Mr Salim M Ahmaida Makhlouf
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During the course of your employment as an Operating Department Practitioner with the York Teaching Hospital NHS Foundation Trust between 25 April 2016 and 17 June 2016:
a) did not take appropriate steps when a patient’s laryngeal mask airway had been lost;
b) did not obtain a pump for an infusion on 13 June 2016;
c) did not provide a reversal drug in a timely manner when this was requested by an anaesthetist on 13 June 2016;
d) did not adequately monitor a patient when working with Colleague X.
2. You demonstrated a lack of clinical knowledge and skills, in that you:
a) did not adequately check an anaesthetic machine on approximately 3 occasions;
b) were unable to do a stocking up list without prompting on what was needed;
c) did not appear to understand the method of keeping a patient asleep, i.e. induction with propofol and maintenance of anaesthesia with gas and inhalation agents;
d) did not list suxamethonium as a required rapid sequence induction and/or an emergency drug when completing competency questions;
e) had to be reminded to label intravenous infusions drips.
3. The matters set out in paragraphs 1 and 2 constitute lack of competence
4. By reason of your lack of competence your fitness to practise is impaired
Service of Notice
1. The Panel found that there had been good service of the Notice of Hearing by a letter dated 18 December 2017 which informed the Registrant of the date, time and venue of the hearing.
Proceeding in the absence of the Registrant
2. Ms Vignoles made an application for the hearing to proceed in the absence of the Registrant.
3. The Panel accepted the advice of the Legal Assessor and applied the guidance in the HCPTS Practice Note “Proceeding in the Absence of the Registrant”.
4. Ms Vignoles informed the Panel that the Registrant’s engagement with the HCPC has been sporadic and that there has been no substantive engagement with respect to the Allegation or the Notice of Hearing. She explained that the HCPC also sent the Notice of Hearing to an alternative address provided by the Registrant and to the Registrant’s e-mail address.
5. The Panel was satisfied that the Registrant was aware of the hearing, that there has been no meaningful engagement, and that his absence was voluntary. He has not requested an adjournment and there was nothing to suggest that he might attend a hearing at a later date. The Panel considered that there was a strong public interest in the hearing proceeding without delay. There was a public interest in an expeditious hearing, particularly because this was the second listing of the case for a final hearing. The Panel also took into account the interests of witnesses who had made arrangements to attend the hearing. The Panel recognised that the Registrant might be disadvantaged because he has not attended the hearing. However, the Panel decided that his interests were outweighed by the public interest.
Amendment of the Allegation
6. Ms Vignoles made an application to amend the Allegation. The Registrant was advised of the proposed amendments in a letter dated 22 May 2017.
7. Ms Vignoles explained the reasons for the proposed amendments. She submitted that the proposed amendments do not change the nature or scope of the Allegation, but clarify and particularise it.
8. The Panel, of its own motion, identified that a further two minor grammatical amendments to the Allegation may be appropriate.
9. The Panel accepted the advice of the Legal Assessor.
10. The Panel considered the amendments proposed by Ms Vignoles and set out in the letter dated 22 May 2017. A copy of the letter was also sent to the Registrant’s alternative address on 29 September 2017. The Panel found that that there would be no unfairness to the Registrant if the amendments were made. The amendments did not expand the seriousness or scope of the Allegation; they particularised the Allegation so that it was easier for the Registrant to answer; and the Registrant had good notice of the proposed amendments. The Panel found that the amendments were appropriate because they clarified and particularised the Allegation.
11. The Panel also decided to make the two minor grammatical amendments to the Allegation. These minor amendments did not make a substantive change to the particulars of the Allegation, there was no unfairness for the Registrant, and the amendments were appropriate.
12. The Registrant commenced employment as a Band 5 Operating Department Practitioner (ODP) at the York Teaching Hospital NHS Foundation Trust (the Trust) on 25 April 2016. He had a six week induction period during which he was orientated to the Trust and given a local induction package to complete. During the induction period the Registrant was supernumerary. He was supported by other ODPs and registered practitioners who provided guidance and orientation when required. The Registrant had not practised in the UK as an ODP.
