Miss Ruth E Yorkston
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Allegation
The following allegation was considered by a Panel of the Conduct and Competence Committee at the substantive hearing on 19 – 21 April 2016 and 18 – 19 April 2017.
During the course of your employment as an Occupational Therapist for Tees, Esk and Wear Valleys NHS Foundation Trust between April 2010 and February 2012, you:
1) Did not demonstrate adequate clinical reasoning and/or skills in that you:
a) Were unable to demonstrate an adequate understanding of the MOHOST tool and/or its rating system.
b) Were unable to demonstrate an adequate understanding of the Mayers Lifestyle Questionnaire.
c) In relation to Case 1:
i) Not found proved
ii) Not found proved
iii) Not found proved
d) In relation to Case 3, on 25 October 2011 recorded a plan to visit the Service User for food shopping on 2 November 2011 but did not state why you had selected this activity in the notes.
e) In relation to Case 4, on or around 25 October 2011 you made an entry in the notes which was fragmented and/or did not make sense.
f) In relation to Case 5:
i) Your entry dated 19 October 2011 was unclear, in that it did not specify what further assessment was to be undertaken;
ii) On 1 November 2011, the information you recorded in relation to a cooking assessment of the Service User did not state how he managed the process and/or whether he was able to continue cooking for himself;
iii) Your entry relating to contact which took place on 9 November 2011 was unclear and/or fragmented.
g) In relation to Case 8:
i) Following a home visit on 25 November 2011 you noted that the Service User wanted to have his teeth removed but did not take any/any adequate steps to clarify whether this was a genuine need or a possible symptom of his mental health;
ii) Your plan, recorded following a home visit on 25 November 2011, did not adequately address the Service User’s needs.
h) In relation to an OT assessment you observed on 6 October 2011 you produced a reflective log but did not include all relevant information.
i) In relation to an OT assessment you observed on 19 October 2011 you produced a reflective log which did not include all relevant information.
2) Did not complete follow-up actions in that:
a) In relation to Case 1, you did not contact and/or did not adequately record your contact with the Service User's Care Coordinator as planned:
i) following a telephone conversation with the Service User on 3 November 2011;
ii) following a home visit to the Service User on 8 November 2011;
iii) until prompted in supervision on 17 November 2011.
b) In relation to Case 1, you did not make and/or record appropriate enquiries into the Service User’s potential vulnerability on:
i) 3 November 2011;
ii) 8 November 2011.
c) In relation to Case 2, having recorded a plan on 24 November 2011 to speak to the Service User’s Care Coordinator you:
i) did not contact and/or adequately record contacting the Care Coordinator in a timely manner;
ii) did not inform and/or record informing the Care Coordinator of a potential risk to the Service User, in that a person who answered the phone indicated that he “did not live there” or words to that effect.
d) In relation to Case 8, following information being provided to you during an assessment on 28 November 2011 as to the Service User’s incontinence, you did not make a referral to an incontinence nurse in a timely manner or at all.
3) Did not maintain adequate records in that:
a) In relation to Case 1, in an entry dated 8 November 2011, you:
i) referred to yourself both as ‘therapist’ and as ‘Occupational Therapist’;
ii) made reference to a telephone call but did not state when it occurred;
iii) your entries made on 3 November 2011 and 8 November 2011 were unclear such that they required subsequent amendments.
b) You made amendments to records after entries had been countersigned by your clinical supervisor, in that you:
i) In relation to Case 1, made amendments to an entry dated 17 November 2011;
ii) In relation to Case 5, made amendments to an entry dated 2 November 2011.
c) Did not record the following relevant information:
i) In relation to Case 1, a telephone conversation between you and the Service User which took place on 8 November 2011;
ii) In relation to Case 3, the outcome of the OCAIRs and/or Mayers Lifestyle Questionnaire completed on 25 October 2011 within the case entry;
iii) In relation to Case 8, your entry following the home visit on 25 November 2011 was blank in respect of Objective 3.
