Mr Simon J Walmsley

Profession: Biomedical scientist

Registration Number: BS46037

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 29/10/2018 End: 17:00 02/11/2018

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 a Biomedical Scientist at New Cross Hospital, you:

1. On 15 September 2014, verbally reported incorrect haematology results by telephone for a patient, leading to an unnecessary transfusion.

2. On 19 January 2015, did not carry out the appropriate compatibility check and allowed the issue of Rhesus D positive blood to a Rhesus D negative patient.

3. On Friday 3 July 2015, issued a neonatal pack for a 23 week new-born child which was not suitable and did not issue compatible blood contrary to the clinical notes on the electronic patient file.

4. On Wednesday 15 July 2015, having technically validated and requested a blood film with blast flags on a patient which was reported as chronic myeloid leukaemia, you:
a) did not alert a senior member of staff or medical officer of the abnormal results for the patient so the patient could be admitted immediately for care, thereby delaying the diagnosis and treatment by 4 days.

5. On Friday 17 July 2015, having technically validated and requested a blood film with blast flags on a patient which was reported as acute myeloid leukaemia, you:
a) did not alert a senior member of staff or medical officer of the abnormal results for the patient so the patient could be admitted immediately for care, thereby delaying the diagnosis and treatment by 3 days during which
time the patient's condition had significantly worsened.

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:

 

Application to amend

 

1.     At the outset of the hearing, Ms Ryan applied to amend all the Particulars to clarify the allegation against the Registrant and to more accurately reflect the evidence relied on once witness statements had been obtained. The Registrant, who had advance notice of the proposed amendments, did not oppose the application and, indeed, indicated that in their amended form he intended to admit them all.

 

2.     The Panel heard and accepted the advice from the Legal Assessor that it could amend the Allegation provided it was satisfied that it was fair to do so and that the proposed amendments could be made without injustice. The Panel noted that the Registrant did not oppose the application and that the amendments requested more accurately reflected the evidence and did not make the Allegation against the Registrant more serious or onerous. The Panel was satisfied that the amendments could be made without causing any injustice and so decided to allow the amendments requested.

 

Application to hear part of the case in private

 

3.     Mr Haycroft, on behalf of the Registrant, made an application for part of the hearing to be heard in private because it would relate to the Registrant’s private life. Ms Ryan did not oppose the application.

 

4.     The Panel heard and accepted the advice from the Legal Assessor that, although the normal position is that hearings are conducted in public, it was open to the Panel to hear all or part of the hearing in private, where necessary, to protect the private life of the Registrant. The Panel therefore agreed that where matters relating to the health or private life of the Registrant were raised, the hearing would go into private session. Mr Haycroft had indicated that the Registrant was content for some references to be made to his health issues in public and the Panel therefore decided that it would go into private session when descending into detail, rather than when dealing with generalities.

 

Background:

 

5.     The Registrant is, and was at the relevant times, registered with the HCPC as a Biomedical Scientist.

 

6.     The Registrant commenced employment at Royal Wolverhampton NHS Trust (the Trust) New Cross Hospital in March 2014, as a Band 6 specialist Biomedical Scientist. His role became permanent in May 2014. At the time of the incidents he was working in the haematology and blood transfusion laboratories and was responsible for:

 

·                     analysing blood transfusion samples

·                     issuing blood products

·                     technically validating and  releasing patient results

 

Particular 1

 

7.     On 5 September 2014, Dr GN called the Registrant to request additional investigations for a patient under his care, in relation to a blood sample from the previous day. The Registrant provided a verbal haemoglobin result to Dr GN. The Registrant had located the result using the patient’s name but did not confirm the hospital number or date of birth.  The result indicated severe anaemia, so the Doctor organised for the patient to be provided with a blood transfusion at 4:15pm. Later, the Doctor checked the Laboratory Information System (“LIMS”) for the reported result and noted that it was not showing. He called the Registrant who, on checking, realised and admitted that there were two patients with the same name from whom blood had been taken on the same day and that he had provided the Doctor with the results for the wrong patient. The Registrant advised the Doctor to stop the transfusion immediately. Dr GN arranged for the transfusion to be stopped and this was around 4:30pm. Dr GN said the patient was well enough in himself and suffered no clinical consequences of having the transfusion. However, the patient was given blood that he did not need.

