Miss Catherine A Weir

Profession: Biomedical scientist

Registration Number: BS43280

Interim Order: Imposed on 28 Jun 2017

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 26/11/2018 End: 17:00 29/11/2018

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

Panel: Conduct and Competence Committee
Outcome: Hearing has not yet been held

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Allegation

 

Whilst Registered with the Health and Care Professions Council (HCPC) as a Biomedical Scientist;

1.Between March 2016 – March 2017 you were unable to maintain your practice as a Band 5 Biomedical Scientist with Kent & Canterbury Hospital in that you:

a. did not follow correct standards of practice on issues of Human Albumen Solution (HAS) correctly on 18 March 2016;

b. did not follow correct standards of practice for samples acceptance criteria, on dates which included 12 April 2016 and/or 18 August 2016;

c. did not follow correct standards of practice for irradiated products alerts on 14 April 2016;

d. did not follow correct standards of practice on serological cross-matching on 29 June 2016;

e. did not follow correct policy for irradiated products/cross-matching on 11 October 2016;

f. did not follow correct standards of practice of reagent control on Gelstation on 25 October 2016;

g. did not follow correct standards of practice on resolution of ABO anomalies on 8 December 2016;

h. did not follow correct standards of practice on the issue of red blood cells on 26 December 2016;

i. made errors regarding antibody identification, on dates which included 24 February 2017 and/or on 3 March 2017;

j. made errors regarding sample identification on 27 February 2017;

k. made errors in relation to an antibody exercise from the Transfusion Science book on 28 February 2017.

2. Did not obtain consent/permission from your managers to use their personal information to support your application for your IBMS Specialist Portfolio.

3. Your actions as set out in paragraph 2 were dishonest.

4. The matters set out in paragraphs 1, 2 and 3 amount to misconduct and/or lack competence.

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

 

 

 

Finding

Preliminary Matters

Proof of Service

1. Miss Catherine Weir (“the Registrant”) is registered with the HCPC as a Biomedical Scientist.

2. The Panel was satisfied that the notice of hearing was sent by post to the Registrant on 16 August 2018.  The version sent by post was sent to the address provided by the Registrant to the HCPC for registration purposes. The Panel was satisfied that there had been good service of the notice of hearing.

Proceeding in the Absence of the Registrant


3. The Registrant did not attend the hearing. On behalf of the HCPC, Ms Thompson asked the Panel to proceed in the absence of the Registrant. She accepted that the Registrant had a right to be present and that a Panel should take great care before deciding to proceed in the absence of a registrant. It was important that the Panel fairly balanced all the relevant circumstances.


4. The Legal Assessor drew the Panel’s attention to the guidance provided in the HCPTS Practice Note “Proceeding in the Absence of the Registrant”. The Panel was advised that the decision on whether it was appropriate to proceed in the absence of a registrant is a matter of discretionary judgment for the panel.


5. The Panel took into account the advice of the Legal Assessor and the guidance provided in the relevant Practice Note. The Panel was satisfied that all reasonable steps had been taken to serve notice of the hearing on the Registrant. The task for the Panel was to strike the proper balance between the public interest in proceeding with cases in a timely manner and ensuring fairness to the Registrant.

In exercising its discretion on whether to proceed, the Panel placed weight on the following considerations:
• there is a burden on professionals to engage with their appropriate regulator in the resolution of allegations.
• there is a public interest in dealing with cases with reasonable expedition. The Panel also bore in mind that the witness for the HCPC was in attendance ready to give evidence.
• there has been little previous engagement by the Registrant in these proceedings. In response to a letter from the HCPC dated 16 August 2018, in advance of a preliminary hearing in this case, the Registrant indicated that she did not wish to attend future hearings.


6. The Panel placed significant weight on the fact that the Registrant has not previously engaged in the proceedings. The Registrant has made no request for the present hearing to be adjourned. The Panel considers that it is unlikely that the Registrant would attend any future hearing given the lack of engagement to date.


7. The Panel accepted that the Registrant would be disadvantaged to some degree by her absence but concluded, on balance, that the wider public interests meant that the hearing should continue in the absence of the Registrant.


Background


8. The Registrant was employed by East Kent Hospitals University NHS Foundation Trust as a Biomedical Scientist. She was initially engaged on a fixed term contract from 18 August 2014. From 1 June 2016, she was engaged on a permanent basis. Her employment with the Trust ended on or around 31 August 2017. This followed concerns raised by CL, in particular from an incident in December 2016 which resulted in an Action Plan being undertaken by the Registrant that did not result in the required improvements.


9. HCPC asserts that the allegations amount to misconduct and/ or lack of competence. It is asserted that the Registrant’s conduct and/or competence fell below the standards expected of a reasonably competent Biomedical Scientist.


10. HCPC produced a bundle of documents in advance of the hearing. The bundle included a detailed witness statement of CL, the Trust’s chief Biomedical Scientist and the Registrant’s line manager. CL was the only witness on behalf of the HCPC.


