User had only been seen “briefly”, giving the impression that she had not been seen as much as was required. In addition, the report should have detailed the Service User’s goals in relation to returning to work.

48. HF told the Panel that she had reviewed the report, added comments and asked the Registrant  to amend the report in light of those comments. However, when HF reviewed the amended report she found that a number of the changes she had suggested had not been made. She said she had in fact made the outstanding amendments herself.

49. In her written representations to the Panel, the Registrant stated:
“It is true that my supervisor assisted me with this report. At the time, I believed this report was to be used as a learning exercise during one of our supervision sessions. For example, I thought we would use the report as a guide to discuss how to appropriately write the management plan, diagnosis etc. The report I sent to HF was a draft report and I, genuinely, had no intention of sending it in that form. It is clear to me now, that I should not have sent a half-written report to a senior therapist and it was very unprofessional of me to do so. In relation to omitting the line about the patient's uncertainty about returning to work, I did this because the patient worked as a receptionist for a GP's office the letter and the report was to be sent to that exact clinic. I was, therefore, uncomfortable including this line in the discharge report. I should have discussed this with my supervisor before omitting the line.”

50. The Panel noted that in her supervision session the Registrant had been asked why she had not implemented all the changes suggested. She is reported to have responded the she wasn’t sure why and that she had not noticed one of the suggested amendments and further that she had chosen not to include explanations of jargon words.

51. HF accepted that the Registrant’s explanation for the reason why she had not included details of the Service User’s return to work goals raised a legitimate concern. However, she told the Panel that this should have been raised with her as a discussion point and not simply omitted.

Particular 2 – found proved
 In relation to Service User C, on or around 8 September 2015, did not  adequately assess whether Service User C was safe for discharge.

52. SB stated that the clinical notes show that although the Registrant had carried out an adequate language screen, she did not pursue pertinent assessment, exploration and information gathering to assist with appropriate discharge planning. She said that it would have been apparent to the Registrant that discharge was being considered, but  the Registrant had not considered or assessed what care support Service User C had, whether she could call for help in an emergency, whether she could manage her medication and whether there were any communication or language difficulties that needed addressing after discharge. SB told the Panel that it appeared that some consideration had been given to Service User C’s home situation but that insufficient assessment, particularly in regard to next steps regarding community re-integration, had taken place.

53. In her written representations to the Panel, the Registrant stated: “I only became aware that I did not adequately assess whether Service User C was safe for discharge when a list of the allegations was sent to me by the HCPC. Nobody informed me this was not a safe discharge, and I have not been provided with a list of the assessments I failed to carry out.” The Panel noted that the Registrant had corrected the assessment the day following her supervision session when she had been prompted as to the issues which should have been considered.

Particular 3(a)(i) – found proved
 In relation to Service User D:
 a) On or around 14 September 2015:
i) did not discuss Service User D’s discharge with your supervisor;
54. SB stated that the Registrant had discharged Service User D from the inpatient Speech and Language Therapy Service with no onward referral to the Community Speech and Language Therapy Service and without discussion of the decision to discharge with SB, her supervisor. SB stated that although not necessarily a formal requirement, it was good practice to provide handover regarding case management as this information was used to facilitate wider multi-disciplinary team planning. Additionally, because the Registrant had required high levels of supervision and support on the unit, discharge decisions would be expected to be discussed with more senior staff. SB said that it was probably not explicitly stated to the Registrant that she should discuss her discharge decisions with her supervisor, but she would have expected her to do so anyway. SB stated that in Service User D’s case, the lack of discussion meant there was a consequent risk that he would not have received a correct assessment, appropriate help with his return to work or constructive advice for his family.

55. In her written representations to the Panel, the Registrant stated: “I did not discuss the discharge of this patient with my supervisor.”

Particular 3(a)(ii) – found not proved
 In relation to Service User D:
 a) On or around 14 September 2015:
ii) discharged Service User D when Service User D required   further assessment;
56. SB stated that post discharge it was identified by a member of the multi-disciplinary team that due to Service User D’s low volume voice and mild high level communication difficulties, further assessment was required in order to facilitate Service User D’s return to work.

