Mrs Louise Middleton

Profession: Dietitian

Registration Number: DT6126

Hearing Type: Review Hearing

Date and Time of hearing: 10:00 15/01/2020 End: 13:00 15/01/2020

Location: Holiday Inn Edinburgh, 132 Corstorphine Road, Edinburgh, Lothian EH12 6UA

Panel: Conduct and Competence Committee
Outcome: Conditions of Practice

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Allegation

During the course of your employment as a Dietitian with NHS Fife, on dates in or between February and August 2011, you:

1. On dates between May and June 2011 in relation to Case 1, you did not maintain accurate patient records, in that you:  

(a) altered an electronic version of a dietetic letter originally dated 25 May 2011;  

(b) destroyed the paper copy of the dietetic letter dated 25 May 2011, previously filed In the dietetic notes, and replaced It with the amended version;  

(c) did not file three emails dated 1-3 June 2011 in the dietetic records  

2. On dates between February and June 2011 in relation to Case 1, you did not conduct an adequate assessment of a Service User, In that you:  

(a) did not take into account and/or adequately consider the case history of the service user when conducting your own dietetic assessment and plan;  

(b) did not use the correct growth chart and/or did not plot growth chart correctly;  

(c) did not sufficiently consider and/or review the information provided by the Health Visitor.  

3. On dates between February and June 2011 in relation to Case 2, you:  

(a) did not undertake an adequate assessment in respect of the Service User, in that you:  

i. [Not proven] 

ii. did not complete and/or plot the preterm growth chart correctly and/or accurately. 

(b) did not formulate an appropriate dietetic plan, in that:  

i. there was no and/or inaccurate information on the feeding requirements; and/or  

ii. [Not proven] 

iii. you did not adequately consider and/or identify that the Service User was being given diuretics and/or  

iv. Identified 4 feeds a day as being adequate  

(c) did not follow a jointly agreed dietetic plan;  

(d) [Not proven] 

4. In relation to Case 4:  

(a) [Not proven] 

(b) You did not undertake an accurate anthropometric assessment of the Service User in that, you:  

i. did not calculate the infant's gestational age correctly; and/ or  

i. did not plot the growth chart correctly.  

(c) You did not undertake an adequate initial assessment in that, you:  

i. did not assess and/or calculate the infant's actual consumed intake; and/ or 

ii. did not assess and/or calculate information relating to feeds such as;  

a. timing of feeds, and/or  

b. length of time to complete feeds, and/or  

c. sucking ability, and/or  

d. feed losses  

(d) You did not take appropriate account of the child's diagnosis and the likely impact on feeding;  

(e) You did not make appropriate plans for frequency of review;  

(f) You did not seek advice from and/or contact the Consultant medical staff.  

5. On or around 5 May 2011 in relation to Case 5, you:  

(a) did not follow the medical management plan;  

(b) did not discuss a change of plan with the doctor and/or document reasons for a different course of action;  

(c) did not undertake an adequate assessment of the Service User in that, you:  

i. did not review and/or consider information in the medical notes, including blood results; and/ or  

ii. [Not proven] 

(d) did not undertake an accurate anthropometric assessment in that, you:  

i. did not measure the Service User's height accurately; and/or  

ii. did not plot the Service User's age correctly on the growth chart; and/or  

iii. did not review the anthropometric data in the medical notes; and/ or  

iv. did not correctly plot and/or interpret data relating to the Service User's nutritional status.  

(e) [Not proven] 

(f) [Not proven] 

(g) requested that a GP undertake blood tests, including some that were unnecessary;  

(h) [Withdrawn by HCPC] 

6. In respect of Case 6, you:  

(a) did not plot accurately the Service User's weight and/or height measurements on a growth chart;  

(b) [Not proven] 

(c) [Not proven] 

(d) documented the need to discuss pump feeding with the Service User's parents, but did not document any such discussions  

(e) did not advise the Service User's parents on an effective, practical feeding plan to achieve satisfactory weight gain.  