13. On 7 June 2016 SC, Principal ODP and Team Leader for chronic pain in the Theatres, Anaesthetics and Critical Care Department, carried out a review of the Registrant’s probation. The Registrant’s induction period was extended due to concerns that had been raised by colleagues during his six week induction period. The concerns related to the Registrant’s clinical knowledge and skills and his ability to practise as an autonomous practitioner.
14. The Registrant was asked to complete a set of questions in line with the expected knowledge of a newly qualified ODP to try to ascertain whether he felt under pressure in clinical situations, had difficulty in communicating, or if he simply did not have the clinical knowledge. SC sought feedback from a number of colleagues who worked with the Registrant during the period of time he worked at the Trust including, DM, Senior staff nurse and Senior ODP in the Main Theatres and Day Unit, ST, ODP, and SS, Staff Nurse. On 16 June 2016 SC met with the Registrant and explained the feedback she had received, her concerns about the Registrant’s answers to the questions, and her concerns about the Registrant’s knowledge and skills.
Decision on Facts
15. The Panel heard evidence from SC and DM. The Panel found that both witnesses were fair, reliable and credible witnesses.
16. The Panel read the witness statements of ST and SS. ST and SS were available to give evidence by telephone if required. The Panel decided to admit the statements of ST and SS as unchallenged evidence. The Panel gave weight to the written statements of ST and SS because the statements were unchallenged, consistent with the contemporaneous documents, and consistent with the oral evidence of SC and DM.
17. There were no written submissions or documents submitted by the Registrant.
18. The Panel found particular 1(a) proved by the evidence of SS, SC and the documentary evidence.
19. SS recorded her concerns in an e-mail to SC dated 15 June 2016. SS was supporting the Registrant in theatre during his induction period. Amongst her concerns, she described a patient who was not ventilating very well and that the Laryngeal Mask Airway needed to be repositioned. The Registrant appeared to be unaware that there was a problem because he did not respond to the situation until SS had done so.
20. The Panel found particular 1(b) proved by the evidence of DM, SC and the documentary evidence.
21. DM recorded her concerns in a written statement provided to SC dated 20 June 2016. She stated: “The anaesthetist asked for an infusion and SM did not know that this required a pump”. DM explained that an infusion is a drug or fluid given at a fixed rate over a period of time. Despite prompting by DM, the Registrant did not know that a pump was required for an infusion to ensure that the correct dosage was given over a period of time.
22. The Panel found particular 1(c) proved by the evidence of DM and the documentary evidence.
23. DM described an incident on 13 June 2016 where a patient was transferred to the Post-Anaesthetic Care Unit (PACU) following a major surgical procedure. The patient’s oxygen saturation level began to decrease and the anaesthetist asked the Registrant for some “reversal”; this would require a drug administered intravenously to reverse the effect of the muscle relaxation. The drug required was Glycopyrronium bromide with neostigmine, the main drug of choice for “reversal”.
24. In this situation the Registrant did not know what to do and did not appear to understand that swift action was required. DM stepped in to obtain the drug for the anaesthetist.
25. The Panel found particular 1(d) proved by the evidence of ST, SC and the documentary evidence.
26. ST recorded her concern in an e-mail to SC dated 16 June 2016. The Registrant and ST were in a theatre with a patient. The Registrant removed a bed from the theatre and did not return for some time. The Registrant should have connected monitors to the patient and should not have left the theatre until the monitors were connected.
27. The Panel found particular 2(a) proved by the evidence of DM, ST, SS, SC and the documentary evidence.
28. It was part of the role of the ODP managing the theatre list to check the anaesthetic machine at the beginning of each shift, in accordance with the mandatory guidelines from the Association of Anaesthetists of Great Britain and Ireland. The anaesthetic machine monitors the patient’s expiration and inspiration of gases and maintains anaesthesia of the patient. The Registrant was expected to carry out a number of methodical steps during the checking process. He was shown how to carry out the checks on a number of occasions prior to the incidents described by the witnesses.