57. In her written representations to the Panel, the Registrant stated:
“I do not believe that this patient required further assessment. To date, I have been provided with neither a list of the additional assessments carried out on this patient nor the exact results of these assessments. I do not understand how the additional assessments contributed or changed the management of this patient as he was discharged without speech and language therapy follow up a day after I discharged him…During_the_assessment, I carried out a detailed assessment of the patient's linguistic profile and his daily use of both his languages. Given that English was not his primary language and his linguistic background, the patient wasgoing to experience difficulty naming rarely used low frequency words.

I believe using increasingly difficult high-level assessments in the English language was inappropriate for this patient. The patient was frequently observed on business calls during his time on the Stroke Unit, showed me examples of text messages sent colleagues and was adamant he was not experiencing any language difficulties. I explained aphasia and speech and language therapy to the patient and his wife. The patient repeatedly informed me that he was not experiencing any language difficulties and did not want further intervention or an onward referral to the local Speech and Language Therapy services. I have no reason to believe the patient did not understand the concept of  communication difficulties or what he was declining.”

58. SB told the Panel that the Registrant’s response set out above was fair and, had it been communicated to her at the time, she would probably have agreed with it.

59. The Panel found this Particular not proved because it had received no evidence that the Service User had required further Speech and Language Therapist input post discharge. The Panel noted that SB’s supportive statement says that another MDT member had identified that further assessment was required, but no case notes or other evidence that this was in fact carried out had been put before the Panel.

Particular 4(a)(i) – found proved
 In relation to Service User E:
 a) On or around 22 July 2015:
i) did not choose the most appropriate assessments; 
60. HF told the Panel that she observed the Registrant conduct this session. She said it had been very informal and disorganised. She said that some informality was appropriate but the session should have been structured. She said the Registrant should have used a formal reading assessment, either from CAT Ax or a similar formal assessment or a structured and thorough informal assessment. By failing to do this the Registrant had used up time which could have been spent more usefully for Service User E.

61. In her written representations to the Panel, the Registrant stated: “I believe I did choose the most appropriate assessment for this patient. I based my choice on the patient's presentation, the previous assessments carried out on this patient and the amount of time I had to carry out the assessment. I do not recall my supervisor stating that it was not an appropriate assessment to use. I would appreciate it if I could inform of the more appropriate assessment.”

62. The Panel considered that the Registrant’s response indicates that she had failed to appreciate that it was her role to lead the session and HF’s role to observe and not to advise the Registrant how to conduct the session. The Panel accepted HF’s analysis of the session.

Particular 4(a)(ii) – found proved
 In relation to Service User E:
 a) On or around 22 July 2015:
ii) did not carry out a formal reading assessment or a structured  informal assessment
63. The Panel noted the evidence of HF in relation to this session as set out above in respect of Particular 4(a)(i). It also noted HF’s evidence that the Registrant did not bring any formal assessments with her to the session.

64. In her written representations to the Panel, the Registrant stated: “I did not carry out a formal assessment of the patient's writing skills during this session as the patient discontinued the formal assessment, therefore, I did not have her consent to complete additional formal assessments. Following the formal assessment, the patient was  experiencing difficulty finding a word. In an attempt to retrieve it, the patient began to use her finger to trace the word on a piece of paper. I, therefore, gave the patient a pen and we completed an informal writing exercise. I agree with HF's evaluation that this was not the best use of time.”

Particular 4(a)(iii) – found proved
 In relation to Service User E:
 a) On or around 22 July 2015:
iii) did not provide adequate feedback to Service User E.   
65. HF told the Panel that the Registrant should have explained to Service User E what she was doing, why she was doing it and why Service User E was experiencing difficulties. HF stated this is standard procedure for carrying out assessments. However, the Registrant did not attempt to do this and did not attempt to relieve Service User E’s distress.

66. In her written representations to the Panel, the Registrant stated: “I did not provide Service User E with adequate feedback during this session. This was a joint session with HF and I believed I was required to discuss the results of the assessment with her before I provided feedback to the patient. I should have discussed the objectives and my role with HF before the therapy session began.”