d) In relation to case 7:
i) on or around 8 December 2011, did not record sufficient information to identify the level of risk arising from the Service User’s failure to take her medication;
ii) did not seek and/or record seeking advice from a consultant or other suitable professional in relation to the Service User missing her medication.
e) In relation to Case 8, on 25 November 2011 you conducted a home visit and did not conduct and/or record a Mental State Examination (MSE) despite being made aware that the Service User's father had halved his medication the night before your visit.
f) In relation to Case 8, your entry following the home visit on 25 November 2011 did not record sufficient information to enable an assessment to be made of the risk involved after being made aware that the Service User’s father had halved his medication.
4) Did not complete an adequate report in that, in relation to Case 3, the Occupational Therapy Functional Assessment report completed between 11 and 16 November 2011:
a) Contained unnecessary repetition;
b) Recorded information in the wrong sections;
c) Did not include observations on the Service User's abilities and/or functioning during the shopping trip.
5) Did not complete tasks in a timely manner in that:
a) In relation to Case 5, a cooking assessment took place on 1 November 2011 but your report was not completed until 24 November 2011;
b) In relation to Case 3:
i) You had not completed an entry on PARIS for a community assessment made on 2 November 2011 by 9 November 2011;
ii) You had not completed an Intervention Plan by 17 November 2011, despite having been instructed to complete this on 9 November 2011.
c) In relation to Case 7, on 14 December 2011 you had not recorded an assessment and/or completed an intervention plan when the original deadline for completion was 6 December 2011.
d) In relation to Case 8:
i) By 12 December 2011, you had not seen the Service User despite having planned to see him the week of 5 December 2011;
ii) By 12 December 2011, you had not completed an intervention plan when the original deadline for completion was 5 December 2011.
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.
At the substantive hearing the Panel found all of the particulars (above) proved with the exception of 1(c)(i) to (iii). The Panel found the proved particulars amounted to a lack of competence and the Registrant’s fitness to practice was impaired. A Suspension Order for a period of 12 months was imposed as a Sanction. It was reviewed and extended for a further 12 months on 10 April 2018, and reviewed and extended for a further 6 months on 17 April 2019.
Finding
Preliminary Matters
Hearing in private
1. Ms Simpson, on behalf of the HCPC, applied for any reference to the Registrant’s health to be heard in private. The Registrant agreed with this course of action.
2. The Panel took into account the HCPTS Practice Note entitled “Conducting Hearings in Private” and accepted the advice of the Legal Assessor. The Panel decided that any references to the Registrant’s health should be in private, in order to protect the Registrant’s private life, pursuant to Rule 10(1)(a) of the Conduct and Competence Committee (Procedure Rules) 2003.
Background
3. The Registrant is an Occupational Therapist (OT). She qualified in 1992 and worked for Tees, Esk and Wear Valleys NHS Foundation Trust (the Trust) as an OT from 2001 until 2012.
4. In 2008, concerns arose relating to her ability to perform her job adequately. These concerns persisted throughout 2008 and into 2009. In about November 2009, the Trust received an Occupational Health report, which outlined that the Registrant suffered from a health condition. In light of this health concern, it was decided to redeploy her to a different team. The team to which she was moved was the South Durham Psychosis Team, based at the Goodall Centre. She moved to this team on 1 April 2010.
5. On 27 July 2010, it was reported that there were continuing concerns about the Registrant’s competence, and she was removed from clinical practice on 05 August 2010 and placed within the inpatient OT Team to complete project work not involving patient contact. An investigation was initiated into the Registrant’s clinical practice.