 

Particular 2

 

8.     On Monday 19 January 2015, the Registrant was involved in the issuing of blood to a patient who was Rhesus D (“RhD”) negative. The Registrant passed the blood to Colleague A from the fridge, or vice versa, as both gave differing accounts of who actually retrieved it. However, what was clear was that both were required to check the blood before it was dispatched to the patient. The Registrant signed the form to say he had performed the second check. RhD positive blood was then issued, but fortunately the error was identified by a nurse before it was administered to the patient.

 

 

 

 

Particular 3

 

9.     On 1 July 2015, a colleague of the Registrant, JR, cross-matched six units of paediatric red cell packs (one adult pack split into six) for a newborn child. She had checked the blood against the mother’s blood to ensure compatibility as the mother possessed anti-Kp(a) and anti-Duffy(a). On 3 July 2015, a request came in for blood for the newborn child when the Registrant was working in the blood bank. The Registrant then issued a paediatric red cell pack which was not one of those previously matched by JR. The records showed that the red cell pack administered by the Registrant had not been cross-matched against the mother’s results.

 

10.   Colleague JR stated, when interviewed by Dr SW as part of an investigation into concerns about the Registrant, that she had provided a handover to the Registrant on 1 July, making him aware of the case and the location of the pre cross-matched blood.  Furthermore, the files for the neonate and mother were linked together on the Trust’s computer system LIMS. JR subsequently discovered, on 22 July 2015, that the blood she had allocated was still in the fridge. When retrospective checks were undertaken with the National Blood Service it transpired that fortunately the blood issued to the newborn child was compatible and therefore no harm was done.

 

Particular 4

 

11.   On 19 July 2015, a colleague, JP, attended the department to clear a backlog of blood films. The second one she reviewed gave her cause for concern. The results had been processed by the Registrant on 15 July 2015. He had technically validated the result from the Sysmex Extended Processing Unit (“EPU”) analyser data management system into the LIMS system. The film had an abnormal full blood count result, a high white blood count and flags warning that the results were abnormal. The Registrant added a “blast flag” comment, which can be indicative of the presence of leukaemia. However, he did not then alert a senior member of staff or medical officer of the abnormal results.

 

Particular 5

 

12.   On 20 July 2015, JP continued reviewing films and discovered a second result that had been processed by the Registrant on 17 July  2015 that caused her concern. In this case there was a high white blood count and warning flags stating the result was abnormal. Again the Registrant had added a “blast flag” comment, which can be indicative of the presence of leukaemia. However, as with Particular 4, he did not then alert a senior member of staff or medical officer of the abnormal results.

 

13.   Both these results should have been escalated for an urgent review by the on-call haematologist or a senior Biomedical Scientist in the team, but the Registrant did not do this in either case. This resulted in a delay for both patients in being diagnosed and receiving treatment. In the second case the patients renal function deteriorated between testing and receiving treatment, which resulted in the patient requiring renal dialysis.  

 

14.   The Panel heard from three witnesses called on behalf of the HCPC:

 

                  Dr SW - Principal Clinical Scientist at the Trust

 

                  KG - Biomedical Scientist Team Manager at the Trust

 

                  MH - Transfusion Laboratory Manager at the Trust

 

15.   The statement of Dr GN was read as agreed evidence.

 

16.   The Registrant gave evidence to the Panel as did a Consultant Clinical Neuropsychologist, Dr TH, on his behalf.

 

17.   In his oral evidence the Registrant adopted his statement in which he admitted all the facts and provided some context about what had gone wrong. He also provided evidence of his insight into his failings and the steps he has subsequently taken to ensure they would not recur.

 

18.   The Registrant said he had reflected long and hard on what went wrong and on what to do in the future to ensure there would be no repetition. He provided details of the Continuing Professional Development he had completed and his reflection. The Panel was also provided with current testimonials from colleagues who speak highly of him. KG, who has been responsible for training the Registrant, said he was very professional and good at doing his work in the anti-coagulation   department. He added, “he might have made a few errors but I think he does a good job and we have missed him when he has not been there.” He was complimentary about the way in which the Registrant deals with patients and said he “goes the extra mile.”

