Mr Christopher Milton

Profession: Biomedical scientist

Registration Number: BS70104

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 18/09/2019 End: 17:00 18/09/2019

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

Panel: Conduct and Competence Committee
Outcome: Conditions of Practice

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Allegation

Allegation:

Whilst employed at St Helens and Knowsley Teaching Hospitals NHS Trust in the capacity of Biomedical Scientist, you:

1) On the 28 April 2017

a) Replenished 3 units of emergency O Positive Sample Blood with 3 units of A Positive Sample Blood

b) Recorded the incorrect blood group on two prescription sheets

2) Between 13 April 2017 and 4 May 2017:

a) Recorded the wrong expiry date on Telepath for a Fresh Frozen Plasma unit

b) Labelled a sample as “Infant of Patient E”, instead of correct label of “Patient E”

3) On the 15 May 2017:

 a) Recorded the results of Patient C’s blood test under Patient D’s specimen number

 b) Recorded the blood group of Patient C’s Blood as A Negative when results found the blood group to be B positive

4) On the 16 July 2017, did not update Patient B’s telepath entry with the results of the Non Spec Antibody Test you had performed.

5) On the 25 July 2017:

a) Did not follow Standard Operating Procedure when performing an Antibody Identification on Patient A’s blood sample;

b) When performing an Antibody Identification on Patient A’s blood sample, found the IAT panel to be Negative, when this was not the case;

c) When performing an Antibody Identification on Patient A’s blood sample, found the Enzyme IAT panel to be positive, when this was not the case.

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

Service

1. The Registrant attended. The Panel was satisfied that Notice of Hearing was sent to the Registrant at his home address in accordance with the Rules.

Application to amend the Allegation

2. The HCPC applied to add Particular 1(c), and to amend Particulars 2, 3, 4, 5 and 6. Mr Renton on behalf of the Registrant did not object to the amendments.

3. The Panel accepted the advice of the Legal Assessor.

4. The Panel acceded to the application to amend the Allegation, having satisfied itself that the amendments were minor and for clarification purposes. The Panel was satisfied that the HCPC was not seeking to introduce a new strand into the case against the Registrant and that there was no prejudice to him in allowing the amendments.

Proceeding in private

5. Ms Sheridan and Mr Renton invited the Panel to hear those parts of the evidence relating to the Registrant’s health and private life in private. The Panel accepted the advice of the Legal Assessor and considered the HCPTS Practice Note on Conducting Hearings in Private. The Panel found that despite the presumption in favour of public hearings, it could exercise its discretion to hear the case in private, where the evidence relates to the health and private life of a Registrant. Having balanced the competing interests, the Panel found that it was in the interests of justice for those parts of the hearing relating to the Registrant’s health and private life to be held in private. Accordingly  this decision has been redacted.

Background

6. The Registrant was employed by St Helens and Knowsley Teaching Hospitals NHS Trust (the “Trust”) as a trainee Biomedical Scientist from March 2016. He qualified as a Biomedical Scientist and was placed on the HCPC register in March 2017. The Registrant resigned from the Trust in September 2017. On 5 January 2018, the Trust made a referral to the HCPC.

7. In July 2017, it came to the Trust’s attention that the Registrant was making errors.  Particular 1(a) relates to the replenishing of 3 units of O positive blood, which is used in emergencies with 3 units of A positive blood.  This could have resulted in a patient receiving the wrong blood group in an emergency. Particulars 1(b) and 1(c) relate to the failure to adequately record the results.  

8. Particulars 2, 3, 4 and 5 relate to further mistakes which occurred between 13 April 2017 and 25 July 2017.

9. Particular 6 relates to an incident on 25 July 2017, when the Registrant failed to follow the correct procedure for antibody identification in relation to a patient who required a blood transfusion. This led to a failure to identify significant antibodies that were present in the patient’s plasma, which had the potential to cause a Haemolytic Transfusion Reaction in the patient when the units were transfused. When this was investigated, the Registrant admitted that he had made an error.  These facts are the basis of Particular 6. The allegations were the subject of disciplinary investigation.

10. The HCPC allege that the mistakes made by the Registrant amount to misconduct and/or lack competence

Assessment of Witnesses
Witness 1 – Blood Bank Manager in the Blood Transfusion and Haematology Department. Called by the HCPC

11. Witness 1 took over as Blood Bank Manager in February 2017. The Panel found Witness 1 to be credible, that she had a straightforward manner and that her evidence was clear and concise. Her technical explanations of the issues were easy to follow and relevant. Witness 1 made it clear that she did not know the Registrant well and that her main discussions with the Registrant centred around the mistakes that he had made between April and July 2017.

