Miss Lisa Hetreed

Profession: Occupational therapist

Registration Number: OT68628

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 14/01/2019 End: 17:00 21/01/2019

Location: Bristol Marriott Hotel City, Centre, 2 Lower Castle Street, Old Market, Bristol, BS1 3AD

Panel: Conduct and Competence Committee
Outcome: Suspended

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Allegation

Between 20 October 2014 and 23 November 2016, whilst working as an Occupational Therapist at University Hospitals Bristol NHS Foundation Trust

1. You did not demonstrate that you could undertake adequate medical observations in that:

A. On 28 December 2015, you did not ensure Patient A was wearing oxygen when being mobilised to the bathroom.
B. On 18 December 2015, you did not sufficiently check Patient B’s observations when mobilising Patent B to the toilet.
C. On or around 04 December 2015, you requested that Patient C be mobilised despite Patient C suffering from a possible vertebral compression fracture.
D. You scored Patient D, incorrectly within the ‘obs chart’.
E. On 21 April 2016, in relation to Patient E who had visual inattention on the left, you:
(i) Did not sit on the left side of Patient E to encourage scanning and improve Patient E’s awareness of the left side,
(ii) Did not place any items on the left side to encourage scanning and improve Patient E’s awareness of the left side,
F. On 08 April 2016, in relation to Patient F,
(i) You began Patient F’s apraxia assessment using the patient’s non-affected hand,
(ii) You asked Patient F ‘what a Cup was’ despite the patient presenting high functionality (cognitively and perceptually)

2. You did not demonstrate that you could record adequate and/or accurate assessments in that:

A. In relation to Patient G, on or around 14 December 2015,
(i). your assessment did not make it clear that Patient G was suffering from delirium.
(ii), your assessment did not make it clear that Patent G needed time to allow the delirium to settle.
B. In relation to Patient H,
(i) Your SOAP notes did not refer to the appropriate equipment for a discharge
(ii) Your SOAP notes did not mention that Patient H was soiled and/or the convene had not worked
(iii) Your SOAP notes did not mention any coordination with other medical personnel.
(iv)You recorded that Patient H was hoisted into a smart careflex chair when Patient H was seated into a flo-teck chair

3. You did not demonstrate that you could undertake adequate discharge planning in that:
A. In relation to Patient I, you did not discuss with a Social Worker around the need for Patient I’s
(i). package of care, (ii). equipment,
(iii), a pre discharge home visit
B. In relation to Patient J, you did not discuss with a Social Worker
(i) Patient J’s incontinence issues
(ii) a strategy of how to summon help in the event of an emergency
C. You delayed Patient K for discharge for over 4 days without good reason
D. You were prepared to discharge Patient L, despite Patient L suffering from inattention and requiring ongoing support
E. You suggested referring Patient M to social services to help Patient M find employment, even though Patient M had not expressed a desire to work during your assessment
F. You recommended that Patient N would be safe to discharge despite evidence of cognitive problems during his assessment
G. You recommended Patient F to be discharged to his home despite evidence of significant weakness in Patient F’s hand

4. You did not demonstrate that you could undertake adequate/safe analysis of clinical observation in that:
A. In relation to Patient O, you did not consider the use of a commode (wheelchair) despite Patient O being hot, dizzy and needing assistance
B. In relation to Patient P, you persisted in an assessment despite Patient P reporting dizziness.
C. On 28 December 2015, you demonstrated poor understanding of observation charts and/or normal blood pressure ranges in that:
(i) you did not understand that blood pressure recorded as 126 systolic was within the normal range, and
(ii) you indicated your understanding to a colleague that that blood pressure was scored by the diastolic value when this was not the case,

5. You did not demonstrate that you could communicate effectively in that:
A. In relation to Patient Q, you did not realise that Patient Q was having increasing problems with his memory during a cognition and delirium assessment
B. You discussed the wrong patient during a handover discussion on or around August 2016
C. On or around October 2016, you persisted with an assessment when Patient R put his hands on his head in discomfort
D. In relation to Patient S, you persisted with a clinical observation and /or grading the task despite Patient S finding the task difficult.

6. You did not demonstrate that you could select patients’ appropriate pathways and/or services in that:
A. You did not identify that Patient T required ongoing therapy and/or follow up services despite clear evidence of Patient T’s non-dominant hand weakness.
B. In relation to Patient U, you did not attempt to communicate with a physiotherapist to discuss:
(i) Appropriate rehab plan
(ii) Follow up treatment/assessment

7. On or around August 2016, you did not demonstrate adequate preparation in that you went to discuss Patient V’s need with Patient V and his family, without
A. Being fully aware of Patient V’s medical needs,
B. Being fully aware of Patient V’s level of mobility and/or equipment needs

8. On or around 08 January 2015, you did not bring the measurements of the bed and/or hoist when attending Patient W’s access visit.

9. The matters set out in paragraphs 1 - 8 constitute misconduct and/or lack of competence.

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

Finding

Preliminary Matters
Hearing in private
1.    The Panel considered an application by the parties that matters relating to personal and health matters should be considered in private. The application was for discrete parts of the hearing, as identified by the parties, to be heard in private.


2.    The Panel considered the representations of both parties that it was appropriate to consider matters relating to personal issues in private. Those representations were that, so far as both parties were able to, they would present these in isolation from other matters.  The HCPC representative had taken the Panel to the relevant portion of the HCPTS guidance on the issue of when the Registrant’s interests might outweigh the public interest.

3.    The Panel received legal advice to the effect that the starting position was for all hearings to be held in public. There was, however, a discretion to exclude the public where a registrant’s interests outweighed those of the public.

4.    The Panel decided that it would exercise its discretion in hearing some parts of the hearing in private where they related to the Registrant’s health or private life, and would rely on the parties to ensure that they indicated when that would be.

5.    During the hearing, the Registrant’s representative withdrew the Registrant’s application for privacy relating to the issue of the Registrant’s dyslexia.