11. The Registrant has not engaged in the final hearing process. No documentation has been lodged on behalf of the Registrant. She did not appear at the hearing.


Decision on Facts


12. The Panel considered with care all the evidence presented, together with the submissions made by Ms Thompson on behalf of the HCPC. The Panel heard and accepted the advice of the Legal Assessor and bore in mind that, it was for the HCPC to prove its case and to do so on the balance of probabilities.


13. The Panel found CL to be open, honest, consistent and credible. She provided her evidence in a balanced and measured way.  She was very knowledgeable and explained carefully how she had tried to support the Registrant both informally and formally.
14. The Panel then considered each allegation in turn.


1. Between around 18 March 2016 and 3 March 2017, whilst employed as a Biomedical Scientist by East Kent Hospitals University NHS Foundation Trust:
a  On 18 March 2016, you  did  not  follow  correct  standards  of  practice  on issues of Human Albumin Solutions (HAS) correctly in that
(i) you did not check the volume and/or concentration requested;
(ii) you issued HAS at the wrong volume and/or concentration

15. CL explained that HAS is a protein fraction from human blood. There are different strengths of HAS. 5% is weak. 20% is strong. Different strengths of HAS are used to treat different conditions. A weak volume would be used as a volume expander, for example if a patient had low blood pressure. A higher volume would be used when performing tasks such as an ascitic drain.

16. CL provided clear evidence of the Trust’s Standard Operating Procedures (SOP) in relation to the issue of HAS as at March 2016. This was consistent with the SOP included within the bundle of documents produced by the HCPC.

17. CL explained that on 18 March 2016, the Registrant was required to prepare HAS at 20%, which would have come in a volume of 100ml of solution. The Registrant issued HAS at 5%. HAS at 5% comes in volumes of 500ml. Accordingly, the Registrant has failed to comply with the request issued to her. She has issued five times the requested volume of HAS and at a lower concentration than required.

18. CL explained that the Registrant accepted that she did not follow the SOP and should have checked what she was doing more thoroughly. This evidence was consistent with the adverse incident report that was included within the bundle of documents. The narration within the adverse incident report strongly suggested that the Registrant accepted that the incident had taken place. The Registrant’s explanation for the incident was that it occurred because she was distracted as she was dealing with multiple tasks at the time of the incident.

19. On the basis of the HCPC’s evidence, the Panel found Particular 1 a (i) and (ii) proved.
b. You did  not  follow  the  Standard  Operating  Procedures  for  sample  acceptance  criteria,  in  that you:
(i) On 12 April 2016,  accepted  a  sample  despite  the  forename of  the  patient  being  misspelt; and/or
(ii) On 18 August 2016, accepted a sample that contained the wrong date of birth for the patient


20. CL explained the Trust’s SOP in relation to the identification of specimens relating to patients. Before accepting a clinical specimen, staff must ensure that certain minimum criteria for sample identification are met. This involves three unique points of identification being checked: name, date of birth and hospital number. These criteria must be cross checked for every sample. If there are any errors, then the sample should not be processed. CL stressed how critical these polices are to ensure that there is no confusion in relation to which samples relates to which individual patient.


21. CL explained that on 12 April 2016, the Registrant accepted a sample where the forename of the patient was misspelt when compared to the relevant form. The Registrant completed a reflective learning statement on 16 April 2016 in relation to this incident. She accepted that the forename on the sample was misspelt by one letter and therefore did not match what was stated on the accompanying form. In the statement, the Registrant notes that she had learned that she needed to be more vigilant when checking the details on samples received in the laboratory.


22. CL explained that on 18 August 2016, the Registrant received a sample from a patient for testing. The sample had the incorrect date of birth for the patient and should not have been tested. However, the Registrant proceeded to test the sample. A reflective statement was produced by the Registrant. In the statement, the Registrant accepted that the patient’s date of birth on the sample was incorrect. The Registrant stated that she had learned that she needed to check the details on the sample more thoroughly before proceeding with testing.


23. On the basis of the HCPC’s evidence, the Panel found Particular 1 b (i) and (ii) proved.
c. On 14 April 2016, you did not follow the Standard Operating  Procedures for irradiated products in that you did not add  the irradiated   products alert correctly onto the patient's electronic record

24. Certain patients require irradiated blood products. If they received non-irradiated blood products, this can have fatal consequences.

25. CL explained the Trust’s policy in relation to irradiated blood products. The Trust has a SOP which requires a “toggle” alert to be added to the computer system for any patient that requires irradiated blood products. Although the SOP provided within the bundle was from October 2015, CL confirmed that the Trusts’ SOP as at April 2016 was, in all material respects, the same as the 2015 version. On the computer system, there is a function known as “SRPAD”. This is a special requirements pad. If the patient required irradiated blood products, when the patient’s details are opened on the system, an alert will flash up to inform the member of staff that the patient requires irradiated blood products.