6. In July 2011, the Professional Head of Allied Health Professionals with the Trust was asked to produce an action plan to support the Registrant’s clinical reasoning, clinical practice, and record-keeping, with a view to returning her to supervised practice. The plan contained 12 objectives. The Registrant was to be based in the Darlington Psychosis Team in October 2011 for three months to receive support and build up her caseload. Other objectives were for her to provide clear evidence of understanding and applying OT processes and to use the Mayers Lifestyle Questionnaire (MLQ) tool and Model of Human Occupational Screening Tool (MOHOST). Her placement was supervised by a Specialist OT and the Registrant was restricted to working on five or six cases. Any work she did was to be supported by formal weekly supervision and informal daily supervision.
7. The action plan was formally reviewed in both November and December 2011. On 12 December 2011, the Registrant’s placement with the Darlington team was terminated owing to concerns about her practice and service user safety. The concerns were collectively referred to a Disciplinary hearing, which took place on 03 April 2012.
8. The Registrant self-referred the concerns about her practice to the HCPC in June 2012. That referral eventually resulted in these proceedings.
9. The Substantive Hearing took place over a number of days in April 2016 and April 2017. At the outset, the Registrant admitted the following particulars of the Allegation: 1(f)(i); 2(b)(i), 2(b)(ii), 2(c)(i), 2(c)(ii), 2(d), 3(a)(i), 3(a)(ii), 3(a)(iii), 3(b)(i), 3(b)(ii), 3(c)(ii), 3(c)(iii), 3(d)(i), 4(a), 4(b), 4(c), 5(a), 5(b)(i), 5(b)(ii), 5(c), 5(d)(i) and 5(d)(ii).
10. The panel at the Substantive Hearing found all the facts proved except for 1(c)(i) - (iii). It concluded that the Registrant’s fitness to practise was impaired by reason of her lack of competence. That panel’s decision noted the Registrant’s lack of insight and remediation.
11. At the resumed Substantive Hearing in 2017, the panel decided that the appropriate and proportionate sanction was a 12-month Suspension Order. In imposing the order, that panel set out that a reviewing panel might be assisted by the following:
• Details of how the Registrant had kept her skills and knowledge up-to-date during the period that she was working as an OT;
• Evidence of the learning the Registrant had acquired;
• Evidence to demonstrate that the Registrant had developed appropriate coping strategies to deal with work-related stress that may impact on her health conditions.
12. At the first review of the Suspension Order on 10 April 2018, the reviewing panel decided that the Registrant’s fitness to practise remained impaired and decided to impose a further Suspension Order for 12 months. It noted that, whilst some progress had been made, a risk to service users remained. That panel suggested that the next reviewing panel would be assisted by the following:
• A testimonial from any OT mentor the Registrant may find to assist her in addressing her shortcomings;
• Details of how the Registrant had kept her skills and knowledge up-to-date during the period that she was working as an OT, including proof of any CPD activity;
• Any further evidence to demonstrate that the Registrant had continued to develop appropriate coping strategies to deal with work-related stress that may impact on her health condition.
13. At the second review of the Suspension Order on 17 April 2019, the Registrant’s fitness to practise was found to be impaired and a Suspension Order was imposed for a further period of six months.
Decision
14. Ms Simpson submitted that the Registrant remains impaired on the basis that there has been very little, if any, progress in respect of remediation and insight since April 2017. In particular, Ms Simpson highlighted a lack of improvement or any further training or courses in the three areas of record-keeping, clinical reasoning, and report writing. Ms Simpson acknowledged that the Registrant presented as sincere and willing to engage, but the issue was that she was unable to address the concerns. Ms Simpson requested a Striking Off Order on behalf of the HCPC.
15. The Registrant gave evidence. She told the Panel that she is unemployed. She told the Panel that being out of OT practice for so long created difficulties in terms of her keeping up-to-date with her professional knowledge and skills. She stated that she had made some enquiries about a return to practice course with two different universities, and acknowledged that she needed to undertake more investigation with regard to the return to practise course at the University of Derby, which seemed to offer the appropriate course. While cost had been an issue in the past, she stated that she was now in a better position financially. She told the Panel about further training done as directed by her work coach at the job centre. She told the Panel that, in respect of the concerns about her OT practice, she had asked those who have criticised her practice at her last place of employment about what she had done, but did not know what she had done wrong. In addition, she told the Panel that she would like to try and find a return to practice course and would like to return to practice as an OT in the future.