 

19.   The Registrant said that his ultimate aim was to return to full-time work, “doing the work I used to do before all this happened, … I miss doing it, I love my job.” He recognised that for this to happen he would have to have a phased return to full-time practice and that would include training, competency testing and mentoring, as detailed by KG in his evidence. He said his employer was very supportive and he had no desire to work anywhere else. He recognised that, until re-trained and confirmed as competent by his employer, he was not safe to return to full-time practice, and his previous range of duties.

 

Decision on Facts:

 

20.   The Panel considered with care all the evidence presented, together with the submissions made by Ms Ryan on behalf of the HCPC and Mr Haycroft on behalf of the Registrant. The Panel heard and accepted the advice of the Legal Assessor and bore in mind that, notwithstanding the Registrant’s admissions, it was for the HCPC to prove its case and to do so on the balance of probabilities.

 

21.   The Panel found the HCPC witnesses to be open, honest and credible. They provided impartial evidence which was not challenged. There was an acceptance that there had been some shortcomings in the workplace and the organisation has since made some changes to working practices. KG, who had been involved in training the Registrant, spoke well of him.

 

22.   The Panel found the Registrant to be open and honest, candid and insightful. He made full admissions to all the facts, as he always had, and provided some contextual background. He believed that his errors amounted to misconduct and that he was currently impaired. He made no attempt to make excuses for his behaviour and was clearly distressed by the errors he had made.

 

23.   The Panel found Dr TH’s unchallenged evidence to be most helpful in providing insight into the Registrant’s behaviour, the actions he had subsequently taken and the improvements he had made, together with the reservations that remained.

 

24.   The Panel then considered each allegation in turn.

 

Particular 1 - found proved

 

25.   The Panel accepted the uncontested evidence of MH and Dr GN that, on 5 September 2014, the Registrant verbally reported incorrect haematology results by telephone for a patient. As a result the patient had an unnecessary transfusion.

 

26.   The Registrant said, On 5 September 2014 I verbally reported incorrect results by telephone to Dr [GN] and this led to an unnecessary blood transfusion. Fortunately, the blood transfusion was stopped and no harm was caused. However, I accept there was a potential for harm.”

 

27.   In his oral evidence the Registrant accepted that his error did lead to actual harm as the patient had a blood transfusion that was not needed.

 

28.   On the basis of the HCPC’s evidence, and the Registrant’s admission,  the Panel found Particular 1 proved.

 

Particular 2 - found proved

 

29.   The Panel accepted the uncontested evidence of KG, that on 19 January 2015 the Registrant did not adequately carry out the second compatibility check of blood, as a result of which a Rhesus D negative patient was issued Rhesus D positive blood.

 

30.   The Registrant said, On 19 January 2015 I did not adequately perform a second compatibility check and so a Rh (Rhesus) negative patient was issued Rh positive blood. Again fortunately no harm ensued as a nurse spotted the error before it could be transfused. Again I accept there was a potential for harm. My error occurred when I failed to spot that my colleague had initially issued the incorrect Rh group for the patient. I also explain [in the Trust interview] how a different computer system I have used before had fail safes to prevent human error. The context was that I was called into blood bank as soon as I started my shift at midday to cover for a lunch break as it was under pressure by the blood bank senior who was to work in haematology instead of me. This was an unexpected change as I was rostered to work in the Haematology lab. I mention this simply as context as I do not believe this was a contributing factor as flexibility is part of the role.”

 

31.   On the basis of the HCPCs evidence, and the Registrants admission, the Panel found Particular 2 proved.  

 

Particular 3 - found proved

 

32.   The Panel accepted the uncontested evidence of Dr SW that on 3 July 2015, the Registrant STAT (immediately) issued a paediatric red cell pack for a 23 week newborn child instead of a cross-matched red cell pack.

 

33.   The Registrant said, On 3 July 2015 I STAT issued a paediatric red cell pack which was not cross matched. Again fortunately no harm ensued but I accept there was a potential for harm.”