Amendment to particular 7(b)
6.    During the hearing, the Panel noted that particular 7(b) included a typographical error in that it referred to 2015 when it should have read 2016. It decided to exercise its discretion and amend 2015 to 2016 in that particular.

Background
7.    The Registrant was employed by University of Bristol NHS Foundation Trust at Bristol Royal Infirmary (BRI), as a Band 5 Occupational Therapist (OT) from 20 October 2014. She rotated between medical departments, working for 6 months in each. She joined the Acute Stroke Ward (ASW) in October 2015, having completed a rotation in the Medical Respiratory Team where some concerns about her practice had already been identified.

8.    The ASW Clinical Lead OT was Ms BC. She received a telephone handover from the Medical Respiratory Team at the start of the Registrant’s ASW rotation. Ms BC was given feedback on the Registrant’s performance while she was working on the Medical Respiratory ward. She subsequently received a copy of the minutes of a meeting in that department dated 18 June 2015 detailing concerns and setting out an action plan. Ms BC identified areas of deficient practice in the first few weeks of the Registrant working within ASW and her concerns increased regarding the Registrant’s ability to work safely and independently. Mr SA, the Registrant’s senior line manager made the decision, based on evidence of unsafe practice and poor decision-making from a variety of staff members, to make the Registrant a supernumerary member of staff on 5 January 2016.  From this time, the Registrant was placed under the close supervision of Ms BC, Ms EL (nee F) and Ms KD (nee J).

9.    Despite supervision and support throughout the Performance management process, which lasted for 38 weeks and was overseen by Mr SA, concerns remained about the Registrant’s ability to practice at the standard of a Band 5 OT. These unresolved performance issues were referred to the HCPC upon the Registrant’s resignation from the Trust in December 2016.

Evidence
10. At the start of the hearing, the Panel had before it a large amount of documentation which had been prepared and presented by each of the parties. This documentary evidence was further supplemented during the course of the hearing by further documents presented by the Registrant’s representative.

11. The Panel received evidence from three HCPC witnesses, from the Registrant and from a character witness (LK) on the Registrant’s behalf. All three HCPC witnesses corroborated and supported the evidence of other witnesses. The Registrant’s testimony as to the facts was consistent with that of the HCPC witnesses.

12. The witnesses were as follows:
·      Mr SA, who had been the senior line manager overseeing the Registrant’s performance management process. He was, in the Panel’s view, a credible, honest, fair and knowledgeable witness. His answers were balanced and accorded with his statement and the supporting documentation. He suggested that the Registrant’s lack of core skills had not been detected earlier because she had not been in a role where she was expected to work as an autonomous practitioner. The Registrant may have been shielded within a co-worker team environment.  He explained to the Panel the various ways in which BRI had supported the Registrant by putting in place strategies that he hoped and believed would assist her. He emphasised that the capability programme had lasted for 38 weeks without any sustained evidence of improvement.
·      Ms BC, who was a Band 7 and the Clinical Lead OT on ASW. She had been responsible for the Registrant’s rotational induction programme within the ASW and then her supervision under the Performance management process. In the Panel’s view, she was a fair, balanced and credible witness. Ms BC told the Panel of the measures she had employed to ensure that the Registrant had been able to fully benefit from the training and supervision she provided. In her view, the Registrant had been unable to demonstrate that she was able to consistently exercise the skills, judgment and knowledge required of a qualified OT. In her words, the Registrant had been unable to make the ‘link’ between the information she had gathered, and the analysis and planning required for treatment. She considered that the Registrant lacked ‘insight’ into the extent and nature of her professional failings.
·      Ms KD was a Band 6 OT who had worked with the Registrant for a short period during the Registrant’s time on the Medical Respiratory Ward and then on ASW. In total, this had only been a matter of 12 weeks, 4 weeks on Medical Respiratory and 8 weeks on ASW. She presented as a straightforward, credible, open, honest and very fair witness. She had been very supportive of the Registrant and keen for her to succeed. She was clear in what she had been asked to do, in supporting the Registrant and the limits of her role in this regard.
·      The Panel considered the Registrant’s testimony to be open, honest, genuine, and at times candid in admitting her deficiencies. She was genuinely trying to assist the Panel. She had been fair in her assessment of her colleagues, indicating that her relationships with BC, EL and KD had been good. The Registrant accepted the validity of the internal process which the Trust had undertaken. She demonstrated that she understood and appreciated the impact that her learning difficulties and her need for close supervision had had on her colleagues, the department and patients. She was described by all the HCPC witnesses as a very nice person who was trying her best, a view which was shared by the Panel. The Registrant’s evidence showed that she had genuine compassion for patients. She accepted that her ability to read patients’ body language and her empathy may have been affected by stress during the Performance management process.
·      LK gave live evidence. She was the wife of a patient who had received care from the Registrant on the Medical Respiratory Ward in 2015. Her testimony supported the comments she had made in a personal letter of commendation to the Chief Executive of the Trust. LK clearly held the Registrant’s skills in high regard. She told of the kindness and support the Registrant had given when she had undertaken an assessment of her and her husband’s needs.

13. The Panel also received the sworn statement of Ms EL who was unable to attend this hearing.

14. The HCPC submitted that in EL’s absence her sworn, signed statement should stand in her stead. It was further submitted that admission of this sworn statement as hearsay was permitted under the HCPC Practice Rules, paragraph 10(1)(c) as it was necessary to protect members of the public. The Panel had brought to its attention by the presenting officer, and by the legal assessor in her subsequent advice, the relevant case law on this issue. The Panel decided to admit EL’s statement as hearsay having heard the reasons for her absence and the steps taken by the HCPC to secure her attendance. The Panel considered that the HCPC had taken all reasonable steps and given that none of the issues raised in her statement were in dispute, concluded that it did not cause the Registrant any prejudice. The Panel noted that EL’s statement was corroborated by other witnesses and supported by the documentation and therefore came to the conclusion that it could give the statement considerable weight.
 