29. Although the Registrant confirmed that he was able to check the anaesthetic machine, DM noticed on one occasion that he had not completed the steps required. She noticed that the Bains circuit was still in a sealed bag in which it is delivered from the manufacturers. It should be removed from the bag, connected to the anaesthetic machine and tested. The Bains circuit is a circuit used to administer oxygen and vapours to an anaesthetised patient. DM stepped in, removed the Bains circuit from the bag, attached the circuit to the machine and completed the full check. When DM asked the Registrant to demonstrate that he had understood what she had shown him and complete a full check, he did not know how to remove the oxygen hose from the Shrader valve. The Schrader valve is the connection to carry piped gas to the anaesthetic machine.
30. On 1 June 2016 SS asked the Registrant to check the small anaesthetic machine. She noticed that he was trying to check the machine while it was switched off. SS explained the on/off button and showed the Registrant what to do. She watched him make the same mistake a few days later, on 6 June 2016 on the same make of machine.
31. ST also observed the Registrant carrying out the checks of an anaesthetic machine. She reported to ST that the Registrant remained unsure of how to check the anaesthetic machine seven weeks after he started work.
32. The Panel found particular 2(b) proved by the evidence of SC, DM and the documentary evidence.
33. Staff members reported to SC that the Registrant was asked to collect stock or equipment, but was unable to recognise or find the items without help. For example SS asked the Registrant to obtain a cardiac monitor/flow track machine. The Registrant told SS that he did not know what this was. DM described in her oral evidence the process of the stocking up list to ensure that a theatre is in readiness for the listed procedures.
34. The Panel found particular 2(c) proved by the evidence of DM and SC.
35. DM had a discussion with SC about the Registrant’s lack of knowledge regarding induction and maintenance of anaesthesia. SC also identified in her discussions with the Registrant that he lacked clinical knowledge about the process of maintaining anaesthesia. Propofol is an induction drug which renders a patient unconscious, but it is not usually the preferred method of keeping patients asleep in theatre. Anaesthesia is commonly maintained by use of inhalational vapours delivered from the anaesthetic machine via the circuit to the patient.
36. The Panel found particular 2(d) proved by the evidence of SC and the documentary evidence.
37. In the list of questions the Registrant was asked “What drugs and equipment need to be prepared for a rapid sequence induction?”. The Registrant failed to list suxamethonium in his answer. The Registrant also failed to answer suxamethonium when asked “what depolarising muscle relaxant is in common use?” and failed to list suxamethonium as an emergency drug. Suxamethonium is a short acting muscle relaxant often given to patients prior to intubation to paralyse them and it can be used for emergency intubation to maintain oxygenation to the patient. Its availability is essential.
38. Members of staff who worked with the Registrant made verbal reports to SC that the Registrant did not understand the urgency for suxamethonium when it was needed in an emergency. The Registrant’s answers to the questions confirmed that he did not have clinical knowledge of suxamethonium as a required rapid sequence induction drug and as an emergency drug.
39. The Panel found particular 2(e) proved by the evidence of ST, SC and the documentary evidence.
40. ST explained the importance of labelling drips to the Registrant because they needed to be disposed of after 24 hours if not used to prevent the risk of infection. Despite this advice, every time the Registrant set a new drip up ST had to remind him to label them.
Decision on grounds
41. The question of whether the proven facts constitute a lack of competence is for the judgment of the Panel and there is no burden or standard of proof.
42. The Panel was satisfied that the facts found proved amounted to a fair sample of the Registrant’s work. The matters were reported by different ODPs and registered practitioners over a period of time. They concerned a broad range of clinical knowledge and skills involving the use of equipment, drugs, maintenance of patient care, and acting in emergency situations. There were repeated failures, such as the failure to check the anaesthetic machine. There was no significant improvement demonstrated by the Registrant during the induction period, despite continuous training and support.
43. The Panel was satisfied that the Registrant was provided with an appropriate level of support and orientation through the induction process. The errors were not due to an inability to locate the relevant equipment or drugs, but to a failure to recognise and understand what was required.
