Ms Paula Hutchinson

Profession: Operating department practitioner

Registration Number: ODP32166

Hearing Type: Final Hearing

Date and Time of hearing: 09:00 01/06/2018 End: 12:00 01/06/2018

Location: Health and Care Professions Tribunal Service (HCPTS), 405 Kennington Road, London, SE11 4PT

Panel: Conduct and Competence Committee
Outcome: Conditions of Practice

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Allegation

 

During the course of your employment as an Operating Department Practitioner at Nuffield Health Leeds, you:

 1. On or around 10 June 2016:

 a. did not check that Patient A was wearing the correct wristband prior to Patient A's operation:

 i. on the ward; and

 ii. in the anaesthetic room.

 b. initialled the Pre-Procedure Checklist confirming that Patient A's identity had been confirmed and corresponded with Patient A's wristband and patient records when you had not checked.

 c. did not record on the Pre-Procedure Checklist that you had obtained signature evidence to confirm your discussion of the Consent Form with Patient A.

 d. allowed Patient A to be transferred to an operating theatre with an incorrect wristband.

2. On or around 21 April 2016:

 a. during surgery on Patient B, prepared and supplied to the Anaesthetist an Insulin ampoule of 1000 units in 50 mls diluent instead of the requested 50 units of Insulin in 50 mls diluent.

3. Not proved.

4. The matters set out in paragraphs 1 - 2 constitute misconduct and/or a lack of competence.

5. The matter set out in paragraph 3 constitutes misconduct. 

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

 

 

Finding

Background:

1. The Registrant is a registered Operating Department Practitioner (ODP) who qualified in 2009.

2. Concerns regarding the Registrant arose in April 2016 when the Registrant was working in the cardiac surgery theatre at Nuffield Health Leeds. Patient B was due for surgery and had been anaesthetised in preparation for the operation. Patient B had type 2 diabetes and when placed on coronary artery bypass, an emergency situation developed. During this emergency, the anaesthetist, SW, asked the Registrant to prepare ’50 in 50’, which means 50 units of insulin in 50ml of saline diluent. Insulin was stored in 10ml vials at the Hospital, and 10ml of insulin equated to 1000 units of insulin. In response to the anaesthetist’s request for insulin of ’50 in 50’, the Registrant used the whole vial of insulin, thus she incorrectly prepared and supplied 1000 units of insulin in 50ml of saline diluent to the anaesthetist.

3. The anaesthetist injected an initial 4ml of the prepared insulin intravenously to Patient B through a central venous line. He then loaded the prepared syringe into a syringe driver and commenced a continuous infusion at a rate of 4ml per hour. Shortly after starting the infusion, SW noticed that the vial was empty. On checking, the Registrant, confirmed that she had used the whole vial of insulin. The infusion was stopped, and Patient B’s blood glucose levels were monitored.

4. Further concerns arose on 10 June 2016 when the Registrant was working in a surgical theatre at the Hospital. Patient A was due to undergo an elective surgical operation under general anaesthetic. He had been issued with an incorrect wrist band, which had been generated from the Hospital’s Patient Information Management System (PIMS). When Patient A had been admitted to the ward, a Health Care Assistant had put the incorrect patient wristband on his wrist, because the wrong wristband had been printed and placed in the folder containing Patient A’s medical notes.

5. On the ward, the nurse who had been allocated Patient A, had not checked that the wristband was correct. A consent form for the elective surgery had been completed in respect of Patient A, which he had signed. Before a patient proceeds to surgery, a Pre-Procedure Checklist (PPC) is required to be completed in respect of the patient. The PPC is a chart listing all relevant matters which should be checked. Both the nurse and the ODP are required to check a certain number of points with the patient. Some of the points must be checked by the nurse on the ward, and then there are further checks to be completed by the nurse and the ODP together when the patient is transferred to the anaesthetic room. They then add their initials to the chart to indicate what has been checked.

6. The Registrant collected Patient A, together with his medical notes, from the ward, to take him to theatre. Whilst on the ward, the Registrant verbally confirmed Patient A’s medical notes with him, however, she did not check that the wristband that he was wearing was correct before she took him from the ward. Patient A was then moved to the anaesthetic room in order to be anaesthetised in preparation for surgery. The Registrant went through the details again to confirm that Patient A was the correct patient in respect of the patient notes, and went through the consent form with him. During this process:

a) the Registrant did not record on the Pre-Procedure Checklist (PPC) that she had obtained signature evidence to confirm her discussion of the consent form with Patient A;

b) the Registrant did not check Patient A’s identity details against the patient wristband; and

c) initialled the PPC to confirm that Patient A’s identity had been confirmed and corresponded with Patient A’s wristband and patient records, when she had not checked the wristband.