26. CL outlined an incident that took place on 14 April 2016. The Registrant received a form which informed her that a patient required irradiated blood products. The Registrant was required to input this information onto the computer system and to ensure that a “toggle” alert was added to the patient’s records. CL explained that she emailed the Registrant to draw this failure to her attention. The Registrant responded and confirmed that she had re-read the SOP. She did not dispute that the incident had taken place. These emails were provided in the bundle of documents provided by the HCPC.

27. On the basis of the HCPC’s evidence, the Panel found Particular 1 c proved.
d. On 29 June 2016, you did not follow the Standard Operating Procedures  on  serological cross-matching in that  you  chose  a  unit  of  Rhesus  positive  blood for  issue  to  a  patient  with Rhesus negative blood type


28. When issuing blood for a blood transfusion, a test is carried out on the patient against the donor to ensure compatibility. Serological cross-matching is the test conducted in the laboratory to ensure compatibility. CL explained the Trust’s SOP in this regard.

29. CL explained that on 29 June 2016, the Registrant was required to cross-match a patient ready for a routine blood transfusion top up. The patient was Rh D negative. For this patient, the Registrant chose Rh D positive blood product. CL explained that this was a basic error. It was also a clear failure to follow the relevant SOP. Such a course would only be adopted in a life or death situation. The incident did not arise from any such circumstances. An incident report was produced. The explanation recorded as accounting for the error was that the Biomedical Scientist was distracted. CL confirmed that the Biomedical Scientist responsible was the Registrant.

30. The incident resulted in a patient being given one unit of incompatible blood which could have ongoing complications if further treatment was required.

31. On the basis of the HCPC’s evidence, the Panel found Particular 1 d proved.
e. On 1 October 2016, you:
(i) did not make further enquiries  in  relation  to   a  patient's  requirements  for  irradiated  blood products; and/or
(ii) ordered one unit of blood to be transported by taxi;
(iii) caused a delay to the patient's blood transfusion.


32. CL explained that the Trust’s SOP for a particular ward required that patients on a specified ward should only receive irradiated blood products. However, not all patients on that ward required irradiated products and that would be obvious if the individual checked the computer system for the patient. The Registrant had not checked the computer system in relation to a particular patient. Rather, she had assumed that the patient required irradiated blood products and had ordered one unit of irradiated blood to be delivered by taxi. This resulted in a delay in the patient receiving the blood product. If the Registrant had checked the computer system she would have realised that irradiated blood products were not required and that blood products were in stock that could have been provided to the patient immediately. CL’s positon was that one unit of blood would never be ordered by taxi as this was a waste of resources.

33. The Registrant produced a reflective statement. In this statement, she acknowledges that one unit of irradiated blood was ordered by taxi. She acknowledges that the patient did not require irradiated blood.

34. On the basis of the HCPC’s evidence, the Panel found Particulars 1 e (i), (ii) and (ii) proved.

f.  On  22 October  2016,  you  did  not  follow  the  Standard  Operating  Procedure of reagent control in that you:

(i)  did not correctly check the expiry dates of the reagents to be used
(ii) recorded the incorrect expiry date for the reagents on Gelstation;


35. CL explained that the Trust has a detailed SOP in relation to the daily set up of the Gelstation, a blood transfusion analyser. Reagents are used for performing blood group and antibody screens for samples put onto the analyser. Reagents are controlled and checked daily. Reagents have an expiry date and should not be used after this date. Checking expiring reagents is a task on the daily task list which staff are expected to accommodate during a shift.


36. On 22 October 2016, the Registrant failed to check the expiry dates of the reagents correctly. She recorded the expiry dates of the new batch of reagents that had been put on the Gelstation, rather than recording the date of the batch that was in use. If she had recorded the expiry date of the batch that was in use, she would have realised the reagents had expired. Accordingly, she both failed to check, and then accurately record, the relevant expiry date. An incident log was created in relation to this incident.


37. On the basis of the HCPC’s evidence, the Panel found Particulars 1 f (i) and (ii) proved.
g. On 8 December 2016, in relation to an ABO blood group anomaly you:
(i) did not conduct further tests when it was appropriate to do so; and/or

(ii) incorrectly concluded that the patient was blood group A Positive;

38. CL explained that, on 8 December 2016, the Registrant was working in the laboratory. She tested a sample but got an anomalous blood group result. She then reached the wrong conclusion about what blood group the patient was. CL described this work as being basic for a Biomedical Scientist and explained that such errors can have catastrophic consequences, including, in extreme cases, causing the death of a patient.

39. The Registrant completed a reflective statement on 14 December 2016. Several versions of the statement were drafted by the Registrant. These acknowledge that the Registrant failed to identify the patient’s blood group correctly.