Witness 2 - Operational Manager in the Haematology and Transfusion Department. Called by the HCPC

12. Witness 2 had been in the role since 2015 when the Registrant began working for the Trust. She undertook the internal investigation.  She had a good relationship with the Registrant and there was no dispute that historically she was supportive of him. The Panel found her to be a credible, reliable and accurate witness. Her evidence was consistent with her statement and her assessment of the gravity of some of the mistakes that the Registrant had made was all the more compelling because she had been so supportive of him. She was knowledgeable both in relation to the practices of the department and the technical issues which gave rise to the Allegation.

The Registrant

13. The Panel recognised that the Registrant is of good character and that he co-operated, in part, with the Trust investigation, although he resigned before its completion. The Panel also recognised that giving oral evidence is a very stressful process and acknowledged that the Registrant had in the past, and is currently, receiving medical treatment for anxiety. It therefore, made appropriate allowances when considering him as a witness.

14. In general, the Panel considered that the Registrant was honest and acknowledged that from the outset, he had admitted all but one of the Particulars. However, at times while seeking to explain some of his failings, he appeared to blame other factors, for example, the computer, his training, supervision, and conflicting advice from senior colleagues. The Panel considered that the Registrant showed a degree of naivety about the working environment. There were aspects of the Registrant’s evidence that could not be clearly understood and at times his evidence lacked focus. Where there was a conflict in the evidence, the Panel preferred the evidence of Witness1 and Witness 2.

Registrant’s Witness – LO

15. The Panel found the witness was able to give some context to the working atmosphere of a blood transfusion laboratory. He found the environment stressful and unsupportive. He left the laboratory and biomedical science shortly after qualification and is currently retraining. He was not an employee at the Trust during the relevant time and therefore the Panel found his evidence of limited use in determining the Allegation.


Decision on facts

Particular 1(a) – found proved

16. The Registrant admitted this Particular. The Panel found it proved on the documentary and oral evidence. 

17. The Registrant accepted that on 28 April 2017, he replenished three units of emergency O positive blood with A positive blood, when he should have used O positive blood. The Panel accepted the evidence of Witness 2 that this was a significant error because in emergency situations, the hospital issues uncross-matched blood for transfusion which has not been tested against the individual patient. A stock of blood group O is constantly checked and replenished to make sure all blood is in date and ready for use in an emergency.

18. The Registrant’s error was discovered when the stock in the laboratory fridge was checked by a member of staff. The Panel accepted the evidence of Witness 1 and Witness 2 that this was a dangerous mistake to make. Transfusing uncross-matched A positive blood could seriously harm a patient.

19. The Registrant accepted that the blood group is clearly labelled on the bag. The Registrant sought to rely on a change in the Standard Operating Procedure (‘SOP’) to account for his mistake rather than openly acknowledging, in his evidence in chief, that he simply failed to read the label on the bag. The Panel considered that it was a basic error which did not require any technical skills.

Particular 1(b) – found proved

20. The Registrant admitted this Particular.  The prescription sheets were exhibited as part of the HCPC bundle and the Registrant accepted that he had written the incorrect blood group on the two prescription sheets.

Particular 1(c) – found proved

21. The Registrant admitted this Particular. The prescription sheet was exhibited and the HCPC bundle contained the blank prescription sheet. 

Particular 2 – found proved

22. This Particular was disputed by the Registrant. Both the Registrant and Witness 1 agreed that the process used to enter frozen plasma onto Telepath was straightforward.  The Panel heard evidence that there is an automated system in place, which involved scanning the barcodes from each bag of frozen plasma onto Telepath. This was the preferred method as it eliminated the possibility of transcription error and was faster.  However, there was only one computer in the laboratory with a scanner. An alternative computer was available which involved entering the information onto the system manually.  Witness 1 told the Panel that when she did the monthly wastage statistics on 4 May 2017, she found that the expiry date of one frozen plasma unit had been entered incorrectly.  The data had been entered by the Registrant. 