67. The Panel considered that the Registrant had failed to appreciate the nature and purpose of the session or the respective roles of herself and HF. The Panel accepted HF’s explanation that it was the Registrant’s role to lead the session and HF’s role to observe. It also accepted HF’s evidence that the Registrant was not expected to discuss the assessment with her before providing the Service User with feedback, but should have provided Service User E with enough feedback to relieve her anxiety as the session went along.

Particular 4(b)(i) – found proved
 In relation to Service User E:
  b) On or around 24 July 2015:
i) did not carry out formal assessments in a standardised and    appropriate manner;
68. HF told the Panel that formal assessments have strict instructions on exactly what the assessor must say, how they score the responses and what prompts can be given. She said the Registrant did not follow the assessment instructions, thereby potentially invalidating the results. HF explained that it is important to have standardised tests so that progress can be monitored by others.

69. In her written representations to the Panel, the Registrant stated: “I did not carry out this assessment in a formal manner. This is not acceptable and I sincerely apologise.“

Particular 4(b)(ii) – found proved
 In relation to Service User E:
  b) On or around 24 July 2015:
ii) did not adequately justify to Colleague HF clinical decisions  relating to Service User E’s care;
70. HF told the Panel that she had observed the 24 July assessment and that the Registrant had started her session with Service User E, which was intended to assess her communication skills, by using a CAT Ax. However, the Registrant had been unable to give a rationale for this choice, other than saying “I like the CAT”.  Further, she had chosen to use spoken word comprehension at a single word level, but was unable to give a rationale for why she was doing so.

71. In her written representations to the Panel, the Registrant stated: “I did not justify my assessment selection. I believed, at the time, the Comprehensive Aphasia Test was an obvious choice for this patient and it did not occur to me that my supervisor required rationale for my selection. I can see how this was perceived as unprofessional.” 

Particular 4 b) iii) – found proved
 In relation to Service User E:
  b) On or around 24 July 2015:
iii) did not complete an adequate Cog-Neuro Model Analysis;
72. HF told the Panel that the ability to complete an analysis of a service user’s assessment results based on a Cog-Neuro Model is core knowledge which demonstrates an understanding of language processing, how to assess properly and provide treatment. HF said it is something she would expect a student to be able to do.

73. HF stated that the Registrant did not plot Service User E on the Cog-Neuro model properly; rather, she used narrative paragraphs instead of a structured analysis as HF had expected. She used a basic model from CAT Ax and talked loosely about Service User E’s assessment performance. HF told the Panel that the Registrant’s assessment had been descriptive without any analysis of what it would mean for the Service User. HF said the assessment indicated a poor understanding of what had been asked from her and why. She told the Panel she was disappointed that the Registrant had not written notes to go through and did not display an in-depth knowledge of the model.

74. In her written representations to the Panel, the Registrant stated: “During this supervision session, I did speak ad-lib and informally about the cog-neuro model. I believe this reflected the informal supervision format that my previous supervisor adopted. I was also genuinely more interested in hearing HF's analysis then demonstrating my own knowledge, as she was well-informed on the topic. I did not mean to come across as unprepared or unprofessional. It is also important to acknowledge timing of this. The week of July 22nd - 26th was my first week back from sick leave, and thus the first week of my two-week phased return to work. This means I had every second day off with reduced daily working hours. These days off were essential to my recovery. I was too unwell to work during my sick days and I believed it was very unfair to ask me to prepare work outside of my work hours. I discussed this with my supervisor and my manager following this incident and they allocated time for me during my work day to complete supervision objectives.” 

75. The Panel accepted HF’s view of the assessment and concluded that it had been inadequate for the reasons stated by HF. It considered that the Registrant’s explanation set out above underlined her lack of knowledge and her lack understanding of the issues.

Particular 4(b)(iv) – found not proved
 In relation to Service User E:
  b) On or around 24 July 2015:
iv) did not provide adequate feedback to Service User E;
76. HF told the Panel that she had observed that during this session the Registrant failed to provide feedback to Service User E regarding the results of the assessments, her strengths and weaknesses, strategies she might use or what the next steps were.

77. In her written representations to the Panel, the Registrant stated: “There was only one session with this patient. This took place on July 22nd. This allegation has already been addressed in allegation 4 (a) (iii). I believe this allegation is a duplicate of allegation 4 (a) (iii)”. 