40. On the basis of the HCPC’s evidence, the Panel found Particulars 1 g (i) and (ii) proved.
h. On  26  December 2016,  you  did  not  follow   correct  standards  of   practice  on  the  electronic  issue of red blood cells in that you:
(i) did  not  input  the  timings of  the two samples into  the  APEX computer system; and/or
(ii) issued red blood  cells  using  electronic issue when it was  not  appropriate to do so


41. CL explained the Trust’s SOP in relation to the issuing of red blood cells. In short, this could either be done electronically or manually. To be done electronically, the APEX computer system would need to be satisfied that the blood samples had been taken in accordance with the SOP. That would involve samples being taken at different times and these different times being inputted into the computer. If that was not done, the product could only be issued after manual serological testing had been conducted, which would take around an hour to complete.


42. On 26 December 2016, the Registrant received two samples which had been correctly taken at separate times. These samples were booked onto the APEX computer system. However, the Registrant did not input the correct time of both samples. The same time was therefore assigned automatically by the APEX system. The Registrant subsequently required to conduct a cross-match to issue red blood cells to the patient. She tried to conduct an electronic issue. However, the APEX computer system would not permit the electronic issuing as the times of the samples were identical. A manual serological cross-match would therefore be required in line with the SOP. The Registrant did not do so. Rather, she circumvented the electronic issue. She input results for a serological cross-match which she had not in fact carried out.


43. The Registrant completed a reflective statement. The Registrant confirmed that she had not completed a serological cross match and should not have issued the units. In this statement, she recorded that:
“On reflection, I shouldn’t have issued the units as selected as I hadn’t performed a serological cross-match on the units and APEX wouldn’t allow the units to be issued electronically…”


44. On the basis of the HCPC’s evidence, the Panel found Particulars 1 h (i) and (ii) proved.
i. You issued untreated fresh frozen plasma to a patient born after 1 January 1996 on:
(i) 13 January 2017 and/or
(ii) 16 January 2017


45. CL explained that the Registrant was asked to defrost fresh frozen plasma for a patient born after 1 January 1996. Patients born after 1996 should be issued with solvent treated fresh frozen plasma. On 13 January 2017 and 16 January 2016, the Registrant issued untreated fresh frozen plasma for this patient who was born after 1 January 1996.


46. The Registrant completed a reflective statement. In this statement, the Registrant acknowledged that the:
 “…guidelines state that patients born after 1/1/1996 should receive MB treated or solvent detergent treated plasma. I used untreated fresh frozen plasma on both occasions”.  


47. The Registrant accepted that, on reflection, she should not have issued the plasma that she did to the patient. She stated that she has re-read the SOP and the relevant guidelines.


48. On the basis of the HCPC’s evidence, the Panel found Particulars 1 i (i) and (ii) proved.
j. On 24 February 2017,  you  were  unable  to  complete  work  on  a  NEQAS  (National  External  Quality Assurance Scheme) sample to the expected standard


49. CL explained that once a month, a random sample would be sent to the laboratory by the National External Quality Assurance Scheme (NEQAS). The sample would have antibodies that needed to be identified. The purpose of the scheme is to demonstrate that a department can produce good quality results. On 24 February 2017, whilst the Registrant was working under the Action Plan, she was asked to perform the work on the NEQAS sample. The Registrant worked on the sample but was unable to complete it and positively identify the antibodies. She stated that she could not identify the antibodies. CL considered that the Registrant could have undertaken more work on the sample to identify the antibodies. An email exchange took place where CL identified the errors that had taken place. The email exchange was in the bundle of documents produced by the HCPC. In CL’s view, this was an exercise that the Registrant should have been well capable of completing.

50. On the basis of the HCPC’s evidence, the Panel found Particular 1 j proved.
k. On 3 March  2017,  you  did  not  demonstrate  an appropriate  level   of  knowledge  in  relation  to High Titre labelling


51. CL provided evidence in relation to the Registrant’s knowledge of High Titre labelling. In an email dated 3 March 2017 from CL to the Registrant, this issue was raised and included the detailed areas of knowledge that the Registrant failed to show. The Registrant replied stating that she had read and understood the email.

52. On the basis of the HCPC’s evidence, the Panel found Particular 1 k proved.
l. On 27 February 2017, you did not follow the Standard Operating Procedures for samples acceptance criteria in that you processed samples for   two patients when the form did not match the information on the sample


53. CL explained that on 27 February 2017, the Registrant processed samples for two patients when the information on the patients’ request forms did not match the information on the samples. This was in breach of the relevant SOP. Reference is made to paragraph 20 above which sets out the Trust’s policies in this regard and the SOP. An email exchange took place between CL and the Registrant on 27 and 28 February 2018 in relation to this issue. In an email dated 28 February 2017, the Registrant stated:

“I am very sorry that I omitted a checking step which I would usually carry out to highlight that the two samples were incorrectly labelled prior to authorising the results…”

54. On the basis of the HCPC’s evidence, the Panel found Particular 1 l proved.
m. On 20 February 2017, you did not demonstrate   awareness   of   the   BCSH (British Committee for Standards in Haematology) Guidelines in relation to the identification of antibodies


55. CL explained that on 20 February 2017, whilst the Registrant was working under the Action Plan, she set the Registrant an exercise to complete. The Registrant was unable to identify the relevant antibodies. This was because they were too complex for a laboratory of the size the Registrant was working in to identify. The Registrant was not aware of this. Such issues are clearly covered in the BCSH guidelines. In an email dated 20 February 2017, the Registrant confirmed that she had now read the BCSH guidelines.