Decision on Facts
15. At the outset of the hearing, the Registrant accepted the factual basis of all limbs of all the particulars within the Allegation. The Panel was aware that notwithstanding these admissions, the burden was upon the HCPC to provide the evidence to the standard required, which is the common law standard of the balance of probabilities. There was no onus on the Registrant to prove or to disprove anything. The Panel therefore undertook an analysis of all the information before it in order to establish whether all limbs of the particulars of the Allegation were supported by reference to live oral testimony, and/or documentation including witness statements. The documentation before the Panel included minutes of performance review meetings and contemporaneous observation records prepared by members of the ASW team, who had been assigned to observe the Registrant’s practice, during every patient contact session.

16. As part of its analysis of the evidence, the Panel cross-referenced the evidence within the sworn statement of Ms EL, to establish whether that evidence accorded with evidence from other HCPC witnesses. The Panel noted that in this regard, those matters which it was unable to cross-refer to another witness or document were nevertheless supported by the Registrant’s acceptance of the factual basis of the particulars.
Findings

Particulars 5(a) and (b) – Not proven
17. Whilst taking the Registrant through the individual events underpinning each particular to establish the surrounding circumstances of each incident, the Panel identified that there was inconclusive supporting evidence for particulars 5(a) and 5(b). The evidence was inconclusive in that it was not apparent to which patient particular 5(b) related, and which information before the Panel related to the person identified as Patient Q in particular 5(a). In his closing submissions, the HCPC Presenting Officer confirmed that it was difficult to identify the relevant evidence for these particulars. After further careful scrutiny, the Panel has concluded that there is insufficient evidence to find these matters proven.

18. The Panel has listed below the sources of evidence it has relied on for all other particulars, each of which has been found proven to the requisite standard.

Particular 1 and 1(a) – Found Proved
1. You did not demonstrate that you could ensure patient safety in that:
 (a) On 28 December 2015, you did not ensure Patient A was wearing oxygen when being mobilised to the bathroom.

19. The evidence came from BC supported by the observation record prepared on 28 December 2015 by KM-J, a Band 7 Physiotherapist. This incident had been discussed at the performance meeting held on 5 January 2016. The Registrant was able to recall the detail of this incident. She was able to explain the context but accepted it happened. 
Particular 1(b), 1(b)(1) and 1(b)(ii) – Found Proved
(b)  On 17 December 2015, when Patient B showed signs of deteriorating health you did not:
(i)      initiate the checking of Patient B’s observations and/or
(ii)    alert the medical staff until prompted to do so.

20. Evidence for both 1(b)(i) and (ii) came from the sworn statement of EL supported by the observation report prepared on 18 December 2015 by EL (nee F). This incident was discussed at the performance meeting on 5 January 2016. It was recorded by EL that the incident had been ‘instantly alarming’. Whilst the Registrant was unable now to recall the incident, at the performance meeting on 5 January 2016, she is recorded as acknowledging what had happened.
Particular 1(c) – Found Proved
(c)    On or around 04 December 2015, you requested that Patient C be mobilised despite Patient C suffering from a possible vertebral compression fracture.

21. The evidence for this particular came from BC and the statement of EL, supported by the record of the meeting on 4 December 2015 between the Registrant, BC and EL. The Registrant still has a clear recollection of this event. She was able to explain the context but accepted that it happened.
Particular 1(d) – Found Proved
(d)   On 4 October 2016, you allowed Patient D to mobilise with only supervision when it was unsafe for him to do so.
22. The evidence comes from the statement of EL supported by the contemporaneous observation record prepared by her on 4 October 2015. The Registrant has a clear recollection of this incident.
 
Particular 1(e) – Found Proved
(e)   In or around March 2016, in relation to Patient O, you did not consider the use of a commode (wheelchair) despite Patient O being hot, dizzy and needing assistance.
23. The evidence for this came from the statement of EL supported by the contemporaneous observation record made by her on 9 March 2016. This matter was discussed at the performance meeting held on 11 March 2016. The Registrant did not recollect this incident but accepted that it happened.

Particular 1(f) – Found Proved
(f)   On or around 12 October 2016, in relation to Patient R, you persisted in an assessment despite Patient R reporting dizziness.

24. The evidence came from BC supported by the observation record prepared on 12 October 2016 by LE, another OT. This matter was discussed at the performance meeting held on 18 October 2016. The Registrant does not now recall the incident but is recorded at the meeting on 18 October 2016 as acknowledging that it happened.

Particular 2(a) – Found Proved
2.    You did not demonstrate that you could carry out and/or record adequate and/or accurate assessments in that:
(i)     In relation to Patient G, on or around 14 December 2015, your analysis did not take into account that Patient G needed time to allow the delirium to settle.

25. The statement of EL states that she has no clear recollection of this incident but is able to rely on her contemporaneous observation and supervision notes of 4 December 2015. The Registrant has acknowledged this incident took place and stated in evidence that as a result she undertook more study about delirium.

26. Whilst the Registrant had undertaken an assessment, in the circumstances it cannot have been either adequate or accurate.

Particular 2(b)(i), 2(b)(ii), 2(b)(iii) and 2(b)(iv) – Found Proved
2.    In  relation  to  Patient  H,  on  or  around  8  January  2016,  your assessment record:
(i)     did not identify the appropriate equipment for discharge
(ii)    did   not   mention   that   Patient   H   was   soiled   and/or the management          of Patient H’s incontinence should be reviewed
(iii)   did not mention and/or recommend any coordination with other medical personnel.
(iv)   included that Patient H was hoisted into a smart careflex chair when Patient H was seated into a flo-teck chair.

27. The statement of EL was supported by her contemporaneous note of 8 January 2016 (mistakenly dated 2015). Her record identifies the matters set out in limbs (i) to (iv). This was a visit to a patient in their home and the Registrant still clearly remembers this visit and accepts these particulars.

28. The Registrant did not carry out this assessment adequately therefore her assessment could not be accurate. If the assessment was neither accurate nor adequate it follows that her recording of her assessment could not be accurate.