 

34.   On the basis of the HCPCs evidence, and the Registrants admission, the Panel found Particular 3 proved.

 

Particular 4 - found proved

 

35.   The Panel accepted the uncontested evidence of Dr SW that on 15 July 2015, the Registrant technically validated and requested a blood firm with “blast flags” on a patient with abnormal result, but did not alert a senior member of staff or medical officer of the abnormal results.

 

36.    The Registrant admitted these facts, but added, Again fortunately no harm ensued but I accept there was a potential for harm.”

 

37.    On the basis of the HCPCs evidence, and the Registrants admission, the Panel found Particular 4 proved.

 

Particular 5 - found proved

 

38.   The Panel accepted the uncontested evidence of Dr SW that on 17 July 2015, the Registrant technically validated and requested a blood firm with “blast flags” on a patient with abnormal result, but did not alert a senior member of staff or medical officer of the abnormal results. Furthermore, the Panel accepted the uncontested evidence of Dr SW that, as a result of the Registrant’s actions and omissions, treatment for the patient was delayed by three days and the patient’s renal function had deteriorated in that time.

 

39.   The Registrant said, On 17 July 2015 I made a similar error to that in allegation 4. I was unaware of the first such error at the time. I was not at work on 16 July 2015 as I was working 3 shifts per week of 12 hours per shift. So in effect they occurred on successive shifts.”

 

40.   On the basis of the HCPCs evidence, and the Registrants admission, the Panel found Particular 5 proved.

 

Decision on Grounds:

 

41.   Having found all the facts proved, the Panel then considered whether they amounted to misconduct. In so doing it took into account the submissions of the parties, written and oral, and accepted the advice of the Legal Assessor. The Panel also considered the relevant Practice Note issued by the HCPC, together with the Standards of Conduct, Performance and Ethics and the Standards of Proficiency.

 

42.   The Panel found breaches of the following parts of the Standards of Conduct, Performance and Ethics, dated August 2012:

 

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

                7              You must communicate properly and effectively with service                                      users and other practitioners.

 

43.   Ms Ryan suggested there was also a breach of standard 12, “You must limit your work or stop practising if your performance or judgement is affected by your health.” The Panel considered whether this standard was breached by the Registrant and decided that it was not, because at the time he had been unaware that his health was impacting upon his performance.

 

44.   The Panel considered there to be serious concerns about the way in which the Registrant had been conducting his practice over this ten month period. A patient received an unnecessary blood transfusion; another patient was issued with the wrong blood; a newborn baby received blood that had not been suitable cross matched; and two patients had abnormal blood results which should have been immediately escalated, resulting in the delay of treatment for one of them. These were serious errors and put patients at risk of harm. The Registrant himself considered all the cases caused harm by reason of the psychological impact on the patients alone.

 

45.   The Panel considered this combined conduct represented a serious breach of professional standards, fell far below the behaviour expected of a registered Biomedical Scientist and thereby amounted to misconduct.

 

46.   Accordingly, the Panel was satisfied that the statutory ground of misconduct was well founded.

 

47.   Having found misconduct there was no need for the Panel to consider lack of competence, which was in the alternative.

 

Decision on Impairment:

 

48.   Having found misconduct, the Panel went on to consider whether, as a result of that misconduct, the Registrant's current fitness to practise is impaired. The Panel took into account all the evidence, the submissions made by Ms Ryan and those made by Mr Haycroft. The Panel noted the Registrant’s candid assessment that his fitness to practise is currently impaired. The Panel accepted the advice of the Legal Assessor.

 

49.   The Panel reached its own independent judgement on the question of impairment. It found significant and serious failings by the Registrant in some of the most fundamental and basic of tasks required to be completed by a Biomedical Scientist when carrying out work in the critical field of processing blood results. Those failings led to the very real risks identified by the witnesses in their evidence and could have caused harm to those patients where the errors were made.