78. The Panel had careful regard to the Registrant’s written representation with regard to this matter. It considered that it was clear from Service User E’s medical notes,  the supervision record and the evidence of HF that the Registrant had conducted an assessment of Service User E on 24 July 2015 as well as 22 July. The panel accepted the evidence of HF as to her observations with regard to feedback on the 24 July session.

Particular 4(b)(v) – found proved
 In relation to Service User E:
  b) On or around 24 July 2015:
v) did not obtain Service User E’s consent for the activity planned.
79. HF told the Panel that her role on this occasion had been to observe, while the role of the Registrant had been to lead the session. She told the Panel that the Registrant had asked Service User E at the start of the session if she was happy for the contact to go ahead. However, she failed to ask if the Service User was happy to undergo the activities and assessments planned. HF said that the Assessor must explain who they are and what they want to do and also that the Service User does not have to participate if they do not wish to do so. In this case the Registrant also failed to ask Service User E if she was happy for HF to be there. HF said all these matters should have been covered at the start of the session in order to ensure that consent was properly obtained and that the assessor did not act against the Service User’s wishes. HF told the Panel that on this occasion Service User E had been drowsy, making it particularly important that correct consent procedures be followed.

80. In her written representations to the Panel (concerning the 22 July session), the Registrant stated: “I obtained consent from the patient for a speech and language therapy session, however, I did not explain that the session involved a formal assessment and, therefore, I did not obtain consent for the assessment. As mentioned previously, this was my first day back from sick leave and I was unsure of my role during this joint session. I, wrongly, assumed HF asked the patient for permission to complete a formal assessment. I should not have assumed this and I apologise for my poor professional behaviour.” 

81. It was clear to the Panel that the Registrant's explanation is directed towards the 22 July session as she has stated that the 24 July session did not take place. As set out above, the Panel found the 24 July session did take place and that it was not HF’s role to do more than observe the session. The Panel found this Particular proved.

Particular 5  – found proved
 In relation to Service User F, on or around 28 August 2015, you provided care to Service User F without reading Service User F’s medical notes.
82. HF stated that in the 28 August supervision session she held with the Registrant they discussed the session that the Registrant had held with Service user F that day. She told the Panel that she was shocked when the Registrant told her that she had not read the medical notes before seeing Service User F. She said this failure had put the Service User at risk of harm and raised serious professional conduct issues.

83. In her written representations to the Panel, the Registrant stated: “I read this patient’s medical notes an hour before I was due to see her. The issue arose when I went back to review the notes before going in to the session. Her notes had been taken into a meeting and I would not have the opportunity to see them for the remainder of the day. I felt it was my duty to see them that day instead of waiting another 24 hours. I described what happened to my supervisor as I was anxious and aware it was not the correct decision to make”.

84. HF told the Panel she did not accept the Registrant’s assertion as set out above. HF said that she would have recorded any such conversation in the record of supervision. The Panel noted that the record states that the Registrant “was advised it was not appropriate to see a patient without reading the medical notes.”

85. The Panel accepted HF’s recollection of the matter which is supported by the contemporaneous supervision notes.

Decision on grounds
86. Having made its findings on the facts, the Panel went on to consider whether the matters found proved constituted misconduct and/or lack of competence. The Panel had careful regard to the submissions of Mr Dite. It accepted the advice of the Legal Assessor. The Panel recognised that there was no burden of proof at this stage in the proceedings.

87. In relation to misconduct, Mr Dite submitted that the Registrant’s performance had fallen seriously below the standards expected of a registered Speech and Language Therapist as set out in the HCPC ‘Standards of conduct, performance and ethics’. He submitted that the facts alleged were serious and amounted to misconduct going to fitness to practise.

88. In relation to lack of competence, Mr Dite submitted that the Registrant had breached the HCPC Standards of Proficiency for Speech and Language Therapists.

89. Mr Dite submitted that the matters alleged demonstrated serious deficiencies in competencies which are fundamental to the work of a Registered Speech and Language Therapist. He said it was a matter for the Panel as to whether or not these deficiencies had been identified through a fair sample of the Registrant’s work and whether or not they demonstrated an unacceptable lack of knowledge, skill or judgment.