16. The Panel read the HCPC’s hearing bundle, as well as a number of documents submitted by the Registrant, including a timeline of events and actions, summaries of research carried out by her, some observations and reflections, and a response to the HCPC’s bundle. The Panel also read a reference about some voluntary work undertaken for a Mind Charity shop and a testimonial from a member of the Registrant’s church.
17. The Panel accepted the advice of the Legal Assessor.
18. The Panel was aware that its purpose today was to conduct a comprehensive review of the Registrant’s fitness to return to unrestricted practice and considered the HCPTS Practice Note entitled “Review of Article 30 Sanction Orders”.
19. The Panel must exercise its own independent judgement with regard to impairment.
20. The Panel carefully considered the Registrant’s oral and documentary evidence. The Panel took into account that the Registrant has not worked as an OT since 2012. The Panel also bore in mind the practical limitations which she has had recently, namely financial difficulties, physical difficulties, and also difficulties in accessing a computer.
21. The Panel was of the view that the Registrant presented as a sincere person who was willing to engage with her Regulator. However, the Panel was of the view that there were no further steps which she had taken since the last review hearing in terms of remediation of the lack of competence found proved. In this regard, the Panel noted that the Registrant has been given a significant amount of guidance and information by the HCPC. In addition to the recommendations made by previous panels about the kind of material which may assist the next panel, today’s Panel noted that on the day of the last review, 17 April 2019, the HCPC sent the Registrant an email outlining helpful steps which she could take to prepare for today’s hearing. Two further emails designed to assist her in a similar way were sent to her on 26 July 2019 and 16 September 2019.
22. The Registrant was questioned specifically about the steps she has taken to address the concerns in record-keeping, clinical reasoning, and report writing, but she was unable to point to anything tangible which she had done to address these concerns.
23. The Registrant told the Panel that she had made some enquiries about the return to practice course, and spoke about the course at Derby University which seemed promising to her. When asked as to what steps she had taken in relation to investigating that course, she conceded that she did not go far enough in her efforts.
24. The Panel also considered insight. When the Registrant was asked by the Panel what she would do differently if she found herself in the same circumstances as she was in at the Trust, she stated that she would have resigned if she had known she was going to go through the experience which she had been through. In addition, the Panel was of the view that she had a tendency to apportion blame rather than face the concerns about her practice in any meaningful or direct way. For example, on several occasions during her evidence when she was asked how she had addressed her fitness to practise concerns, she spoke about her previous employer’s flaws and the risks emanating from the organisation, rather than from her own practice as an autonomous practitioner. Despite appearing to try her best to answer several questions on the topic of insight, the Panel was unable to find any evidence of insight into why the lack of competence occurred, and what could be done to ensure that it was not repeated.
25. As such, the Panel was of the view that there remains a real risk of repetition of the lack of competence, and therefore a real risk of harm to service users.
26. With regard to the wider public interest, which includes public confidence in the profession, the Panel was of the view that in light of the concerns which have not been addressed, and the consequent risk to service users’ safety, it was satisfied that a fully informed and fair-minded member of the public would be gravely concerned if the Registrant were returned to unrestricted practice. The Panel was therefore satisfied that the need to maintain public confidence in the profession and to uphold proper standards would be undermined if a finding of impairment were not made in the particular circumstances.
27. The Panel therefore found that the Registrant’s fitness to practice remains impaired in respect of the personal and public components.
28. The Panel next went on to consider sanction and took into account the HCPC Sanctions Policy (SP). The Panel bore in mind that sanction is a matter for its own independent judgment, and that the purpose of a sanction is not to punish the Registrant but to protect the public. Further, sanction must be proportionate, so that any order it makes be the least restrictive order necessary to protect the public interest, including public protection.