23. During his evidence in chief, the Registrant stated that he was sure that he had scanned the bags of plasma onto Telepath and that this was a computer error. He said that because frozen plasma needs to be logged in fast he would not have performed the task manually.  However, under cross-examination he was unable to explain why the barcode worked when it was scanned by Witness 1 and the Panel found that his explanation lacked logic and detail. He also admitted under cross-examination that he could not be sure that he had not used another computer in the department which would have meant that he would have had to enter the date manually. When asked about it on the 4 May 2017, closer to the incident, he could not offer an explanation.  Having considered this Particular carefully, the Panel found that one rogue result from the computer was improbable. Witness 1 in her evidence stated that the computer which automatically scanned in the date was validated annually and she could not recall any similar error before or since the Registrant’s. The Panel therefore preferred the evidence of Witness 1 on this point and found the Particular proved on the balance of probabilities.

Particular 3 – found proved

24. The Registrant accepted that he had recorded the baby’s results on the mother’s Telepath record instead of on its own Telepath Record. The Panel heard from Witness 2 that as part of the antenatal programme at the Trust, the blood group of all babies born to a Rhesus negative mother needs to be checked. This usually involves testing the baby’s cord blood or heel blood on delivery. As the babies are often not named when the blood is taken, the blood group is recorded on the baby’s own record and then booked into their own Telepath record using the prefix ‘Infant of mother’.

25. The Registrant stated that he mistook the request form as being the mother’s and not the baby’s request form. He also stated that he did not realise that this was a cord blood sample. The request form reads under clinical details in capital letters:-“CORD BLOODS” and then “rh neg mum”.

26. The Panel found that it was very clear that the blood sample had been taken from the infant’s cord. The Panel therefore found this Particular proved and considered that this was a basic error. The Panel did not accept the Registrant’s account that the form itself was unclear. 

Particular 4 (a), 4(b), and 4(c) – found proved

27. The Registrant admitted Particular 4. The Panel found this Particular proved based on the oral and written evidence and the exhibits contained within the HCPC bundle. 

28. On 15 May 2017, the Registrant was working alone on the late shift from 4.40 p.m. - 0.00 a.m. and was responsible for maintenance work on the machines as well as a full workload.  He was asked to manually enter blood test results onto the Telepath system. The Registrant had to enter the information for 25 patients, ensuring that he inputted the correct blood group for each patient.

29. In relation to Particular 4(a), the Registrant put the blood results for two patients C and D under the incorrect specimen numbers.

30. In relation to Particular 4(b) the Registrant accepted that he entered Patient C’s details as A negative when the patient was B positive.

31. In relation to Particular 4(c), the Registrant accepted that for Patient D whose blood group was B positive, he entered it onto Telepath as being O positive.
 
32. At the time of the incident and during his oral evidence the Registrant acknowledged that he should have double checked all of his results. Witness 2 accepted during her oral evidence that at the time of this incident there was no SOP in existence within the Trust. This has now been rectified. The practice at the time was in principle all blood results should be checked and validated before release.

Particular 5 – found proved

33. The Panel found this Particular proved based on the Registrant’s admission and the oral and written evidence contained in the HCPC bundle.  

34. On 16 July 2017, the Registrant carried out an antibody identification screening test on plasma from Patient B, to establish whether there were any antibodies present. Having completed the procedure the Registrant obtained a positive result, which meant that a non-specific antibody had been detected in the plasma. When the result came through, the Registrant realised that he was unsure what to do next and so he telephoned a colleague for advice. He was told to send a sample off to the referral laboratory for further testing to assist in the identification of specific antibodies. On 17 July 2017, the referral laboratory contacted the Trust’s laboratory to confirm that they had identified an anti D antibody in Patient B’s plasma.  On 20 July 2017 a colleague (SA) carried out the same test on the same patient and identified an anti D antibody. When the colleague was inputting the result from the sample onto Telepath, she realised that the Registrant had not updated the system correctly on 16 July with the antibody status of the patient. The Particular itself simply alleges that the Registrant did not update Patient B’s antibody file to “confirm that a Non-specific Antibody had been detected”. 

35. Whilst the Panel found that this Particular of the Allegation is proved, the Registrant did not find a specific antibody so he did not update Telepath with that information. The Panel noted that the Registrant sought advice from a colleague and followed the advice he was given to send the sample off to the referral laboratory. The Panel accepted that the Registrant did not identify anti D during the testing process, but that this does not form part of this Particular as drafted. The Panel noted from the documentation that the Registrant had entered information into Telepath, but did not update the patient’s antibody file to confirm that a non-specific antibody had been detected.