 

50.   In relation to Particular 1 the Registrant said, “I have reflected upon why I made this error and I consider that the following factors are relevant:

 

  1. At the time I was still relatively new to New Cross and I was still adjusting to there being a much higher work load than at my previous employer;

     

  2. I received the call during a busy period;

     

  3. There were a large amount of results to review;

     

  4. I felt under pressure to get everything done and uncharacteristically panicked a little as I knew I had a lot to do;

     

  5. As a result I did not follow my usual mental checklist due to feeling this pressure to keep up to date with the work and so failed to make the appropriate checks to make sure it was the correct patient;

     

  6. The doctor gave me the patient’s name only. I did not ask for another identifier and as I was unaware there were two patients of the same name we were talking about 2 different patients.”

     

51.   The Registrant said that on 15 September 2014, he emailed MH, fully accepting his error and explaining certain matters. He said that the error was dealt with by way of a verbal warning and has never been repeated. He said that he believed he had learnt from it and reflected on preventing the error recurring. He added,

 

  1. “I will not allow myself to feel rushed in this manner and have spent my time since the start of this investigation working on mindfulness, stress and time management;

     

  2. I will give myself time to ensure that I am dealing with queries properly irrespective of workload;

     

  3. I have a checklist with me at all times so that it is automatic and scripted so I do not stray from making sure I ask the correct questions; this includes checking more than one identifier to ensure I have the correct patient;

     

  4. I make sure that at the end of the call I do a further check with the person on the line that the details are correct;

     

  5. I make a note of the person who has called and document that full checks have been done.”

     

52.   In relation to Particular 2, the Registrant said, “I have reflected upon why I made this error and I consider that the following factors are relevant:

 

  1. Working in the blood bank that day was a BMS who had just come back from maternity leave and seemed to lack confidence in their work due to their time off. As a result she (rightly) was asking a number of questions but this caused interruptions.

     

  2. There was no senior member of staff nor manager present in the blood bank lab at this time.

     

  3. The Lab was unusually busy with a number of issues. I think there was an ongoing bleed, a busy day with cardiac patients and numerous phone calls which led to BMS’s being interrupted. Ultimately it was very hectic.

     

  4. There was some uncertainty over who was doing what. I had started doing the issuing of blood products when I started and then a colleague took over from me when she came back from lunch. I believe this also contributed to the situation being hectic.

     

  5. Due to the situation in the lab I believe that my colleague and I were trying to get some order to the proceedings in place as quickly as possible but in doing so neither of us performed adequately and possibly relied on the other to get their work correct.

     

  6. So I did the second check but I did so inadequately in not picking up the initial error.”

     

53.   The Registrant added,

 

“I would point out that an almost identical incident took place just before and again just after my error. These incidents involved different people and had nearly half of the BMS staff under investigation for them. The three incidents took the trust over a year to investigate and this slow progress had a profound effect on the department as it was left hanging over each staff member. I believe that the poor communication around this investigation and the worry over its outcome directly contributed to my overall stress and anxiety which was building up at the time. This factor is also relevant to the next aspect I now turn to.

 

I consider it unlikely I would now repeat my mistake because of the following matters:

 

  1. My time management was not up to standard in this instance so in future I will make sure to slow down my work and put other work needing doing out of my mind and deal with one thing at a time;

     

  2. I will follow a checklist and check against it when I have completed each step;

     

  3. Some of the issues leading to this error were addressed within the department after the above three similar errors (all involving different members of staff). The departmental manager introduced a system whereby the person on the cross-match bench would wear a tabard so other staff knew not to disturb them. The person doing the 2nd check would then also wear a tabard when doing this check.”

     

54.   In relation to Particular 3 the Registrant said:

 

I prepared new units of blood following the SOP [Standard Operating Procedure] … This relates to the issuing of blood to neonates, specifically the part around issuing blood to neonates where there has been previous cross-matches and blood transfusions. When reading the pop-up message on the childs notes I was not aware that they meant the childs mother had blood group antibodies. Because of this I selected units for the child as I would have done for other neonatal cross matches where blood has previously been prepared. In such circumstances I would have to just select the correct blood group and issue the blood pack without any further testing.