Particular 2(c) – Found Proved
(c)  On 4 October 2016, you scored Patient D incorrectly on the National Early Warning Score (NEWS) chart.

29. The evidence for this came from EL and her contemporaneous observation record of 4 October 2016. The Registrant recalls the incident and told the Panel that she was cross with herself for not writing it down correctly. This assessment was therefore not accurate nor was it accurately recorded.

Particular 2(d)(i) an 2(d)(ii) – Found Proved
(d)  On 21 April 2016, in relation to Patient E who had visual inattention on the left, you:
(i)  Did not sit on the left side of Patient E to encourage scanning and improve Patient E’s awareness of the left side,
(ii) Did not place any items on the left side to encourage scanning and improve Patient E’s awareness of the left side.

30. The evidence came from KD supported by her contemporaneous observation record prepared on 21 April 2016. The Registrant recalled the incident and told the Panel that she had always had trouble remembering her left from her right and that ‘this happened a lot’.

31. As the Registrant had not carried out the assessment adequately, it could not have been either accurate or recorded accurately.

Particular 2(e)(i) an 2(e)(ii) – Found Proved
(e)  On 08 April 2016, in relation to Patient F,
(i)     You began Patient F’s apraxia assessment using the patient’s non affected hand,
(ii)    You asked Patient F ‘what a Cup was’ despite the patient presenting high functionality (cognitively and perceptually).

32. The evidence came from BC supported by her observation note of 9 April 2016 of the incident on 8 April 2016. The Registrant had no clear recollection of this incident but accepts that it happened, and explained that it related to her training which encouraged her to ask patients about everyday objects. The assessment was not carried out adequately or accurately.

Particular 3(a) – Found Proved
3.    You did not demonstrate that you could undertake adequate discharge planning in that:
(a)   On or around 12 October 2016 you suggested referring Patient M to social services to help Patient M find employment, even though Patient M had not expressed a desire to work during your assessment.

33. The evidence came from BC supported by the contemporaneous record prepared on 12 October 2016 by LE. This matter was discussed at the performance meeting on 18 October 2016 but not recorded within the minutes of that meeting. The Registrant has a clear recollection of this incident and recalls her wish to demonstrate that she could ‘think outside of the box’ on this occasion.

Particular 3(b) – Found Proved
(b)  On or around 19 January 2016 you recommended that Patient N would be safe to discharge despite evidence of cognitive problems during her assessment.

34. The evidence came from BC supported by the observation note made on 19 January 2016 by EL. The Registrant recalls this incident.
Particular 3(c) – Found Proved
(c)  You recommended Patient F be discharged to his home despite evidence of significant weakness in Patient F’s hand.

35. The evidence came from BC supported by her note made on 9 April of events she observed on 8 April 2016. The Registrant cannot recall the detail of this incident but accepts that it happened.
 
Particular 4(a) – Found Proved
4.    On 28 December 2015, you demonstrated poor understanding of observation charts and/or normal blood pressure ranges in that:
(a)   when assessing Patient X you did not understand that blood pressure recorded as 126 systolic was within the normal range, and

36. The evidence came from BC supported by the observation record prepared on 28 December 2016 by KM-J. The Registrant acknowledged that she had issues with knowing and remembering the correct ranges for blood pressure.

Particular 4(b) – Found Proved
(b)   when assessing Patient Y you indicated your understanding to a colleague that blood pressure was scored by the diastolic value when this was not the case.

37. The evidence came from BC supported by the observation record prepared on 28 December 2015 by KM-J. The Registrant again accepted that her understanding of blood pressure ranges had not been clear which was why she had relied on other members of staff to take them, however she did acknowledge that this was a normal part of an OT role.

Particular 5(c) – Found Proved
5.    You did not demonstrate that you could communicate effectively in that:
(c)  On or around October 2016, you persisted with an assessment when Patient R put his hands on his head in discomfort.

38. The evidence came from BC supported by the contemporaneous note prepared on 12 October 2016 by LE. The incident was discussed at the performance management meeting on 18 October 2016. At that meeting, the Registrant is recorded as acknowledging the event although she now has no clear recollection of the incident.

Particular 5(d) – Found Proved
(d)  On or around 21 April, in relation to Patient S, you persisted with a clinical observation and/or grading the task  despite Patient S demonstrating that she would be unable to grasp any of the task.

39. The evidence came from KD supported by her contemporaneous note of 21 April 2016. The Registrant did not recall the detail of this incident.
 
Particular 6(a) – Found Proved
6.    You did not demonstrate that you could identify patients’ appropriate pathways and/or services in that:
(a)  On or around 8 April 2016, you did not identify that Patient F required ongoing therapy and/or follow up services despite clear evidence of Patient F’s hand weakness.

40. The evidence came from BC supported by her note dated 9 April 2016 of events on 8 April 2016. The Registrant did not recall the detail of this incident but accepted that it happened and that her recommendation had not included any referral for further therapy or rehabilitation.

Particular 6(b)(i) and 6(b)(ii) – Found Proved
(b)   On or around 12 October 2016, in relation to Patient U, you did not attempt to communicate with a physiotherapist to discuss:
(i)   An appropriate rehab plan
(ii) Follow up treatment/assessment.

41. The evidence came from BC supported by the observation record prepared on 12 October 2016 by LE. The Registrant did not recall this incident but accepted it happened.

Particular 7(a), 7(a)(i) and 7(a)(ii) – Found Proved
7.    You did not demonstrate adequate preparation in that:
(a)  In or around 15 August 2016, you went to discuss Patient V’s need with Patient V and his family, without
(i)     Being fully aware of Patient V’s medical needs,
(ii)    Being fully aware of Patient V’s level of mobility and/or equipment needs.

42. The evidence came from the statement of EL supported by reference to her contemporaneous observation note dated 15 August 2016. This matter was then discussed at the performance management meeting held on 30 August 2016. The Registrant did not recall this incident.