Particular 6 – found proved

36. The Panel found this Particular proved on the Registrant’s own admission and on the evidence adduced by the HCPC. On 25 July 2017, the Registrant was working on the final night of a four night shift. He set up an antibody identification panel and obtained a negative result. He then set up an enzyme panel and identified an anti E antibody. He entered his results on Telepath. The Registrant’s hand-written note on the back page of the cross-match confirms that he did not detect an incompatible reaction at the cross-match stage. Blood was cross-matched with the patient and was transfused. The following morning the anti-body identification panel was repeated by a different biomedical scientist and the anti JKa antibody was detected.

37. When this was investigated the Registrant accepted that he had missed a stage by failing to add the plasma to the panel. He stated that this probably happened because the alarm went off in the laboratory while he was at the bench and he was distracted by his maintenance duties. At the time of the internal investigation and during his oral evidence the Registrant stated that he did not feel comfortable doing panels and that he had asked a senior colleague for extra training on this.  Witness 2 confirmed that the record showed that this was correct but that this request came the day before the Registrant was due to start his first night shift. The Panel accepted that working nights is potentially daunting for a newly qualified Registrant and that the Registrant had to multi-task. It considered that the error occurred because the Registrant did not follow basic rules not because he did not know what the process was.  This is a critical test carried out in an emergency situation and accuracy is paramount. Witness 2 stated that all biomedical scientists are taught never to leave this procedure half finished. If they do they must start again. The Registrant accepted that he knew this. In addition, if he was unsure of this procedure he should have consulted the SOP. 

Decision on grounds

Submissions

38. The Particulars were pleaded in the alternative – as lack of competence and/or misconduct. The Panel therefore considered each ground separately and considered the HCPC Standards of Conduct, Performance and Ethics and the Standards of Proficiency for Biomedical Scientists, in relation to both grounds.

39. Ms Sheridan on behalf of the HCPC invited the Panel to consider both lack of competence and misconduct. Both representatives agreed that the question of competence needed to be assessed by reference to the post that the Registrant was appointed to - an entry level biomedical scientist.  Both agreed that the sample of cases contained within the Allegation could amount to a ‘fair sample’ of the Registrant’s work. However, Ms Sheridan submitted that Witness 2 had stated that the Registrant had demonstrated his competency; had done well in passing his assessment; and was developing well. Ms Sheridan stated that on one view, these basic errors were easily avoidable as opposed to a gap or inadequacy in his training. She further submitted that the Registrant’s errors were careless and sloppy and she told the Panel that the Registrant himself accepted that his errors were not scientific. She submitted that there was no real request for retraining apart from the day before he went on nights.

40. Mr Renton invited the Panel to find that this was a ‘competence’ case and that the Registrant had recently qualified and had openly acknowledged at the time of the incident and during the Trust investigation that he needed further training. He argued that the Registrant had made a number of errors over a short period of time. There was no history of errors while in training. He referred to the evidence that the Registrant passed his final assessment on his first attempt. He submitted that the errors came about because the Registrant was junior and found the working environment stressful. He relied on the investigation report which confirmed that the Registrant raised issues of training.

41. The Panel accepted the advice of the Legal Assessor.

Lack of Competence

42. In considering the question of lack of competence, the Panel considered the submissions of both parties and accepted the advice of the Legal Assessor.

43. The Panel found that the Particulars contained in the Allegation do not amount to a lack of competence. The Panel has approached competence on the basis that the Registrant was a newly qualified Biomedical Scientist. The errors do not appear to the Panel to emanate from gaps in the Registrant’s knowledge but were caused by carelessness. The labels on the blood bags which formed the basis for Particular 1 had the blood group clearly marked on them. There is no scientific skill in reading a label. Similarly, in relation to Particular 3 the request form   clearly showed that it was “CORD BLOOD”. In relation to Particular 6, the mistake occurred because the Registrant failed to follow the basic principle not to leave the bench during the procedure, or if so, begin the procedure again from the start.

Misconduct

44. In considering the question of misconduct, the Panel considered the submissions of both parties and accepted the advice of the Legal Assessor.

45. In reaching a decision on misconduct, the Panel used as its starting point the guidance set out in Roylance v GMC (no 2) [2000]1 AC 311 that ‘misconduct’ is a word of general effect, involving an act or omission which falls short of what would be proper in the circumstance. The Panel accepted that in order to cross the threshold for misconduct to be found, the act or omission must be serious.