29. The Panel first considered taking no action. The Panel concluded that, in view of the breadth of the Registrant’s lack of competence, which has not been remedied, and the ongoing risk to service users, it would be inappropriate to take no action. It would be insufficient to protect the public, maintain public confidence, and uphold the reputation of the profession. The Panel concluded that a Caution Order would be inappropriate and insufficient to protect the public and meet the public interest for the same reasons.
30. The Panel next considered a Conditions of Practice Order. However, on the basis of the breadth of the Registrant’s lack of competence, the Panel was of the view that any conditions that could be formulated which would be sufficient to protect the public and uphold the public interest would need to be so restrictive that they would be tantamount to suspension. In any event, the Panel noted paragraph 106 of the SP, which states that conditions are appropriate where the Registrant has insight, and on this basis, the Panel also found that conditions would not be appropriate.
31. The Panel next considered a Suspension Order and considered paragraph 121 of the SP, which states as follows:
“A suspension order is likely to be appropriate where there are serious concerns which cannot be reasonably addressed by a conditions of practice order, but which do not require the registrant to be struck off the Register. These types of cases will typically exhibit the following factors:
• the concerns represent a serious breach of the Standards of conduct, performance and ethics;
• the registrant has insight;
• the issues are unlikely to be repeated; and
• there is evidence to suggest the registrant is likely to be able to resolve or remedy their failings.”
32. The Registrant has not shown any insight today, and this is a matter which weighed heavily with the Panel. There remains a real risk of repetition of the lack of competence. Having considered the Registrant’s oral and documentary evidence very carefully, the Panel concluded that she is unable to acknowledge or resolve the concerns. The underlying issues of a lack of insight, remediation, and the ongoing real risk of repetition led the Panel to conclude that suspension would not be appropriate or sufficient to protect the public or uphold the wider public interest.
33. The Panel considered the following paragraphs of the SP:
“130. A striking off order is a sanction of last resort for serious, persistent, deliberate or reckless acts
131. A striking off order is likely to be appropriate where the nature and gravity of the concerns are such that any lesser sanction would be insufficient to protect the public, public confidence in the profession, and public confidence in the regulatory process. In particular where the registrant:
• lacks insight;
• continues to repeat the misconduct or, where a registrant has been suspended for two years continuously, fails to address a lack of competence; ...”
34. Despite several opportunities given to the Registrant to demonstrate these matters, as well as several examples of written guidance and suggestions by way of communications from the HCPC in an effort to assist the Registrant, there is a lack of evidence of insight and remediation. The Panel is of the view that the Registrant is unable to address the concerns. This is to be seen within the context of the extension of the Suspension Order on two occasions since 2017 without any tangible, clear, and direct steps taken by the Registrant to address the concerns. There remains a real risk of harm to service users. All of these factors led the Panel to decide that Striking Off is the only way in which the public can be protected and which can uphold the wider public interest.
35. In coming to its decision, the Panel took into account the principle of proportionality, and the impact that such a sanction will have on the Registrant’s right to practise her profession, as well as the likely reputational and financial impact. However, in light of the circumstances, the Panel was of the view that no lesser sanction would be sufficient and that the need to protect the public and uphold the public interest outweighed the Registrant’s interests in this regard.
36. The Panel therefore decided to impose a Striking Off Order, which will come into effect on the expiry of the current Order.
Order
That the Registrar is directed to strike the name of Miss Ruth E Yorkston from the Register on the date this order comes into effect.
Notes
No notes available
Hearing History
History of Hearings for Miss Ruth E Yorkston
| Date | Panel | Hearing type | Outcomes / Status |
|---|---|---|---|
| 11/10/2019 | Conduct and Competence Committee | Review Hearing | Struck off |