7. In respect of Case 7, you:  

(a) did not obtain any and/or sufficient information about the infant's recent feeding history;  

(b) did not undertake an accurate anthropometric assessment in that you did not plot the growth chart correctly;  

(c) did not appropriately discuss your findings with the doctor;  

(d) did not re-assess nutritional intake to compare with requirements when you realised that despite your request to the GP to prescribe SMA High Energy formula, the baby was still consuming standard formula.  

8. On dates between 25 May 2011 and 2 June 2011 in relation to Case 7, you:  

(a) did not assess the Service User's actual nutritional intake and/or document nutritional aims;  

(b) did not record in the dietetic record the date when the infant's feed changed to SMA High Energy formula;  

(c) did not record in the dietetic record any advice given regarding maximum length of time to feed.  

9. On or around 18 May 2011 in relation to Case 8, you:  

(a) did not make accurate records in that you did not make it clear whether the infant changed to SMA High Energy milk;  

(b) [Not proven] 

(c) [Not proven] 

i. [Not proven]

ii. [Not proven]

iii. [Not proven] 

iv. [Not proven]

v. [Not proven] 

10. In respect to Case 9, you:  

(a) did not communicate effectively with the Service User's parents in that, you:  

i. provided the Service User's parents with conflicting and/or misleading information about the child's condition; and/ or  

ii. gave the Service User's mother inadequate written supplementary information.  

11. In respect of Case 10, you:  

(a) did not measure the child's height accurately;  

(b) did not plot available weights and lengths from medical correspondence and/or medical notes;  

(c) did not carry out an adequate assessment in that you did not review and/or consider

i. the Service User's total fluid intake; and/or

ii. eating environment; and/or

iii. number of children in the household;  

(d) did not provide appropriate advice based on nutritional strategies that are known to work with this service user group.  

12. [Not proven] 

13. The facts set out in paragraphs 1-12 constitute misconduct and/or a lack of competence.  

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

 

Finding

Background
 
1. The Registrant commenced employment as a Band 7 Dietitian at Kirkcaldy and Levenmouth Community Health Partnership in December 2009. On 19 January 2019, a panel of the Conduct and Competence Committee found that the Registrant’s fitness to practise was impaired by reason of her lack of competence, having found a breadth of failings across a wide range of skills expected of a Band 7 dietitian and in relation to ten patients as set out in the allegation above.  These occurred in the course of a twelve week return to work plan following a period of sick leave from May 2010 until February 2011. Prior to the period of sick leave, the Registrant had been under supervision due to perceived concerns about her ability to carry out the duties of a Band 7 Dietitian. 
 
2. On 19 January 2018 the Panel imposed a twenty four month Conditions of Practice Order, having found that the Registrant had the required level of insight and understanding to indicate that a Conditions of Practice Order would be adhered to and that such an order would minimise the risk of future harm to patients.
 
Today’s Hearing:
 
3. The Panel today is conducting a review of that Conditions of Practice Order in terms of Article 30(1) of the Health and Social Work Professions Order 2001.
 
4. The Panel heard from Ms Ktisti who referred to the background of the case and the circumstances which led to the imposition of the Conditions of Practice Order.  Ms Ktisti advised the Panel that the Registrant had complied with Condition 1 of the order in that she had submitted evidence of completion of a Return to Practice Course. Ms Ktisti also advised that as the Registrant had not gained employment, she had not produced evidence of remediation in a clinical setting. Given the lack of evidence of remediation, Ms Ktisti submitted that the HCPC was of the view that her fitness to practise remained impaired. Ms Ktisti advised that the Registrant was making progress by positively engaging with the HCPC, a further period of Conditions of Practice would be appropriate to provide the Registrant with a further opportunity to demonstrate remediation and comply with the conditions. She submitted that the HCPC was of the view that a minimum of 12 months would be appropriate
 