56. On the basis of the HCPC’s evidence, the Panel found Particular 1 m proved.
n. On 28 February 2017, you were unable to complete an antibody exercise from the Transfusion Science book to the expected standard


57. CL explained whilst the Registrant was working under the Action Plan, she set the Registrant an exercise from the Transfusion Science book, a standard textbook, regarding antibody identification. The Registrant was unable to complete the exercise. In CL’s opinion, this demonstrated that the Registrant did not have a grasp of the basic principles of antibody identification. The Registrant acknowledged the conversation she had with CL about the errors in the antibody exercise.
 
58. On the basis of the HCPC’s evidence, the Panel found Particular 1 n proved.
2. Did not obtain consent/permission from your managers to use their personal information to support your application for your IBMS (Institute of Biomedical Science) Specialist Portfolio


59. CL explained that the Institute of Biomedical Science provides a range of Specialist Portfolios. It would take at least 2 years to complete this qualification. An applicant must have the support of their employer and identify a supervisor. The Registrant had asked if the Trust would support her seeking a Specialist Portfolio at her original interview. As the post was for a fixed period, and the Specialist Portfolio was not required for the role, she was advised that this would not be possible. The Registrant asked whether the Trust would support her in seeking an advanced portfolio at various points during her employment and was consistently told that the Trust would not support her and the reasons for this.

60. Notwithstanding that the Registrant had consistently been told that the Trust would not support her application, she proceeded to make an application. Part of the application form was provided in the bundle of documents provided by the HCPC. An email exchange between CL and the Registrant was also included. In an email dated 3 September 2015, CL highlighted that the application had been made without her consent. Email addresses for CL and a colleague had been used without permission. The Registrant replied stating:

“I am very sorry that I used both yours and Mike’s details without your consent or permission”

61. On the basis of the HCPC’s evidence, the Panel found Particular 2 proved.

3. Your actions as set out in paragraph 2 were dishonest.


62. The Panel considered the submissions Ms Thompson made in relation to dishonesty. Ms Thompson drew attention to the guidance on this issue provided in Ivey v Genting 2018 AC 391:

“When dishonesty is in question the fact-finding tribunal must first ascertain (subjectively) the actual state of the individual's knowledge or belief as to the facts. The reasonableness or otherwise of his belief is a matter of evidence (often in practice determinative) going to whether he held the belief, but it is not an additional requirement that his belief must be reasonable; the question is whether it is genuinely held. When once his actual state of mind as to knowledge or belief as to facts is established, the question whether his conduct was honest or dishonest is to be determined by the fact-finder by applying the (objective) standards of ordinary decent people. There is no requirement that the defendant must appreciate that what he has done is, by those standards, dishonest.” [paragraph 74]

63. The Panel were advised by the Legal Assessor that this set out the current law on this issue.

64. Applying that guidance, the Panel was satisfied that the Registrant knew that the Trust would not support her application. Moreover, she had not obtained the consent of CL or her colleague, MK, the training officer at the Trust, to use their personal details in accordance with any such application. However, the Registrant put in MK’s work address as the delivery address for the portfolio so she knew that the Trust would be contacted directly.

65. The part of the application form which the Panel saw did not contain any personal details for CL, rather, they contained details for MK at the Trust.

66. CL’s evidence was that the form would always have been returned to the Registrant’s employer and therefore the fact that she had applied would always have been discovered. Therefore, CL and the Trust would always have been made aware that the application had been made. The Panel considers that this is a relevant factor in relation to whether the actions of the Registrant were dishonest.

67. Applying the objective standards of ordinary decent people, the Panel concluded that the actions of the Registrant were not dishonest. She made the application in the knowledge and belief that it would be returned to the Trust. Accordingly, while the steps taken by the Registrant were unprofessional, misguided and illogical, the Panel, on balance, considering all the circumstances, reached the view that the actions of the Registrant were not dishonest.


Decision on Grounds


68. Having found the facts set out above to be proved, the Panel then considered whether they amounted to misconduct or lack of competence. In so doing the Panel took into account the submissions of the HCPC and the advice of the Legal Assessor.


69. The Panel also considered the following documents produced by HCPC: (i) “Standards of Conduct, Performance and Ethics; and (ii) Standards of Proficiency for Biomedical Scientists. In relation to document (i), the Panel considered that standard 3 (work within the limits of your knowledge and skills), 6 (manage risk) and 10 (keep accurate records) were particularly relevant to the present case.