46. The Panel found that Particulars 2, 4 and 5 which were found proved do not amount to misconduct. The Panel considered that although the Registrant’s conduct fell short of good practice, it was not so serious as to be considered deplorable by fellow practitioners. The Panel took into account that the Registrant was newly qualified and working in a stressful environment. The Panel also accepted that there were changes in personnel and that the Registrant’s supervisor worked part time and had been absent for a period of time during his training.

47. In relation to Particular 2, this error was detected during a routine check and the procedures in place meant that it would have been discovered before the plasma was sent out.

48. In relation to Particular 4, Witness 2 in her evidence suggested that when manually inputting results human error can occur.  At the time of this incident there was no SOP in existence within the Trust. This has now been rectified. The practice at the time was in principle all blood results are checked and validated before release. The Panel considered that the Registrant made careless errors that were avoidable. In relation to this task, the risk of errors was increased by the fact that he did not follow the practice in place at the time which was to enter one sample at a time. Had he done this and had he double checked his results, the errors might well not have occurred.
 
49. In relation to Particular 5, the Registrant followed recommended procedures in that he did seek help when he did not get the result he expected, which is the advice that newly qualified biomedical scientists are given. He then followed the advice he was given.  The Particular was drafted only to encompass the failure to record the result on Telepath. The Panel accepted that the Registrant had updated Telepath, but not the anti-body file in the Telepath record.

50. The Panel found that the following Particulars 1a), 1b), 3 and 6 found proved, amount to misconduct, in that the failings of the Registrant in respect of these Particulars had the potential to put  patients at serious risk of harm and represent a serious departure from the standards of conduct expected of a newly qualified  biomedical scientist.

51. The failings in Particular 1 occurred because the Registrant did not read the labels on the blood bags. This was serious because there was the potential for a patient needing emergency bloods to receive the wrong blood type with potentially catastrophic results.

52. In relation to Particular 3, the referral form had the words “CORD BLOOD” and the Panel concluded that the Registrant could not have made the mistake had he simply read the form.

53. In relation to Particular 6, this mistake was not a technical mistake, but occurred because the Registrant failed to follow established procedures. As this test is conducted in an emergency situation care and attention is of paramount importance. The patient was given the incorrect blood and required careful monitoring, although ultimately he came to no real harm. The incident also had to be reported to the Medicines and Healthcare products Regulatory Agency.

54. The Panel considered that these Particulars are serious and were due to carelessness and lack of attention. It concluded that the Registrant’s conduct amounts to a serious falling short of the standards expected of a newly qualified biomedical scientist. Therefore, the ground of misconduct is established.

55. The matters on which the Panel found misconduct represent a breach of the following HCPC Standards of Conduct, Performance and Ethics (January 2016):
Standard 6  Manage Risk

 Standard 6.1  You must take all reasonable steps to reduce the
risk of harm to service users, carers and colleagues as far as possible.

Standard 6.3  You must make changes to how you practise, or
stop practising, if your physical or mental health may affect your performance or judgement, or put others at risk for any other reason. 

Standard 9  Be honest and trustworthy

Standard 9.1  You must make sure that your conduct justifies the
public’s trust and confidence in you and your profession.

Standard 10  Keep records of your work

Standard 10.1 You must keep full, clear, and accurate records for
everyone you care for, treat, or provide other services to.

Decision on impairment

56. Having found misconduct in relation to Particulars 1, 3 and 6, the Panel went on to consider whether, by reason of that finding of misconduct, the Registrant’s fitness to practise is currently impaired. The Panel reminded itself of the contents of the HCPTS Practice Note on Finding that Fitness to Practise is Impaired. The Panel has had regard to the decision in Cohen v GMC [2008] EWHC 581 Admin, 65 where the Court provided guidance to panels on the proper approach to a decision on impairment. The Panel also took into account the observations of  Cox J in CHRE v NMC & Grant [2011] EWHC 927 Admin, at paragraph 74, where she held that: “In determining whether a practitioner’s fitness to practise is impaired by reason of misconduct, the relevant panel should generally consider not only whether the practitioner continues to present a risk to members of the public in  his or her current role, but also whether the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular case”.