90. In considering the issues of misconduct and lack of competence, the Panel had careful regard to all the evidence as well as the written representations of the Registrant. In particular, the Panel noted:
i. LE’s evidence that in June 2015 concerns had been raised with regard to the Registrant’s work and that these had been met by providing the Registrant with additional training and support. However, “despite the additional support the Registrant was receiving she still was not making significant progress against the goals she had been set in her supervision sessions.”
ii. HF’s evidence that the Registrant had “not only received hours of direct supervision but also many hours of joint sessions, clinical discussions and shadowing which were over and above the expectation of an SLT with approaching one year’s clinical practice…The Registrant did not demonstrate any significant improvements prior to leaving the Trust. At this point she remained unable to independently manage a small caseload of patients… It was deemed too much of a risk to patients for the Registrant to commence any dysphagia practice (a core competence when working with this patient group) by the time she left the Trust.”
iii. SB’s evidence that “as a Band 5, the Registrant would be expected to deliver competencies around managing and assessing swallowing, appropriate use of formal assessments, liaison with the multi-disciplinary team , information gathering and sharing, and to some degree diagnosis through supervisory discussion. This requires an ability to act independently and under supervision…There was always an underlining concern about the Registrant’s knowledge base around strokes…The Registrant’s ability to use information that she would gather through patient observations and assessment did not seem to be refined enough for her to problem solve effectively. The Registrant often struggled to present a comprehensive picture of a patient’s situation…Her core knowledge base was not in keeping with a Band 5…She lacked confidence in herself…Other matters made the working environment difficult for her…She did improve but that improvement was clouded by her other issues.”

91. The Panel noted the Registrant’s written representation that she had returned to work from sick leave too early and that her health issues partially explain her poor performance. The Panel had careful regard to the 17 September 2015 Occupational Health report which supported this view, and to the evidence of SB concerning the impact of “other issues” on the Registrant’s improvement.

92. In the Panel’s view, it is likely that the Registrant’s health issues did have some impact on her clinical performance. However, the evidence of the Registrant’s supervisors led the Panel to the conclusion that the deficiencies in her performance as a Band 5 Speech and Language Therapist could not be attributed to health issues alone. Further the Panel noted that these deficiencies persisted after the 17 September 2015 when the Occupational Health Report stated that the Registrant’s health condition was now stable and anticipated improvement in her performance.

93. The Panel gave careful regard to the guidance provided in the cases of Roylance v GMC [2001] 1 AC 311 and Calhaem v GMC [2207] EWHC 2606 (Admin). It recognised that misconduct and lack of competence can both involve a falling short from the professional standards that would be proper in the circumstances. It considered that the key distinction between misconduct and lack of competence is that while misconduct typically involves a deliberate or reckless falling short where a registrant is capable but unwilling to adhere to the proper standard, lack of competence involves an involuntary falling short where a registrant may well be willing to, but is simply not capable of, performing to the required standard. In the Panel’s judgment, this is a case where the Registrant either did not know what was required of her or was not capable of doing what was required. For this reason, the Panel concluded that the facts found proved do not amount to misconduct.

94. The Panel found that, by reason of the facts found proved, the Registrant had breached the following standards in the HCPC Standards of Proficiency for Speech and Language Therapists:
Standard 1 be able to practise safely and effectively within their scope of practice
Standard 3       be able to maintain fitness to practise
Standard 4  be able to practise as an autonomous professional, exercising their own professional judgement
Standard 8  be able to communicate effectively
Standard 9 be able to work appropriately with others
Standard 11  be able to reflect on and review practice
Standard 13  understand the key concepts of the knowledge base relevant to their profession
Standard 14  be able to draw on appropriate knowledge and skills to inform practice

95. The Panel considered that the facts found proved represented a fair sample of the Registrant’s work. They demonstrated that the Registrant fell well below many of the standards of proficiency expected of her through a lack of knowledge, clinical reasoning and skills, and that these deficiencies put patients at risk of harm. Even when supported and encouraged to develop by her colleagues over a period of months, she was unable to improve her performance consistently or in a sustained manner and continued to repeat earlier errors and failings.