70. The Panel considered there to be serious concerns about the way in which the Registrant had been conducting her practice over a sustained period. The Panel was satisfied that in relation to the facts found at 1a, b, c, d, e (i), f, g, h, i and l the statutory ground of misconduct was found. This combined conduct represented a serious breach of professional standards which fell far below the behaviour expected of a registered Biomedical Scientist and thereby amounted to misconduct which was serious. The Panel was not satisfied that the other facts found amounted to misconduct or lack of competence.


71. In relation to 1a, the Panel was satisfied that this amounted to misconduct which was serious and not a lack of competence. This failure could have had far reaching consequences for patients receiving this treatment and was a basic requirement of a Band 5 Biomedical Scientist as outlined in the relevant SOP. The Registrant was a Biomedical Scientist with twenty years’ experience.


72. In relation to 1 b, the Panel was satisfied that this amounted to misconduct which was serious. The standards of practice for sample acceptance are critical to patient safety. The Registrant had not learned from the first error and it is highly concerning that a further error took place. The lack of diligence and care in such an importance issue is characteristic of the practises adopted by the Registrant in the relevant period and, in the view of the Panel, amount to misconduct.


73. In relation to 1 c, the failings were extremely serious. These failures had the potential to cause extreme, and potentially fatal consequences for patients. In the judgment of the Panel, these failings amount to misconduct.


74. In relation to 1 d, the failure to follow correct standards for serological cross-matching was extremely serious. It was described by CL as “bread and butter” work for a Biomedical Scientist. The Registrant fell well below the standard properly to be expected of a Biomedical Scientist. These failings amounted to misconduct.


75. In relation to 1 e (i), the Panel concluded that the failure to make enquiries into the patient’s requirements was misconduct and was serious. The patient had, in fact, never received irradiated products. Accordingly 1 e (i) is made out. The Panel was not satisfied in respect of 1e (ii) and (iii) that the other grounds were made out. In relation to the ordering of blood to be transported by taxi, the Panel did not consider, in its exercise of judgment that this amounted to misconduct and / or lack of competency. It would have had financial consequences for the Trust. However, it did not impact on patient care. Accordingly, 1 e (ii) is not made out. In relation to 1 e (iii) the Panel was not provided with evidence of the length of the delay in the blood product being provided. However, there was no evidence to suggest that the delay was prolonged or impacted on patient care. Indeed, the step of ordering the taxi appears to have been taken in an attempt to avoid any unnecessary delay. Accordingly, the Panel concluded that 1 e (iii) is not made out.


76. In relation to 1 f, the Panel concluded that this amounted to misconduct and was serious. The Registrant failed to correctly check the expiry dates of the reagents to be used. She also recorded the incorrect expiry date on the Gelstation analyser. This fell well short of the standards to be expected of a Biomedical Scientist.


77. In relation to 1 g, the Panel concluded that this amounted to misconduct. This was a routine task. The failure to carry out further testing, and the failure to detect the correct blood group, were serious failings that amount to misconduct.


78. In relation to 1 h, this involved the deliberate circumvention of a SOP established to ensure patient safety. The failure to follow the SOP, and the deliberate decision to input incorrect information to override the computer system, were serious failings and were matters of particular concern to CL. The conduct falls well short of that expected of a Biomedical Scientist both in terms of conduct, performance and ethics. The Panel was in no doubt that this amounted to misconduct.


79. In relation to 1 i, this was a serious failure on the part of the Registrant. The guidelines were basic information that a band 5 Biomedical Scientist should have been aware of. The failure to comply with the established procedures amounts to misconduct.
80. In relation to 1 j, the Panel was not satisfied that the statutory grounds alleged were made out. This was a failure to complete an exercise to the required standard whilst she was under an Action Plan. In the Panel’s opinion, it did not demonstrate lack of competence or amount to misconduct.


81. In relation to 1 k, the Panel concluded that this may demonstrate a poor uptake of training under the Action Plan. However, the Panel formed the view that it did not amount to misconduct or lack of competence.


82. In relation to 1 l, the Panel was satisfied that this behaviour constitutes misconduct. The requirement for the information on the sample to match the information on the relevant form is a fundamental part of the procedures to ensure patient safety. The repeated failure by the Registrant to adhere to the prescribed standards amounts to misconduct. The Registrant’s conduct in this regard fell well short of that to be expected of a Biomedical Scientist.


83. In relation to 1 m, the Panel was not satisfied that the alleged statutory grounds were made out. The Panel concluded that this was not a serious failing which would amount to misconduct and/ or a lack of competence because this incident occurred as part of the Registrant’s training and learning under the Action Plan and was not a serious falling short.


84. In relation to 1 n, the Panel concluded that the failure to complete the textbook exercise was not a serious failure which would amount to misconduct and/ or a lack of competence as this incident occurred as part of the Registrant’s training and learning under the Action Plan and was not a serious falling short.