57. The Registrant accepted both through Mr Renton and during his oral evidence that he remains impaired.

58. On the personal component, the Panel accepted that the Registrant has some insight. He accepted the factual Particulars of the Allegation, with the exception of Particular 2. He did not try to hide his mistakes. The Registrant has written a reflective piece and in his oral evidence he acknowledged that he remains impaired. However, the Registrant’s reflections do not address the key cause for the omissions and his explanations deflected from his own culpability, blaming lack of training and/or adequate supervision amongst other things. The Panel found that he had limited insight into the potential impact of his failings on patients.  The Panel found that  there was a disconnect towards the end of the Registrant’s oral evidence in which he stated that the blame for these mistakes lay entirely at his door,  and his  earlier evidence that the mistakes occurred due to other factors. The Panel has found that these were careless mistakes which were not caused by a lack of scientific knowledge. 

59. Whilst the failings are remediable, the Registrant has not worked in biomedical science for almost two years and has only recently made enquiries about updating his professional knowledge. The Registrant has enrolled on a mindfulness course in June 2019, but is at the early stage of this online course. Whilst the Registrant has taken some steps to remediate his failings he is in the early stages of remediation and insight and the Panel found that the risk of repetition and the consequent risk to service users remains high.

60. The Panel then considered the public component - whether the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in this case.  The misconduct found amounts to a serious falling short of the HCPC Standards of Conduct, Performance and Ethics (2016) 6, 9 and 10. The failings in Particulars 1, 3 and 6 had the potential to put patients at serious risk of harm. The Panel found that the public component has been met in this case and that public confidence in the profession and the regulator would be undermined were a finding of impairment not made.

61. The Panel therefore found that the Registrant’s fitness to practise is currently impaired in both the personal and public components.

Resumed hearing on 18 September 2019

62. On 18 September 2019 neither Mr Renton nor Mr Milton attended the hearing.  Mr Milton, in an email dated 29 July 2019, sent to the HCPC  explained that he did not have any further funds to pay counsel or to travel to the hearing. He invited the Panel to take into account his reflective piece when considering sanction.

Service

63. Ms Sheridan invited the Panel to find that service had been effected in accordance with the Rules.  She referred the Panel to the notice of hearing. The Panel accepted the advice of the Legal Assessor. The Panel is satisfied that notice of the hearing was sent to the Registrant at his registered address on 11 July 2019 in compliance with the Rules.

Proceeding in absence

64.  The Panel next considered whether it was appropriate to proceed in the absence of the Registrant.  The Panel heard submissions from Ms Sheridan and accepted the advice of the Legal Assessor.

65. The Panel determined that it was in the interests of justice to proceed in the absence of the Registrant. The Registrant did not ask for the hearing to be adjourned nor did he indicate that he would like to attend on a future date. He provided written submissions in the form of a reflective piece and indicated that he did not have the funds to travel to the hearing, thereby implying that an adjournment would serve no purpose. The background facts relate to incidents in 2017 and the hearing had adjourned in July 2019, part-heard. As the Panel had a reflective piece from the Registrant and had heard oral evidence from him, the Panel determined that it had sufficient material to proceed to conclude the hearing in the absence of the Registrant.

Decision on sanction

66. The Panel heard submissions from Ms Sheridan with regard to the sanction stage of this hearing and had read the Registrant’s reflective piece carefully. The Panel accepted the advice of the Legal Assessor. 

67. The Panel had regard to all the evidence presented, and to the HCPC’s Sanctions Policy. The Panel reminded itself that sanctions are not intended to be punitive although they may have a punitive effect. The Panel bore in mind the principles of fairness and proportionality when determining what the appropriate sanction in this case should be. The primary function of any sanction is to address public safety from the perspective of the risk which the Registrant may pose to those who use or need his services and to the wider public interest; namely the deterrent effect on other Registrants, the reputation of the profession and public confidence in the regulatory process.

Mitigating Factors

68. The mitigating factors in this case were that the Registrant was a newly qualified Biomedical Scientist, was of good character and admitted all but one of the allegations. His reflective piece showed that he is developing more insight and that he has taken on board the Panel’s previous findings. He has demonstrated remorse for his conduct. The incidents which led to these proceedings occurred over a short period of time and relate only to one area of his work in blood transfusion. The Registrant had done well in all other areas as stated by Witness 2 during her oral evidence before the Panel. Lastly, the Panel noted that the Registrant had some health issues during the relevant period.

Aggravating Factors

69.  The aggravating factors in this case were that the errors that the Registrant made were careless and some so serious that patient’s lives were put at risk. Whilst the Registrant has shown some insight into the seriousness of his mistakes, he has not yet fully acknowledged the extent of the potential consequences of his conduct to patients and the profession.