Particular 7(b) – Found Proved
(b)  On or around 08 January 2016, you did not bring the measurements of the bed and/or hoist when attending Patient H’s access visit.

43. The evidence for this came from EL supported by her contemporaneous record of the home visit she undertook with the Registrant. The Registrant still has a clear recollection of this incident. She explained that she had seen EL getting the measurements to take with her on the visit so concluded that she did not need to take them herself. The Panel found this proved as a matter of fact.
Decision on Grounds

44. The Panel appreciated that at this stage in the proceedings, there is no burden upon the HCPC, and it is a matter of the Panel applying its professional judgment as to whether the matters found proved, individually or collectively, amount to misconduct and/or lack of competence. For this purpose, the Panel discounted the matters set out in 5(a) and 5(b) (which were not found proved) from its considerations.

45. On the issue of what constituted misconduct or lack of competence, the Panel received advice from the Legal Assessor. The Panel had received representations from the HCPC that the sample of matters before the Panel supported a finding of lack of competence.

46. In support of its submission, the HCPC identified those sections of the HCPTS Standards of Proficiency for Occupational Therapists and Standards of Conduct, Performance and Ethics current at the time of the events, which it submitted had been breached by the Registrant’s poor performance. In relation to the Standards, there were two sets of Standards to be considered by the Panel as the events straddle the introduction of new Standards of Conduct, Performance and Ethics in January 2016.

47. The Registrant’s representative maintained that the Registrant had worked without any cause for concern for two years before going to ASW. It was also argued that the number of incidents had reduced drastically over the months, and there had been marked improvement in her performance. The level of stress which the Registrant had suffered during the period while she was under a performance management process was significant. It had led to a deterioration in the Registrant’s health which may have been avoidable if she had been treated with more empathy and understanding. It was highlighted that by retaining her on three rotations in ASW her stress levels increased further and that it would have been appropriate to move her to a department where she had been better able to perform her tasks. The need for further measures to assist her and specific adjustments which suited the Registrant was highlighted. The Registrant’s representative also highlighted the failure to consider the Registrant’s personal wishes in relation to the issue of reasonable adjustments to address her learning difficulties, stressing the particular adjustments which the Registrant found helpful but which were not implemented, e.g. written feedback.

48. The Registrant’s representative stressed that the Registrant had been given an enormous, and at times increasing, number of competencies to attain and relatively short deadlines to achieve them. She was expected to achieve this when she was not able or allowed to show her true abilities in that stressful and busy ward. Given her physical, mental and emotional state at that time, it was no wonder that she not only failed but that her concentration and short term memory got worse.

49. The Registrant’s representative referred the Panel to the Occupational Health report dated 19 January 2016 and an Information Guide on Dyslexia produced by Nottinghamshire NHS Trust. She explained that certain methods of support (Dictaphone, Dragon software) provided by BRI were not suitable for the Registrant’s particular needs, as she had already developed her own coping strategies. She also explained that insufficient support had been offered to the Registrant in connection with her health.
50. The Panel started its discussion by considering whether the matters before it could properly support a finding of misconduct. As stated above, it had been taken to relevant case law. There was no evidence that the Registrant had wilfully, intentionally or negligently, by commission or omission, behaved inappropriately. This being the case the Panel concluded that this was not a matter of misconduct.

51. The Panel considered that it had a sufficient sample of examples of the Registrant’s poor professional performance to support a finding of lack of competence. There were 17 patients involved in the matters found proved during the period from 4 December 2015 to 12 October 2016. The Panel noted that with the exception of five incidents, these events happened during the 38 week period when the Registrant was supernumerary and therefore under very close one-to-one supervision and daily observation. The Panel also noted the evidence that this was only a sample of the matters which had been identified as of concern in the Registrant’s performance at this time. The evidence of BC was that concerns arose on a daily basis. The Registrant acknowledged that the same performance issues arose many times.

52. The Panel has identified from the evidence that the Registrant was unable to demonstrate proficiency in the core OT competencies. The Allegation reflects the range of basic knowledge and skills that were missing. The Panel noted Mr SA’s comments that patient safety had been his main concern and had led to him making the Registrant a supernumerary, at which point the number of potentially harmful incidents had dropped dramatically as a result of the close supervision. He believed that there had always been issues with the Registrant’s performance and that it did not all arise out of her moving to a more stressful ward. He had identified within his management report that the Registrant’s work on her previous rotation had resulted in the imposition of performance measures the previous summer, when she was newly in that rotation.

53. The Panel noted that there was evidence of concerns in June 2015 but that no evidence had been provided about the Registrant’s performance in the Older People’s Rehabilitation rotation ward, or during the previous year when she had been working in Bath. The Panel noted, however, that there was a large body of evidence from the ASW witnesses, which demonstrated a total lack of consistency in the Registrant’s performance on that ward. Things which she did well one day were not performed to the required standard the next day. The Panel also noted that the Registrant had only very slowly achieved the level of proficiency required to be signed off in some of the core competencies. For instance, the Registrant’s lack of knowledge and her ability to take and interpret blood pressure recordings correctly and accurately had been identified in December 2015 but was not signed off until August 2016. Many other competencies were never achieved.

54. The Panel also noted that the Registrant on occasions failed to use her knowledge appropriately, as evidenced in particular 2(e)(ii) when she asked the patient to identify a cup even though it should have been obvious to her that the patient was cognitively able to recognise common objects.

55. It was clear from the information before the Panel that the Registrant had been taught and shown what she was supposed to be doing but was unable to consistently follow and apply that guidance. She did not deliberately do the wrong thing, nor did her lack of competence generally arise from a lack of knowledge, but was the product of her inability to perform competently and consistently, despite constant supervision, repetition and a reduced and simplified caseload.