 

I believe on reflection that my error occurred because of the following matters:

 

  1. I failed to interpret correctly details written on the child’s notes regarding the blood already available;

     

  2. I failed to understand that the pop-up message when entering the units about the previously cross-matched blood meant there were maternal antibodies;

     

  3. As a result I did not adequately check the mother’s previous details;

     

  4. I also think that a contributing factor in this error was having not been faced with a similar situation at this trust before. This though is not an excuse for making the error nor do I intend it to be.

I do consider it unlikely I would now repeat my mistake because of the lessons I have learned as a result of this error. These lessons are centered around taking more time and reading on-screen messages a number of times to ensure that I am understanding what they tell me. A painful lesson from my errors is that rather than allow myself to feel rushed when there is a large volume of work, I should and will put the feelings of pressure aside and work at an appropriate speed. In particular:

 

  1. Again I believe that the best way to prevent this happening again is to use a checklist to mark all of the steps that are needed to be made within the process;

     

  2. At the end of the task I will double check that I have done everything listed;

     

  3. Having researched this area, I understand this approach works well in pharmacies when the pharmacist is working alone – they prescribe the drugs and put them to one side and then recheck a short time later. Having some time between the task makes it likely to pick up any errors. This measure would work well with non-urgent requests.

     

  4. For urgent work the approach I will take is to ensure that all other work is put out of my mind. This would remove any potential distraction of worrying about other work to do once this task is completed. I will again use the checklist as an additional step to mitigate errors being made.”

 

55.   In relation to Particular 4, the Registrant said:

 

I would point out the context in which the error occurred. In summary, I did spot the anomaly and I then followed what I was supposed to do except the final step which was to inform a senior person or doctor:

 

  1. I reviewed the blood result and recognized it as abnormal;

     

  2. I added a comment that there were ‘blast flags’ from the analyser – this flag would always lead to a blood film being made if the patient was not known to already have leukaemia;

     

  3. I checked that a request for a blood film had been made and sent to the analyser and I had intended to have a quick look at the film when it had finished;

     

  4. The film would have finished around an hour later as there were a number being made;

     

  5. By the time the film had stained I had forgotten about the abnormal results and therefore did not pass them onto a senior or the out-of-hours consultant as I should have done.

 

I consider the error occurred in the following way:

 

By this date with the benefit of hindsight, I was experiencing a high level of stress and anxiety and I believe I was not able to function to normal levels. I believe this led to my being distracted and forgetting the final step. At this time, I recognised I was under a lot of pressure and needed a break (with annual leave booked in shortly after) but I did not recognise the extent it was affecting me nor the impact it was having on my ability to work safely. Had I recognised this I would have taken action as needed.

 

I believe this is not down to competence as this is the first time in fifteen years of working in this field that I have failed to complete a task in this way.”

 

56.   In relation to Particular 5 the Registrant said:

 

My error occurred in the context of my ill-health at that time as I explained above. Again I would point out that I had previously carried out all such similar tests without error. I would point out that by then I had worked in a haematology lab since 2004 and so there would have been many thousands of tests without error.

I consider it unlikely I would now repeat my mistakes in allegations 4 and 5 because of the following matters:

 

  1. I have spent the last few years working on my stress and time management skills. I have also done a lot of reflecting on how I can recognise signs of triggers of stress and put things in place to stop myself slipping into stress and anxiety as experienced in 2015.

     

  2. I have been working on recognising the limits of what I can achieve – I believe I was working in a manner which meant I tried to do too much, as I don’t like leaving work for others to mop up.

     

  3. I have improved my communication with managers and I am now more comfortable in speaking with them at times of stress and showing my vulnerabilities.

     

  4. I have spent this time working on relaxation strategies which allow me greater focus at times of increased anxiety/stress.

     

  5. As described above, I already produce checklists which helps me to double check accuracy in my work. I have found this very beneficial and intend to use this approach in all practicable areas of my work. This would make sure that any samples which require urgent referral are followed up.”