85. The Panel concluded that ground 2 did not amount to misconduct and/ or lack of competency. The decision to use personal information without consent was ill advised. The Panel was not satisfied that there was any deceitful intent to gain any benefit from the use of the information. The Trust would always have been advised of the fact that the application had been made. While the actions were inappropriate and ill advised, the Panel concluded that it did not meet the threshold for misconduct which was serious and/ or lack of competence.


Decision on Impairment


86. The Panel has taken into account the submissions made by Ms Thompson, and the HCPTS Practice Note “Finding that Fitness to Practise is Impaired”. It also heard and accepted the advice of the Legal Assessor.


87. The Panel requires to determine whether fitness to practise is impaired as at today’s date. The Panel’s task is not to punish the Registrant for past acts. However, the Panel does require to take account of past acts and omissions in order to make an informed assessment whether the Registrant’s present fitness to practise is currently impaired.


88. The Panel has taken into account in the HCPTS’ Practice Note:
• the ‘personal’ component: the current competence,   behaviour  etc. of the individual Registrant; and
• the ‘public’ component: the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession.


89. The Panel found significant and serious failings by the Registrant in some of the most fundamental and basic of tasks to be completed by a Biomedical Scientist. There were a significant number of incidents over a relatively short period of time. They were not isolated incidents with a low risk of repetition. The incidents identified by the Panel led to significant risks arising to patients. As CL explained in her witness statement, and in her oral evidence, some of these failures could have caused serious harm to patients if they had not been spotted by others.


90. In respect of the personal component, the Panel concludes that the failings were widespread and related to basic areas of practice. The Panel notes that the Registrant has shown limited insight into the serious nature of the failings. The reflective statements produced by the Registrant show little insight or appreciation of the serious nature of the failings. Moreover, the fact that some mistakes were repeated after the reflective statements were made strongly suggests that that any remedial steps taken by the Registrant, for example, re-reading the relevant SOPs, were not effective.


91. The Panel was not provided with any evidence to demonstrate genuine insight or remediation. The Panel could not have any confidence that the serious failings made in the past would not be repeated in the future.


92. The Panel went on to consider whether this was the type of case that required a finding of impairment on public interest grounds in order to maintain public confidence in the profession, and the regulator and to uphold proper standards. The Panel was satisfied that a fully informed member of the public, who was aware of all the background to this case, would have their confidence in the profession and the regulator undermined if a finding of impairment were not made. This is because of the serious nature of the errors and the potential harm that could have been caused to patients. Moreover, given the lack of any evidence of remediation, the Panel concluded that the Public would rightly be highly concerned about similar mistakes potentially being made in the future by the Registrant.


93. The Panel was satisfied that the actions of the Registrant put patients at unwarranted risk of harm, brought the reputation of the profession into disrepute and she has breached some of the fundamental tenets of her profession as outlined above.


94. The Panel therefore concluded that the Registrant’s fitness to practise is currently impaired on both the personal and public components.


Decision on Sanction


95. Ms Thompson stated that the decision on what sanction, if any, to impose was a matter for the judgment of the Panel. Ms Thompson addressed the Panel on the HCPC Indicative Sanctions Policy. While the HCPC did not invite the Panel to impose any particular sanction, Ms Thompson submitted that on the facts of the present case, it would not be appropriate for the Panel to impose no order or a caution order. Ms Thompson addressed the Panel on relevant mitigating and aggravating factors in the present case. In terms of mitigation, the Registrant has not been the subject of any previous misconduct proceedings and is otherwise of good character. However, in terms of aggravating factors, Ms Thompson stated that the lack of insight on the part of the Registrant, and lack of remediation to address the failings found by the Panel, required to be given careful consideration by the Panel. Ms Thompson accepted that remediation may be possible in the present case. However, there is no evidence available to the Panel of any steps having been taken in this regard. As such, the Registrant presents a significant risk to Patients.


96. The Panel received, and accepted, advice from the Legal Assessor. The Legal Assessor addressed the Panel on the HCPC Indicative Sanctions Policy and advised the Panel that, in deciding what, if any, sanction to impose, panels should ensure that any sanction is proportionate and strikes a proper balance between the protection of the public and the rights of a registrant.


97. The Panel has taken into account the HCPC Indicative Sanctions Policy. However, the Panel has reached its own independent decision on the appropriate sanction based on the individual facts of the present case.


98. The Panel proceeds on the basis that it is not automatic that any sanction will be imposed merely because a finding of misconduct has been made. The purpose of any sanction is not to be punitive. The primary objective is public safety. However, other public interest objectives have a role to play. These include:
(i) the deterrent effect to other registrants; 

(ii) the reputation of the profession concerned; and 

(iii) public confidence in the regulatory process. 



99. The Panel first considered whether there were any aggravating and/or mitigating factors to be taken into account when deciding the appropriate sanction.