56. The Registrant’s case load had been reduced from the normal Band 5 expectation of 6 to 8 per day to 2 or 3, however this had not assisted in her completing tasks in a timely, organised and accurate manner. The complexity of her cases had also been reduced, and her cases were ‘handpicked’ to be the least complex available. Despite being provided with detailed feedback after each patient contact, there was no identifiable or sustained improvement in performance. It was of great concern to the Panel that some of the incidents which had been observed whilst under the performance management process could have resulted in very serious harm to patients. For instance:
·      Patient F, who could have been discharged home without the correct therapy and support. In such an instance his recovery would have been delayed or inhibited.
·      Patients O and R could have fallen and sustained a serious injury.
·      Patient C who had a possible vertebral compression fracture and could have been seriously injured if he fell
·      Patients N and F who could have been discharged unsafely

57. The Panel also noted that the Registrant had little understanding of the need for good use of her time and for the use of effective processes and systems. An example of this was her unnecessary referral of Patient M to Social Services. This was a waste of her time and others time. It would eventually have resulted in wasted cost to the public. Delays in ordering equipment would also result in the additional expense of paying for express delivery. Her poor personal organisation had resulted in the delay in the discharge of patient H. Delayed discharges also have implication for public resources.

58. The Panel noted that the Registrant had chosen not to inform her employer about her dyslexia at an early stage, with the result that the Trust was unable to provide her with the requisite support at the earliest opportunity. The Panel noted the measures which had been put in place to assist the Registrant when it was appreciated that she needed reasonable adjustments. These included:
·      Use of pocket-sized cue cards (developed by the Registrant) to assist with recollection of acronyms, sequences and core information.
·      Use of blue paper.
·      Installation of a blue background screen on the computer terminal.
·      Rulers with letterbox hole to guide reading
·      Use of a quiet room when available
·      Performance feedback after each patient contact in addition to weekly supervisions
·      Provision of a Dictaphone
·      Offer of Dragon voice recognition and dictation software
·      Number of patients drastically reduced from 6/8 per day to 2/3
·      Patients handpicked to be those presenting the least complex conditions
·      Access to LAWDI, Learning and Working Disability and Illness service

59. When asked in this hearing if there was in fact more that could have been done to assist her, the Registrant was unable to identify anything. In her submissions the Registrant’s representative however suggested that the best thing that the Trust could have done was to move the Registrant away from ASW and to allow her to work using her own established systems. This would have included her making her case recordings in a less structured way. It was also emphasised that Mr SA had provided a range of solutions for the problem but had done so without consultation with the Registrant as to whether they would work for her or not.

60. This Panel appreciates that it is not assessing this matter from the perspective of whether the employer has discharged its responsibility to make reasonable adjustments. However, it notes that, notwithstanding this range of support measures, the Registrant was unable to attain the standard required of a newly qualified practitioner. Further, it heard from witnesses that in their view, the Registrant was unlikely to be able to reach that standard. The Panel noted the following comments from the live evidence:
KD: ‘a longer period would not have made any difference – no matter how many times you told her she just didn’t seem to be able to retain it’.

 
KD: ‘she could not seem to take it in’.
 

KD: ‘she did try her best but it was inconsistent. Maybe she did things well one day but then a few days later went back to the start’.
 

BC: ‘we wanted to support her as best we could throughout the process – we wanted to help her.’
 

BC: ‘we didn’t see any evidence she could deliver the basic OT process. We did not see consistent improvement’.
 

BC: ‘Some days she saw one to two patients some days 3 – she had difficulty reading non-verbal signs of fatigue and adjusting her approach or ending a session.’
 

BC: ‘she had a lack of insight into her difficulties throughout the entire process’
 

BC: ‘her skill level was worse than newly qualified’.
 

BC: ‘Was she ever likely to ever reach the standard? No we were still identifying issues late in the [performance management process].’
 

BC: ‘her performance remained the same throughout’
 

SA: ‘She was putting in the effort and trying but not succeeding’
 

SA: ‘My team was here to support her and not looking for fault’
 

SA: ‘all the positives were recorded and praised to encourage her’
 

SA: ‘we just wanted the core run of the mill OT skills – we were not worried about the stroke speciality.’
 

SA: ‘Danger to patients – these supports did not make a difference to the issues accumulating.’
 

61. Despite these frank comments, the Panel received from all three HCPC witnesses, a clear picture of the considerable support and encouragement offered to the Registrant and the willingness of her colleagues to support her and see her achieve. It was clearly a disappointment and a frustration to them that they had not succeeded in that aim. In the Panel’s view, the Registrant was given a lot of support but this had failed to improve her performance to the standard required.

62. The Panel has considered the terms of the standards issued by the HCPTS and has concluded that the Registrant has breached the following:
Standards of Conduct, Performance and Ethics 2012 edition

This Standard related to the Panel’s findings on 1(a), 1(b) 1(c) 2(a) and 4, all of which occurred prior to 1 January 2016.

Standards 1, 5, 6, 7, 8, and 10
Standards of Conduct, Performance and Ethics 2016 edition

The Panel consider that the following standards have been breached and/or not attained by the Registrant:

Promote and protect the interests of services and carers
Paragraphs 1, 1.1, 1.2, 1.3, and 1.4,

 
Communicate appropriately and effectively
Paragraphs 2, 2.1, 2.2, 2.3, 2.5, and 2.6,

 
Working within the limits of your knowledge and skills
Paragraphs 3.1, 3.2, 3.3, 3.4, and 3.5,

 
Delegate appropriately
Paragraphs 4.1, and 4.2

 
Managing risk
Paragraphs 6.1, and 6.2

 
Keeping records of your work
Paragraph 10.1

Standards of Proficiency for Occupational Therapists 2013 edition

1.1 and 1.2  - breached
 

2.1,2.2, 2.3, 2.7, 2.8  - breached
 

3.1, 3.3  - breached and not attained
 

4.1, 4.2, 4.3, 4.4, 4.5, 4.6 - breached and not attained
 

8.1, 8.3, 8.4, 8.5, 8.6, 8.8, 8.9, 8.10 - breached
 

9.1, 9.2, 9.3, 9.4, 9.5, 9.6, 9.7, 9.10 - breached
 

10.1, 10.2 - breached
 

11.1,11.2 - breached and not attained
 

12.1, 12.2, 12.3, 12.4, 12.5,12.6, 12.7 breached & not attained
 

13.1, 13.2, 13.3, 13.4,13.5, 13.7, 13.8, 13.9 not attained yet, 13.10 breached, 13.11 breached, 13.13 breached, 13.14 breached
 