     

57.   The Registrant said that his employer was supportive and recommended various aspects of training including formulating a training plan once this hearing is concluded and the outcome known. The Registrant said that he has been performing his duties well and received good feedback. He believes his confidence is returning, and in the long term, he wishes to increase the variation of his duties and return to the main laboratory so that he can once again be an autonomous practitioner in haematology and blood transfusion. He provided details of training courses and CPD he has done in an effort to remain up-to-date and fully informed, and added, “I have also begun collating a number of other pieces of evidence towards CPD to show my absolute determination to recover from these errors and to show how much I wish to improve as a person and as a Biomedical Scientist.”

 

58.   The Panel was satisfied that the Registrant had demonstrated significant insight into his failings in 2014/2015 and had reflected on why things had gone wrong and what he would do in the future to ensure such failures were not repeated. The Panel considered that the matters found proved were of a kind that could be remedied and it was clear that the Registrant was keen to demonstrate complete remediation once he was able to return to full-time practice.

 

59.   The Panel noted that the Registrant had been deemed safe by his employer to practice autonomously in the limited field of anti-coagulant work and working part-time, but that before he could return to full-time work with the full range of haematology work, he would require re-training, competency assessment and mentoring.

 

60.   The Panel noted that the Registrant himself accepted that there could still be public protection issues were he to return to full-time unrestricted practice at this time.

 

61.   The Panel therefore concluded that the Registrant’s fitness to practise was currently impaired on public protection grounds.

 

62.   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. 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 and could be caused in the future, were the Registrant allowed to return to unrestricted practice before being deemed safe to do so. Accordingly, the Panel did find the Registrant’s current fitness to practise impaired on public interest grounds as well as public protection grounds.

 

63.   The Panel therefore concluded that the Registrant’s fitness to practise is currently impaired and that the case is well founded at the impairment stage.

 

Sanction:

 

  1. In reaching its decision on sanction the Panel took into account the submissions made by Mr Haycroft and Ms Ryan, together with all the documents provided. The Panel also referred to the Guidance issued by the Council. The Panel had in mind the fact that the purpose of sanctions is not to punish the Registrant but, to protect the public, maintain public confidence in the profession and maintain proper standards of conduct and performance. The Panel was also cognisant of the need to ensure that any sanction is proportionate. The Panel accepted the advice of the Legal Assessor.

     

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

     

  3. The Panel considered an aggravating factor in this case to be the number of different serious failures spread over a ten-month period.

     

  4. The Panel considered the following mitigating factors: no previous disciplinary record in a long and unblemished career as a Biomedical Scientist; major personal and health related issues which impacted upon his performance; significant reflection and insight; admissions to his errors from the outset and taking full responsibility for those errors; some challenging issues at work that have since led to changes being made; current testimonials; relevant further training and CPD; steps taken to address the likelihood of recurrence and demonstrating genuine remorse.

     

  5. In light of the seriousness of the conduct, the Panel did not consider this was an appropriate case to take no further action or consider mediation, since this would not protect the public from the risks identified by the Panel.

     

  6. The Panel then considered whether to caution the Registrant. However, the Panel was of the view that such a sanction would not reflect the seriousness of the misconduct in this case nor protect the public. The Registrant’s failings put a number of patients at risk of harm and the Panel has already concluded that there is a risk of such behaviour being repeated if the Registrant were to return to full-time, unrestricted practice. Notwithstanding the apparent health and work monitoring already in place, and the Registrant’s stated intention to remain at New Cross Hospital, it is always possible that he could decide to change employer and the necessary support structure might not be the same elsewhere. The Panel was also of the view that public confidence in the profession, and the HCPC as its regulator, would be undermined if such behaviour were dealt with by way of a caution.

     

  7. The Panel next considered whether to place conditions on the Registrant’s registration. As identified at the impairment stage, the failings are of a kind which could be remedied and the Registrant has demonstrated a clear desire to rectify his failings and ensure they do not happen again. He has reflected on his errors and shown significant insight. He has expressed a willingness to engage with conditions and has the benefit of a supportive employer who is keen to ensure he is properly trained, assessed and mentored before being allowed to return to diverse, full-time, autonomous practice.

     

  8. The Panel was therefore satisfied that it could formulate workable, realistic and appropriate conditions to protect the public, whilst allowing the Registrant to return to full-time work and responsibilities, in the phased manner agreed by both him and his employer. The Panel was confident that such an order would reflect the seriousness of the misconduct and provide the necessary degree of protection for the public.