100. In respect of mitigating factors, there was no previous disciplinary record in an otherwise long and unblemished career as a Biomedical Scientist. Furthermore, for many of the issues, the Registrant had accepted, at the relevant time, that she had made errors. She had produced reflective statements and had sought to take some remedial steps including reading SOPs and relevant guidance.


101. The Panel also notes that there was some evidence that the Registrant may have been experiencing health issues at the time of the incidents in question. The Panel proceeds on the basis that such issues may have had an impact on the Registrant’s performance: in particular, her ability to perform within a busy laboratory environment.


102. However, the Panel considers an aggravating factor in this case to be the number of different, serious, repeated, failures spread over a short period of time. Moreover, there was no evidence of any genuine insight, remorse or steps being taken to address the likelihood of recurrence. While reflective statements had been produced by the Registrant, these do not demonstrate a genuine appreciation of the serious nature of the failings. Moreover, the remedial steps taken appear to have done little to address these issues as further serious mistakes were made. The Panel considers these factors to be highly relevant as, in the opinion of the Panel, there still exists a risk of serious harm to patients.


103. In this case it is not appropriate to make no order because of the serious nature of the allegations that are now proved. Mediation is not appropriate because the failings of the Registrant were neither minor nor isolated.


104. A Caution Order is not appropriate because the behaviour on the part of the Registrant was of a serious nature, the Registrant has shown limited insight and has not provided any evidence of any significant remedial action being taken.


105. The Panel considered a Conditions of Practice Order. Such an order would be appropriate where a panel is confident that a Registrant will adhere to the conditions, is genuinely committed to resolving the issues they seek to address and can be trusted to make a determined effort to do so. The Panel considered that the Registrant’s failings are capable of being remedied. Indeed, this was fairly conceded by Ms Thompson on behalf of the HCPC. However, the Panel considers that there is a significant lack of insight on the part of the Registrant regarding the serious nature of the failings identified above. At the moment, the Panel has no evidence that allows it to be confident that the Registrant is committed to resolving the issues and that she will make a determined effort to comply with conditions. The Panel could not therefore formulate any Conditions of Practice that would provide sufficient public protection, maintain confidence in the Biomedical Science profession and which would be workable and enforceable. The Panel concluded that such an order is not appropriate.


106. A Suspension Order may be appropriate where the allegation is serious and cannot be addressed by any of the lower sanctions, but there is a potential for the Registrant to remedy their failings. The view of the Panel, for the reasons recorded above, is that the Registrant at the moment has limited insight into the seriousness of her actions. The Panel has however taken into account the fact that the failings are potentially capable of remediation and the Registrant may have been suffering from health issues at the relevant time. She may, with appropriate help, training and support, be capable of developing insight and addressing her failings in the future.


107. In these circumstances, the Panel has determined that the Registrant should be suspended for a period of one year. This marks the gravity of the matters and has been chosen in order to meet the public interest in this case including a deterrent effect on the profession. However, it also gives the Registrant, who has had a long and previously unblemished career, an opportunity to demonstrate that she is capable of remediating the relevant failings with a view to continuing her career.


108. The Panel gave serious consideration to making a striking off order given the serious and repeated failures identified above which jeopardised patient safety. However, the Panel ultimately concluded that such a sanction would be disproportionate at this stage as the failings on the part of the Registrant may be capable of remediation.


110. The Suspension Order will be reviewed by the HCPTS before the expiry date and the Registrant will be invited to engage in that process. This Panel cannot tie the hands of any Reviewing Panel but this Panel suggests that, in connection with any Review, the Registrant (when invited by the HCPTS to do so):
• attends any future review hearing because it would be helpful to hear from her directly.
• provides a written reflective piece for that Review Panel in which she reflects upon the impact of her past failings and addresses the impact which her actions have had on members of her profession and public confidence in the Biomedical Science profession. That reflective piece should also set out what the Registrant would do differently to ensure that her past mistakes and poor practises will not be repeated.
• Provides evidence of what steps she has taken to remediate the failings identified above, for example, the Registrant may wish to consider working in a role such as a Medical Laboratory Assistant where she would have scope to seek to remediate the failings identified above in a supervised environment. References from any paid or voluntary work would also be of assistance to any future panel.

The Registrant may also wish to provide any relevant medical evidence to a future panel.


111. The Registrant should be aware that if she does not positively engage with a future review panel the option of a more serious sanction may be open to a future review panel.

Order

The Panel imposed a Suspension Order for a period of 12 months.

Notes

The Panel also imposed an Interim Suspension Order to cover the 28 day appeal period.

 

 

Hearing History

History of Hearings for Miss Catherine A Weir

Date Panel Hearing type Outcomes / Status
26/11/2018 Conduct and Competence Committee Final Hearing Hearing has not yet been held
29/06/2018 Investigating committee Interim Order Review Interim Suspension