7. The substantive hearing panel on 14 – 15 September 2017 determined that only the incident concerning Patient B in April 2016 amounted to the ground of lack of competence and that the Registrant’s fitness to practise was impaired by reason of that lack of competence and imposed a Conditions of Practice Order for 9 months. The Conditions were:

1) You must promptly inform the HCPC if you take up any employment, and provide details of that employment;

2) You must undertake and successfully complete an administration of medicines course, with a particular focus on the administration of insulin, and forward a copy of your results to the HCPC;

3) You must undertake monthly supervision meetings with your line manager in order to support your return to practice;

4) You must provide a report to the HCPC from your line manager, commenting on your progress and the standards of your practice, before the review hearing;

5) You must inform the following parties that your registration is subject to these conditions:

A. Any organisation or person employing or contracting with you to undertake professional work;

B. Any agency you are registered with or apply to be registered with (at the time of application); and

C. Any prospective employer (at the time of application).

8. This is the first review of that Conditions of Practice Order.

Decision

9. Miss Wills, on behalf of the HCPC, submitted that the Registrant has not been working as an ODP since the last hearing and has not yet completed an administration of medicines course or undertaken monthly supervision meetings. Those are both requirements of the present Conditions of Practice, but there has been no breach of the conditions because the Registrant has not been in employment as an ODP. However, Miss Wills submitted that the Registrant’s fitness to practise remains impaired and that a sufficient and proportionate order on this review would be to extend the present Conditions of Practice Order.

10. The Registrant confirmed the contents of a statement she provided to the HCPC on 29 May 2018 which explained that she will start a new job as an ODP on the 04 June 2018 with Scarborough Hospital. Her new employer is aware of the present Conditions of Practice and will assist her to comply with them. She will be employed on a planned preceptorship as a Band 5 with a probationary period of 3 months, during which she will have a Band 6 acting as her mentor. The Registrant said that she knows the Scarborough team well as she spent 7 years there after qualifying. The Registrant explained that she has worked in a farm shop since June 2017. She also said that she has made efforts to keep her skills and knowledge up to date by reading relevant professional books and articles including Medicines Management Skills 2013. The Registrant accepted that her fitness to practise remains currently impaired because she has not been able to undertake the training and supervision required by the Conditions of Practice, and she had no objection to an extension of the Order.

11. As advised by the Legal Assessor, the Panel first considered the issue of current impairment which is a matter for the independent judgement of the Panel. The Panel took account of the principle set out in Abrahaem v GMC [2008] EWHC 183 (Admin) that there is, in practical terms, a persuasive burden at a review hearing for the Registrant to demonstrate that she has “fully acknowledged why past performance was deficient and through insight, application, education, supervision or other achievement sufficiently addressed the past impairments.”

12. The Panel carefully considered all the documentary and oral evidence, the submissions made by Miss Wills and the Registrant, and the HCPTS Practice Note “Finding that Fitness to Practise is ‘Impaired’” as advised by the Legal Assessor.

13. The Panel was impressed with the Registrant’s commitment to her career as an ODP and her willingness and readiness to comply with Conditions of Practice once she starts in her new post next week. The Panel was also satisfied that her new employer was committed to assisting her compliance with any Conditions of Practice of the sort presently imposed. The Panel concluded that without having undertaken an administration of medicines course, and undertaking the required monthly supervision meetings, the Registrant’s fitness to practise currently remains impaired.

14. The Panel therefore considered what action it should take in respect of the present Order and took account of the HCPC’s “Indicative Sanctions Policy”. The Panel determined that the present Order should be slightly varied to clarify its requirements and be extended by 9 months so that the Registrant has time to comply with those requirements. 

Order

Order: 

The Registrar is directed to annotate the Register to show that, for a period of 9 months from the date that this Order comes into effect (“the Operative Date” namely, upon the expiry of the current Order on 13 July 2018), you, Ms Paula Hutchinson, must comply with the following conditions of practice:

1) You must promptly inform the HCPC if you take up any employment as an Operating Department Practitioner (ODP), and provide details of that employment;

2) You must undertake and successfully complete an administration of medicines course, with a particular focus on the preparation and administration of insulin, and forward a copy of your results to the HCPC;

3) You must undertake monthly supervision meetings with your line manager in order to support your return to practice;

4) You must provide a report to the HCPC from your line manager on completion of any preceptorship, commenting on your progress and the standards of your practice, before the review hearing;

5) You must provide a report to the HCPC, one month before the next review hearing, from your line manager commenting on your progress and the standards of your practice as an ODP.

6) You must inform the following parties that your registration as an ODP is subject to these conditions:

A. Any organisation or person employing or contracting with you to undertake professional work;

B. Any agency you are registered with or apply to be registered with (at the time of application); and

C. Any prospective employer (at the time of application).

Notes

The order imposed today will apply from 13 July 2018 (the Operative Date).

This order will be reviewed again before its expiry on 13 April 2019.

Hearing History

History of Hearings for Ms Paula Hutchinson

Date Panel Hearing type Outcomes / Status