     

  9. The Panel considered a Suspension Order would be both disproportionate and unduly punitive in a case where the errors are remediable, there were health and personal issues which impacted upon the performance of the Registrant, there has been significant reflection and insight and a clear willingness to comply with conditions. The Registrant has exhibited no attitudinal problems and the Panel was satisfied that the Registrant will do his utmost to comply with conditions and thereby be able to return to safe, unrestricted practice. The panel considered that, in all the circumstances, it would not be in the public interest to suspend a previously competent Biomedical Scientist.

     

  10. Accordingly, the Panel made an order directing the Registrar to place conditions on the Registrant’s practice for a period of 12 months. The Panel considered this would allow sufficient time for the anticipated, phased return to full-time practice and for the Registrant to demonstrate to a review Panel that he is safe to practice without restrictions on his registration.

     

  11. This order will be reviewed before its expiry.

     

  12. The review Panel will be assisted by:

     

      • the Registrant’s attendance at the review;

      • evidence of how his practice has developed;

      • details of any training undertaken;

      • details of CPD;

      • up-to-date testimonials.

         

        Interim Order:

         

  1. The Panel heard submissions from Ms Ryan on the need for an Interim Order to cover the period during which an appeal may be made and, if one is made, whilst that appeal is in progress. Mr Haycroft did not oppose the application. The Panel heard and accepted the advice of the Legal Assessor.

     

  2. The Panel has found that the Registrant failed in some significant, fundamental and basic tasks required to be completed by a Biomedical Scientist. Those failures exposed patients to a real risk of harm. The Registrant, whilst demonstrating significant insight into his failures, has not as yet had the opportunity to fully remediate them. Consequently, there remains a real risk of significant harm to the public if the Registrant were to be allowed to practise without restriction. The Panel is also of the view that public confidence in the regulatory process would be undermined if the Registrant were allowed to remain in practice on an unrestricted basis. For these reasons, the Panel has determined that an Interim Conditions of Practice Order, in the same terms as the substantive order, is necessary to protect the public and is otherwise in the public interest.

     

  3. The Panel decided to make an Interim Conditions of Practice Order for 12 months. This would allow sufficient time for any appeal, should one be made. If no appeal is made then this order will fall away at the conclusion of the 28 days appeal period and the substantive Conditions of Practice Order will take effect.

     

Order

 

ORDER: The Registrar is directed to annotate the Register to show that, for a period of 12 months from the date that this Order comes into effect (the Operative Date), you, Simon John Walmsley, must comply with the following conditions of practice:

 

 

 

  1. You must confine your professional practice to working at the Royal Wolverhampton NHS Trust New Cross Hospital.

     

  2. You must remain under the care of your General Practitioner and inform him or her that you are subject to these conditions.

     

  3. You must inform your General Practitioner about these conditions of practice and authorise that person to provide the HCPC with information about your health and any treatment you are receiving, if requested.

     

  4. You must keep your professional commitments under review and limit your professional practice in accordance with the advice of your General Practitioner, Occupational Health Specialist and/or any other clinician responsible for your care.

     

  5. You must cease practising immediately if you are advised to do so by your General Practitioner, Occupational Health Specialist and/or any other clinician responsible for your care.

     

  6. Together with your employer, you are to devise a training and development plan detailing proposed sections of laboratory activity starting with routine haematology and then blood transfusion. That plan must be provided to the HCPC within 28 days of the operative date of this order.

 

 

 

  1. Prior to any review of this order, you must provide the HCPC with a report from your Line Manager detailing:

     

 

  1. your competency and ability to work safely

     

  2. how your scope of practice has developed

     

  3. your ability to cope with full-time or increased hours

 

 

 

  1. any significant errors during the currency of this order and how you have dealt with those errors.

 

Notes

No notes available

Hearing History

History of Hearings for Mr Simon J Walmsley

Date Panel Hearing type Outcomes / Status
29/10/2018 Conduct and Competence Committee Final Hearing Conditions of Practice