44. The Registrant’s lack of knowledge and skills was at a basic level for an ODP; this included the ability to check and assemble equipment, identify and prepare equipment and drugs for the operating list, provide skilled assistance to the anaesthetist, and the ability to respond in emergency situations. The ODPs who supported the Registrant during his induction period with the Trust were not confident that the Registrant could work safely and autonomously as an ODP. SC described the Registrant’s level of knowledge and skill as being lower than a first year student at the end of the first year of a three year degree.
45. Although the Registrant was able to establish a good rapport with patients, and was pleasant when communicating with colleagues, his clinical skills and knowledge fell far short of the requirements for a Band 5 ODP. The Registrant agreed with SC that his knowledge of the role was not “at the standard of a qualified ODP” in the meeting on 16 June 2016.
46. The Panel considered that the area of lack of competency included the Registrant’s lack of knowledge of technical terms used in healthcare but did not extend to general communication difficulties. The witnesses explained that the Registrant had lived in the UK for approximately seven years and that he was able to communicate with patients without difficulty.
47. Although there was no actual harm to patients because the Registrant was working in a supernumerary role and was supervised and supported by ODPs and other registered practitioners at all times, there was the potential for very serious harm to patients if the Registrant had been practising autonomously. For example, in particular 1(a) the Registrant had failed to recognise that the patient’s airway had become compromised. If SS had not been present, the anaesthetist would have had to rectify the airway. If this had been missed the patient could have developed laryngospasm and become deprived of oxygen. A further example is particular 1(c). DM described in her oral evidence that if the reversal drug had not been administered the patient’s oxygen saturation would have continued to decrease.
48. The Panel considered the ODP Standards of Proficiency and identified a breach of the following standards:
• standard 1 “be able to practise safely and effectively within their scope of practice”;
• standard 4 “be able to practise as an autonomous professional exercising their own professional judgment”;
• 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”.
49. In the Panel’s judgment the facts found proved constituted a lack of competence.
Decision on impairment
50. The Panel applied the guidance in the HCPTS Practice Note “Finding that Fitness to Practise is Impaired” and accepted the advice of the Legal Assessor. The Panel considered the Registrant’s fitness to practise at today’s date.
51. The Panel first considered the personal component, which is the Registrant’s current level of competence. There was no information on the Registrant’s current employment or circumstances. He provided no information to assist the Panel in assessing the current level of his insight or any remedial action.
52. The Panel noted that when the Registrant spoke to SC in June 2016 he demonstrated some insight. In particular he agreed that his knowledge was not at the standard of a qualified ODP. However, this insight, without any evidence of remedial action, was not sufficient to reassure the Panel that there is no ongoing risk to patients.
53. Although the Registrant’s lack of clinical knowledge and skills is remediable, the Panel considered that the deficits were not easily remediable because of their nature and extent. The Registrant did not demonstrate the basic level of competency of a first year student. An anaesthetist told SC that a training period of 8-12 months would be required for the Registrant to work safely. However, the Panel noted that this would not cover all elements of the knowledge and skills required for an ODP, only those that were required for the role at the Trust in anaesthetics. The full range of knowledge and skills could be acquired through obtaining a degree qualification, but that would take three years. The Panel noted that even if the Registrant had commenced a degree course in 2016, he would not have completed it.
54. There is no evidence that the Registrant has taken any steps to remedy his lack of competence. The Panel therefore decided that there was an ongoing risk of repetition and an ongoing risk to patients.
55. The Panel next considered the wider public interest considerations including the need to maintain public confidence in the profession and to uphold standards.
56. Members of the public place a high level of trust in the ODP as a vital member of the multi-disciplinary team during an operation. The patient who is undergoing an operation under anaesthesia relies wholly on the members of the team, including the ODP to use their knowledge and skill and to respond quickly to changing circumstances. Members of the public would expect the Regulator to take action to ensure that a Registered ODP who does not have the required knowledge and skills is not permitted to practise unrestricted, especially when there is a risk of harm to patients. Members of the public and the profession would also expect the Panel to find that the Registrant’s fitness to practise is impaired to send a clear message to the public and to the profession that Registrants must meet the Standards of Proficiency.
57. The Panel decided that the Registrant’s fitness to practise is currently impaired on the basis of both the personal component and the public component.