70.  The Panel first considered whether a Caution Order was appropriate. The Panel has concluded that the omissions made by the Registrant were too serious for a Caution Order. Although the Registrant has partial insight, he has not remediated his failings and there continues to be a risk of repetition and therefore a serious risk of harm to patients.

71.  The Panel next considered a Conditions of Practice Order. The Panel concluded this is the appropriate sanction and that, notwithstanding the seriousness of the omissions, a Suspension Order would be disproportionate and punitive. The Panel considered that the Registrant’s conduct was remediable. The Registrant was newly qualified when the errors occurred and has demonstrated some insight and remorse. The Registrant in his reflective piece has indicated a real desire to return to his profession and stated a willingness to comply with any conditions of practice. Further, he has engaged with the HCPC throughout. The Panel considers that with rigorous conditions and the right structure, guidance and education, the Registrant could practise safely and that there would be value in allowing him to develop within the profession rather than excluding him from it.

72.  Therefore, for these reasons, the Panel determined that the proportionate sanction to protect the public and to uphold public confidence in the profession is a Conditions of Practice Order for a period of 12 months.

73. This Conditions of Practice Order will be reviewed prior to the expiration date of the Order.

Order

The Registrar is directed to annotate the Register to show that, 12 months from the date that this Order comes into effect you, Mr Christopher Milton, must comply with the following conditions of practice:

1. You must not work in a blood transfusion laboratory as a Biomedical Scientist unless directly supervised by a supervisor registered with the HCPC until you have been deemed as competent. This competence should be demonstrated by the successful completion of the appropriate retraining, assessment and demonstration of safe practice.

2. Whilst working as a biomedical scientist, you must place yourself and remain under the supervision of a workplace supervisor registered with the HCPC.

3. You must work with your supervisor to formulate a personal development plan to ensure that your knowledge, skills and competencies meet the proficiency standards of the HCPC for a biomedical scientist.

4. Within 3 months of obtaining employment as a biomedical scientist you must forward a copy of your PDP to the HCPC.

5. You must meet with your supervisor on a monthly basis to consider your progress towards achieving the aims set out in your PDP.

6. You must allow your supervisor to provide information to the HCPC about progress towards achieving the aims set out in your PDP.

7. You must maintain a reflective piece for the next review panel in relation to:  safeguards that you have or will put in place to reduce errors; the impact of errors on patients and the profession; how you manage work in a stressful environment.

8. You must inform the HCPC within seven days if you take up employment as a biomedical scientist.

9. You must inform the HCPC within seven days of any disciplinary proceedings taken against you by your employer.

10. You must inform the following parties at the time of application that your registration is subject to these conditions:

A. Any organisation or person employing or contracting with you to undertake professional work;
B. Any agency you are registered with or apply to be registered with; and;
C. Any prospective employer

 

Notes

Interim Order

Ms Sheridan indicated that she wished to make an application for an Interim Order and submitted that it should proceed in the Registrant’s absence. She submitted that the Registrant had been given notice within the notice of hearing, dated 11 July 2019, that the HCPC may make such an application at the conclusion of the hearing, should a sanction which removes, suspends or restricts the right to practise be imposed.

The Panel accepted the advice of the Legal Assessor and decided that it was appropriate to proceed in the Registrant’s absence. It was satisfied that the Registrant had been given clear notice within in the notice of hearing, of the HCPC’s intention to apply for an interim order if such a substantive Order was made.

The Panel considered that the same factors applied as for its decision to proceed in absence in respect of the resumed hearing, namely that the Registrant had voluntarily waived his right to attend, and it was in the public interest to proceed.

The Panel makes an Interim Conditions of Practice Order under Article 31(2) of the Health and Social Work Professions Order 2001 in the same terms as the substantive Order, this being necessary to protect members of the public and being otherwise in the public interest. 
This order will expire: (if no appeal is made against the Panel’s decision and Order) upon the expiry of the period during which such an appeal could be made; (if an appeal is made against the Panel’s decision and Order) the final determination of that appeal, subject to a maximum period of 18 months.

 

Hearing History

History of Hearings for Mr Christopher Milton

Date Panel Hearing type Outcomes / Status
18/09/2019 Conduct and Competence Committee Final Hearing Conditions of Practice
01/07/2019 Conduct and Competence Committee Final Hearing Adjourned part heard
05/04/2019 Conduct and Competence Committee Interim Order Review Interim Conditions of Practice