96. In all the circumstances set out above, the Panel had no doubt that the matters found proved were serious and connoted a standard of professional performance which was unacceptably low and which constituted lack of competence going to the Registrant’s fitness to practice.

Decision on impairment
97. The Panel went on to consider whether the Registrant’s fitness to practise is impaired by reason of her lack of competence. It had careful regard to all the evidence before it and to the submissions of Mr Dite. It accepted the advice of the Legal Assessor and had particular regard to the HCPC’s Practice Note on ‘Finding that Fitness to Practise is Impaired’.

98. The Panel concluded that, by reason of the matters found proved, the Registrant had put patients at unwarranted risk of harm, breached fundamental tenets of the profession and brought the profession into disrepute. In those circumstances the Panel had no doubt that the Registrant’s fitness to practise had been impaired by reason of her lack of competence.

99. The Panel then went on to consider whether the Registrant’s fitness to practise is currently impaired by reason of her lack of competence. In addressing the personal component of impairment, the Panel asked itself whether the Registrant is liable, now or in the future, to repeat or persist in this lack of competence. In reaching its decision, the Panel had particular regard to the issues of insight, remediation and the Registrant’s history.

100. In considering the extent to which the Registrant had or had not demonstrated insight into her failings, the Panel recognised that the Registrant had engaged with the HCPC and, through her written representations to the Panel, had accepted some failings in her performance and had expressed some remorse for these. However, in the Panel’s view she had demonstrated only limited insight. In particular, she appeared to underestimate both the seriousness and extent of her lack of knowledge, clinical reasoning and skills. Further, she seemed unable to accept that her inability to achieve sustained and sufficient improvement in her performance might be rooted in her own lack of ability rather than in other factors such as issues of health and miscommunication.

101. In considering the extent to which the Registrant had or had not demonstrated remediation of her lack of competence, the Panel recognised that clinical failings are usually easier to remedy than those, for example, which involve entrenched attitudinal problems. However, it had received no evidence of any steps which the Registrant may have taken since the events in question to remediate her failings.

102. In considering the Registrant’s history, the Panel noted that it had received no evidence to suggest that the Registrant had been the subject of any previous or subsequent regulatory concern. However, it also noted her relative inexperience as a registered Speech and Language Therapist and the absence of any information as to what if any employment she has held since leaving the Trust.

103. Given its findings on insight, remediation and history, the Panel had no choice but to conclude that the Registrant’s lack of competence is highly likely to persist. For this reason, the Panel determined that a finding of personal impairment is required on the ground of public protection.

104. The Panel then went on to consider whether a finding of impairment is necessary on public interest grounds.  In addressing this component of impairment, the Panel had careful regard to the critically important public issues identified by Silber J in the case of Cohen when he said:
“Any approach to the issue of whether .... fitness to practise should be regarded as ‘impaired’ must take account of ‘the need to protect the individual patient, and the collective need to maintain confidence in the profession as well as declaring and upholding proper standards of conduct and behaviour.”

105. The Panel considered that achieving and maintaining competence to undertake safe and effective practice is a fundamental requirement of the profession of  Speech and Language Therapists and that the public would be concerned to learn of the deficiencies in fundamental and basic skills and competencies demonstrated by the Registrant. The Panel had no doubt that the need to maintain public confidence in the profession, and to declare and uphold proper standards, would be undermined if a finding of impairment of fitness to practise was not made in the circumstances of this case.

106. For all the reasons set out above, the Panel determined that the Registrant’s fitness to practise is currently impaired, both on the grounds of public protection and in the public interest. 

Decision on sanction
107. The Panel next considered what, if any, sanction to impose on the Registrant’s registration. It had careful regard to all the evidence put before it and to the submissions of Mr Dite. It accepted the advice of the Legal Assessor.

108. Mr Dite drew the Panel’s attention to the HCPC’s Indicative Sanctions Policy (ISP) and submitted that the question of sanction is a matter for the Panel’s own independent judgment.

109. In reaching its decision, the Panel had at the forefront of its thinking the principle of proportionality and the need to balance the interests of the Registrant with the protection of the public and the wider public interest in maintaining confidence in the profession and the HCPC, and declaring and upholding proper standards of conduct and performance.