Standard 13 aspects not attained
 

14.1Breached, 14.2 breached, 14.3 breached
 

14.4 to 14.24 breached
 

Standard 14 aspects not attained
 

15.2 to 15.3 breached, 15.5. and 15.6 breached

Standard 15 aspects not attained

63. The Panel did not find evidence that Registrant had yet attained the standards of proficiency expected at this stage of her career. It noted that there was a paucity of evidence to indicate whether she was functioning at an appropriate level within work settings prior to the Stroke rotation, although it noted that concerns had arisen on the previous rotation.

64. The Panel appreciates that breaches of the code do not automatically amount to a finding of lack of competence. However, in this instance the number of aspects of the code which the Registrant has either breached or failed to attain, is in the Panel’s view demonstrative of a serious lack of competence. The Panel has concluded that the ground of lack of competence has been established in respect of each and every allegation found proven and cumulatively.

Decision on Impairment
65. The Registrant’s work since leaving the Trust has been in positions which did not require her registration. She has worked in three posts since leaving. She is currently working as a Band 4 OT Technician in an open ward for mentally ill patients with complex needs and behaviours. The information contained in a recent review undertaken by her employer showed that she was performing satisfactorily and there had been an overall improvement in her performance in recent months, including an increase in her confidence in her professional abilities, and in her communication with patients albeit at a Band 4 Technician level. She told the Panel that she enjoys this job.

66. The Registrant had undertaken some in-service continuing professional development. This had been relevant to her previous post as a care worker and her current role as a Band 4 OT Technician in a mental health rehabilitation unit. The Registrant was working long hours and was poorly paid and so unable to dedicate the time, or able to afford, further training or study.

67. The HCPC in its submissions highlighted the limitations of the remediation the Registrant had been able to undertake since her departure from BRI. Her subsequent roles may have developed some OT skills but not at Band 5 level.
68. In reaching its decision the Panel took into account the following:
In relation to impairment, the Panel reminded itself that the test of impairment is expressed in the present tense, that fitness to practise ‘is impaired’.

 Whether the Registrant’s fitness to practise is impaired is a matter of judgment for the Panel.
 

Rule 9 of the Health Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 (as amended) provides ‘where the Committee has found that the health professional has failed to comply with the standards of conduct, performance and ethics established by the Council under Article 21(1)(a) of the Order, the Committee may take that failure into account, but such failure will not be taken of itself to establish that the fitness to practise of the health professional is impaired.  

The advice of the Legal Assessor.

The guidance issued by the HCPTS entitled ‘Finding that fitness to practise is impaired.’

69. The Panel started by considering the personal component of its decision. It noted that there was no evidence of remediation in respect of the core OT competencies. There was therefore, in the particular circumstances of this case, a high likelihood of repetition. The Panel has noted the Registrant’s satisfactory performance as a Band 4 OT Technician (which does not require HCPC registration) and her progress in resolving some of her deficiencies at that level, including communication skills, teamwork and goal planning. Nevertheless, since resigning from the Trust the Registrant has not worked as an autonomous Band 5 OT and has therefore been unable to demonstrate that she is now able to work safely at that level.

70. Given the Registrant’s lack of competence and the comments of all the HCPC witnesses, the Panel remains to be convinced whether the Registrant is capable of fully resolving the deficiencies in her performance at the level of a qualified OT. As patient safety issues are a paramount consideration in this case, the Panel was concerned that unless the Registrant is able to demonstrate that she has achieved those core competencies, patient safety will continue to be at serious risk of harm.

71. The Registrant did demonstrate some insight in, that she accepted her deficiencies and the impact they had had on the team, the management of the ward and on the patients. She said she was ‘terrified’ of harming a patient. However, the Panel had some doubts as to whether she had truly recognised the extent of those deficiencies, the efforts put in to help her address them and whether, in fact, she was capable of resolving them and achieving the core competencies of a Band 5 OT.

72. In relation to the issue of public interest, the Panel came to the conclusion that a finding of impairment was warranted in the public interest. There were, as identified above, numerous incidents that could have resulted in real harm to vulnerable patients. There is no evidence that this will not continue to be the position in the future should the Registrant be permitted to return to unrestricted practice as a Band 5 OT. The public would rightly be concerned if a practitioner who possessed such a low level of competence was not found currently impaired.

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

Decision on Sanction   
74. In reaching its decision the Panel considered the guidance contained in the HCPTS Practice Notes entitled Indicative Sanctions Policy and Drafting of Decisions. The latter document has annexed to it the suite of standard conditions, which may be employed if a Conditions of Practice Order is considered appropriate and proportionate in the circumstances of a case.

75. The HCPC representative told the Panel that the HCPC took a neutral view on the level of sanction, it being a matter of judgment for the Panel. However, it submitted that any measure which allowed the Registrant to return to work without the necessary checks and controls in place to ensure patient safety would be inappropriate given the real risk of patient harm which the Panel has identified in its determination on grounds and current impairment. It was submitted that until the Registrant had demonstrated that she had addressed the low level of competence displayed during the period of her performance management process she should not be permitted to work autonomously.