Decision on Sanction
58. In considering which, if any, sanction to impose the Panel had regard to the HCPC Indicative Sanctions Policy (ISP) and the advice of the Legal Assessor.
59. The Panel reminded itself that the purpose of imposing a sanction is not to punish the practitioner, but to protect the public and the wider public interest. The Panel ensured that it acted proportionately, and in particular it sought to balance the interests of the public with those of the Registrant, and imposed the sanction which was the least restrictive in the circumstances commensurate with its duty of protection.
60. The Panel decided that the aggravating features include:
• the depth and extent of the deficiencies covering the core areas of practice;
• potential risk of serious harm to patients;
• repeated failures e.g. the anaesthetic machine;
• no significant improvement despite continuous training, support and supervision;
• no pro-active steps by the Registrant to obtain training or support.
61. The Panel decided that the mitigating features include:
• good interpersonal skills including with patients;
• acceptance of and engagement with feedback.
62. The seriousness of this case and the ongoing risk of repetition meant that taking no action was not an option and a Caution Order, even for the maximum duration, would not provide adequate protection to the public or the required level of public reassurance. Mediation is not appropriate in this case.
63. The Panel next considered a Conditions of Practice Order. The Panel decided that the current level of the Registrant’s knowledge and skill is not sufficient for conditions of practice. The Registrant would need to be subject to constant supervision, which is not workable, and the conditions would be so restrictive that they would amount to a Suspension Order. The deficiencies in the Registrant’s practice are so many and so basic that he is not currently safe to practise, even under conditions of practice. The facts found proved occurred while the Registrant was in a supernumerary position and subject to supervision, but this was not sufficient to prevent the repetition of errors. The Panel considered that direct supervision would not be sufficient to address the risk of repetition. The Registrant’s level of knowledge and skill would need to be increased before he could practise safely under conditions of practice.
64. The Panel therefore decided that conditions of practice would not be sufficient to protect the public. They would also not provide a sufficient degree of reassurance for members of the public that the Panel was taking the appropriate regulatory action.
65. The Panel next considered the more restrictive sanction of a Suspension Order. The Panel considered that a Suspension Order is appropriate. It provides adequate public protection because the Registrant will be unable to practise as an ODP while he is subject to the Suspension Order, and the Order will be reviewed before it expires.
66. The Panel decided that a Suspension Order is also appropriate in the wider public interest. It is the most restrictive sanction available to the Panel. It marks the seriousness and extent of the deficiencies in the Registrant’s practice. The decision not to permit the Registrant to practise for the duration of the Suspension Order sends a clear message to members of the public and to the profession.
67. The Panel recognised that the consequences for the Registrant of the imposition of this sanction may be severe and may damage his financial interests and his reputational interests. Nevertheless, the Panel decided that the Registrant’s interests were outweighed by the need to protect the public and the need to maintain public confidence in the profession and the regulatory process.
68. The Panel decided that the length of the Suspension Order should be for the maximum period of twelve months. The Panel was informed that the Registrant has been subject to an Interim Suspension Order since August 2016. The Panel explained earlier in its decision that it considered that deficiencies in this case were not easily remediable and that remedial steps would take a considerable length of time. There is no information which suggests that the Registrant has already begun this process. The Panel considered that the maximum period of twelve months would be the minimum for the Registrant to demonstrate that he has started to remedy the deficiencies in his practice.
69. The Panel therefore decided that the appropriate and proportionate order is a Suspension Order for a period of twelve months.
70. The Suspension Order will be reviewed before it expires. A review panel may be assisted by:
• evidence of any steps taken by the Registrant to address the deficiencies in his clinical knowledge and skills;
• the attendance of the Registrant to explain any remedial steps he has taken since 2016.
History of Hearings for Mr Salim M Ahmaida Makhlouf
|Date||Panel||Hearing type||Outcomes / Status|
|13/03/2020||Conduct and Competence Committee||Review Hearing||Hearing has not yet been held|
|14/03/2019||Conduct and Competence Committee||Review Hearing||Suspended|
|19/03/2018||Conduct and Competence Committee||Final Hearing||Suspended|