110. In reaching its decision, the Panel had regard to all the circumstances, including the following mitigating and aggravating features of the case:


Mitigating features
• The impact of the Registrant’s health on her performance;
• At the times in question the Registrant had recently qualified and was in her first role, in an acute setting, as a Speech and Language Therapist;
• The Panel received no evidence that the Registrant had previously been brought before her regulator in respect of any other matters;
• The Registrant had engaged with the HCPC to the extent of providing written representations to assist the Panel. These included acceptance of some deficiencies in her performance.

Aggravating features
• The basic and fundamental nature of the deficiencies in respect of a wide range of core competencies;
• The persistence of the failings, even after assistance, training and advice had been provided;
• Patients were put at unwarranted risk of harm
• The Registrant had demonstrated only limited insight into her failings.

111. The Panel first considered whether it would be appropriate to impose no sanction in this case. It gave careful consideration to Paragraph 8 of the ISP. The Panel determined that in light of its findings that the Registrant has demonstrated little insight and no remediation, there remains a high risk of repetition or persistence of her serious and wide-ranging lack of competence. In the circumstances the imposition of no sanction would neither protect the public nor serve the wider public interest in maintaining confidence and declaring and upholding proper standards.

112. The Panel next considered the imposition of a Caution Order. It gave careful consideration to the factors set out in ISP. The Panel determined that in light of its findings that the Registrant has demonstrated little insight or remediation and that there remains a high risk of repetition or persistence of her serious and wide-ranging lack of competence, the imposition of a Caution Order would be inappropriate as it would neither protect the public nor be sufficient to mark the wider public interest.

113. The Panel then considered the imposition of a Conditions of Practice Order. It gave careful consideration to Paragraphs 30-38 of the ISP. In considering the suitability of a Conditions of Practice Order, the Panel noted that, although in principle it is possible to remediate clinical failings through a Conditions of Practice Order, the Registrant’s lack of competence is wide-ranging and at a fundamental level, and the Panel has received no evidence of remediation or more than limited insight. As a consequence, any conditions would need to be so onerous as to be unworkable and tantamount to suspension. Further, the Panel noted that in her resignation letter to the Trust in November 2015 the Registrant had stated that she had “come to the conclusion that this is no longer the career I wish to pursue”. In light of that letter and the absence of any information as to the Registrant’s current employment situation and future intentions with regard to practice as a Speech and Language Therapist, the Panel could have no confidence that she would engage with a Conditions of Practice Order. In all the circumstances, the Panel concluded that such an option is neither workable nor appropriate at this time.

114. The Panel went on to consider the imposition of a Suspension Order. It gave careful consideration to Paragraphs 39-45 of the ISP. Such an order would protect the public and satisfy the wider public interest in declaring and upholding proper standards and in maintaining public confidence in the profession. The Panel recognised that such an order would also provide the Registrant with an opportunity to reflect on her failings and to develop an appropriate level of insight into those failings. Further, it would provide her with an opportunity to take the first steps towards remedying those failings by undertaking training in the core competencies necessary for compliance with the HCPC Standards of Proficiency for Speech and Language Therapists.

115. The Panel considered that the nature and seriousness of the case was such that a period of 12 months would be both appropriate and proportionate. However, it would be open to the Registrant to seek an early review.

116. The Panel recognised that a Striking-off Order is not available to it at this time.

117. For all the reasons set out above the Panel decided that a 12 month Suspension Order is the appropriate and proportionate sanction at this time.

118. The Panel considered that a reviewing panel would be likely to be assisted by:
• The Registrant’s attendance;
• A reflective piece from the Registrant with regard to the failings found;
• Evidence from the Registrant as to any steps she may have taken in order to remediate her failings;
• References and testimonials in respect of any employment or work she may have undertaken since the events in question.

Order

That the Registrar is directed to suspend the registration of Ms Ruth Vaughan for a period of 12 months from the date this order comes into effect.

Notes

The order imposed today will apply from 29 August 2018 (the operative date).


This order will be reviewed again before its expiry on 29 August 2019.
 

Hearing History

History of Hearings for Ruth Vaughan

Date Panel Hearing type Outcomes / Status
30/07/2018 Conduct and Competence Committee Final Hearing Suspended