The Registrant’s representative stated that the Registrant should be given credit for “continuing bravely” during the 38 weeks of her performance management process. There had been no other options open to her, having been refused a move to another section, and the offer of another Band 3 position having been rescinded on receipt of references.
77. In making its assessment, the Panel considered all the mitigating and aggravating factors that had been identified in this case. These were:
Mitigating
·         The Registrant made early admissions of her failings which had led to the incidents identified in the Allegation.
·         The Registrant had cooperated with the Trust throughout the performance management process.
·         The Registrant has fully engaged in the HCPC process.
·         The Registrant has taken the opportunity to attend this hearing and to present her perspective on events, thereby putting some of the incidents into a wider context for the Panel.
·         The Registrant has freely admitted that she did not meet the competencies of a Band 5 OT during the performance management process. She demonstrated remorse and stated that she would be “devastated” if she harmed a patient.
The Registrant has developed insight, and now recognises the risk to patient safety and the impact on her colleagues and her employer arising from her lack of competence.
As a further demonstration of insight, the Registrant agreed that she still lacks confidence working with complex service users and stated that she ‘completely agrees’ that she could not currently return to practise as a Band 5 OT.

Her performance was adversely affected by her dyslexia and, at that time, additionally by her health.
Aggravating
·         There were many incidents which could have resulted in significant patient harm.
·         These were vulnerable patients due to their cognitive and/or physical impairments.
·         There were many examples over a lengthy period of time of incompetent performance, which supported the view that the Registrant was unable to work as an autonomous practitioner.
·         There is a high risk of repetition.

78. The Panel noted that in her testimony the Registrant had said that she was unclear about her long-term future professional plans. She was uncertain whether she would be able to, or indeed whether she would wish to, return to work as a qualified OT at some point. She is currently enjoying her role as a band 4 OT Technician within the mental health sector, and hopes to continue with a career in the field of mental health care in the future. However, she wanted to leave open the possibility of working as a qualified OT in the future.

79. On the issue of what was the appropriate and proportionate sanction to impose, the Panel, as advised, started its deliberations by working up from the bottom of the range of sanctions available until it found the least restrictive measure that would balance the interests of the Registrant with patient safety and the wider public interest. The Panel appreciated that as this was a lack of competence case, by virtue of Article 29(6) of the Health and Social Work Professions Order 2001 (as amended), (the 2001 Order), the full range of sanctions are not available at this final hearing: the Panel is unable to impose a Striking Off Order unless and until the Registrant has been the subject of either a Conditions of Practice Order or a Suspension Order, for a continuous uninterrupted period of two years starting from the date the appeal period concluded.

80. The Panel considered whether taking no action, mediation, or the imposition of a Caution Order was appropriate in this case. The Panel was conscious that these measures would not restrict the Registrant’s ability to work autonomously. Given the Panel’s level of concern about the Registrant’s abilities to work safely as a qualified OT, it considered that it would not be appropriate in this case to impose those measures, as they would not provide any degree of public protection. 

81. The Panel gave careful consideration to the imposition of a set of conditions of practise. The Panel noted the lengthy and detailed supervision and guidance which the Registrant had been given during her performance management process. This had in effect been one-to-one observation and supervision for a period of 38 weeks. This level of oversight had not produced any consistent or sustained improvement in the Registrant’s practice and had therefore failed to mitigate the possibility of further incidents arising if she were to practice autonomously. Any set of conditions imposed by this Panel, would therefore, have to be even more draconian than the close supervision put in place during the performance management process. In the Panel’s view any such conditions would be overly restrictive for the Registrant, and unworkable for any mentor or employer.  Any conditions would, on the evidence before the Panel, have to be so restrictive that they would be tantamount to the imposition of a Suspension Order by another means.

82. Further, the Panel appreciated that once conditions of practise are imposed, it places a pressure and responsibility on a registrant to demonstrate that they have fulfilled those conditions. The Registrant has indicated that she is still endeavouring to rebuild her confidence and is not yet ready to practice at Band 5 level. Placing more professional pressures on her at this time may undermine that process, or erode what confidence she has rebuilt. For these reasons, the Panel has concluded that a Conditions of Practice Order is neither practicable nor appropriate, and would not at this time, be in the interests of the Registrant.

83. The Panel considers that a period of suspension will permit the Registrant time to reflect on events, regain her energies and confidence, and if possible, demonstrate that she has the necessary skills. A period of suspension would also provide the Registrant with the time to gain further experience and confidence in her Band 4 OT Technician role, giving her a fuller basis on which to make a final decision about her future within OT and her long-term professional future. The Panel does not consider this measure of suspension to be punitive; it is a reflection of the current situation, which is that the Registrant will have to make further adjustments to her personal coping strategies to attain the relevant level of professional performance, and to undertake extensive further training to retrieve and improve on her level of professional knowledge and skills.   

84. The Panel has therefore concluded that a Suspension Order, for a period of twelve months, is the appropriate and proportionate sanction in this instance. The Panel notes that it is open to the Registrant to request an early review of this order. However, in the Panel’s view this would not necessarily be in the Registrant’s best interests as it is likely to take a substantial period of time for the Registrant to undertake the necessary remediation and demonstrate her competence. 

85. The Panel then considered whether guidance would be of assistance to the Registrant in preparing her for the mandatory review, which will be undertaken pursuant to Article 30(1) of the 2001 Order, before the period of the Substantive Suspension Order comes to an end. The Panel appreciates that any reviewing panel is not bound by this Panel’s indications of evidence that may be presented at a review. However, the Panel, considers it appropriate to suggest that the Registrant should consider gathering and presenting the following evidence at such a review:
References or testimonials from current and/or recent employer(s) stating whether she has achieved the basic OT competencies, including details of any supervised practice undertaken at Band 5 level.

 
A reflective piece in a format suitable for the Registrant (in writing or verbally) giving examples evidencing her ability to complete the full OT process e.g. initial assessment, analysis, goal setting, discharge planning.

Evidence of any training or Continuing Professional Development undertaken which addresses the core OT competencies.

Order

The Registrar is directed to suspend the registration of Lisa Hetreed from the operative date for a period of twelve months.

Notes

No notes available

Hearing History

History of Hearings for Miss Lisa Hetreed

Date Panel Hearing type Outcomes / Status
14/01/2019 Conduct and Competence Committee Final Hearing Suspended