5. Ms Brown addressed the Panel and directed them to evidence that the Registrant had successfully completed the BDA ‘Work Ready’ Programme which enabled her to work on a self-employed or freelance capacity, although not in a clinical dietetic role. She also advised the Panel that the Registrant had an offer from NHS Lothian to support her in her return to practice while complying with the conditions. Ms Brown confirmed that NHS Lothian were considering offering her a paid position on the staff bank or a 12 month honorary  contract, both of which would provide direct supervision as required by the Conditions of Practice order. Ms Brown submitted that the Registrant accepted that she had been unable to work in a clinical role and was not able to provide evidence that she had addressed the Panel’s concerns and appreciated that the Panel may wish to see clinical evidence to demonstrate remediation. Ms Brown advised that she accepted it was likely that a further period of conditions would be appropriate and that in her view an extension of 12 month would be ample time to allow the Registrant to produce her evidence of remediation.
 
Decision:
 
6. The Panel is mindful that its task today is not to go behind the decision of the previous panel but to determine whether or not the Registrant’s fitness to practise remains impaired and if there is current impairment, what, if any, order should be made when the current order expires. The Panel has considered the submissions of Ms Ktisti and Ms Brown together with the advice of the Legal Assessor.
 
7. In reaching its decision, the Panel has exercised its own independent judgement.
 
8. The Panel first considered whether the Registrant’s fitness to practise is currently impaired. In reaching this decision, the Panel has considered both the personal component and the public component. The previous panel acknowledged that the Registrant had demonstrated insight into the matters which led to the making of the allegation and considered that the conditions would be sufficient to allow the Registrant to work as a Dietitian under supervision. However the Registrant has not been able to obtain employment as a Dietitian and has not therefore had an opportunity to demonstrate that she can practice safely as a Dietitian. The Registrant herself also accepts that she would need to be subject to conditions on her return to practice.  This Panel has therefore concluded that the Registrant’s fitness to practice remains impaired in terms of the personal component. 
 
9. The Panel has also considered the wider public interest considerations which include the need to protect patients, to declare and uphold proper standards of behaviour and to maintain public confidence in the profession.  In the absence of evidence of remediation, the Panel has concluded that public confidence in the profession would be undermined if a finding of impairment were not made in these circumstances.
 
10.The Panel has therefore concluded that the Registrant’s fitness to practise remains impaired in terms of both the personal component and the public component.
 
11. The Panel next considered the sanctions available to it in ascending order of severity. The Panel is aware that the primary function of any sanction is to address public safety from the perspective of the risk the Registrant may pose to those using or needing her services in the future and determine what degree of public protection is required. The Panel must also give appropriate weight to the wider public interest which includes the deterrent effect on other registrants, the reputation of the profession and public confidence in the regulatory process.
 
12. The Panel considered that to impose a Caution would not be sufficient to address the wider public interest considerations or to protect the public. The Panel then considered whether a Conditions of Practice Order would be appropriate and sufficient. The Panel considers that the current Conditions of Practice Order (subject to the deletion of Condition 1) remains an appropriate and proportionate sanction in that it adequately protects the public, addresses the public interest considerations and will allow the Registrant to return to practice as a Dietitian under supervision. The Panel considers that a further period of twelve months would afford the Registrant the opportunity to comply with the conditions and demonstrate remediation.
 
13. The Panel did consider whether a Suspension Order would be appropriate. However, the Panel determined that this would be disproportionate at this time in circumstances where the conduct found proved is remediable and the Registrant is committed to returning to practice, having demonstrated insight into the matters which brought her before the HCPC.
 

Order

ORDER: The Registrar is directed to annotate the HCPC Register to show that, for a period of 12 months from the date that this Order takes effect (“the Operative Date”), you, Louise Middleton, must comply with the following conditions of practice:
 
1. You must inform the HCPC within 14 days of your start date if you take up any employment or other engagement as a Dietitian in a clinical role which includes the giving of advice or treatment to individuals.
 
2. While working as a Dietitian, either in an employed or voluntary capacity, you must promptly place yourself and remain under the indirect supervision of a workplace supervisor at Band 6 or higher, who must be registered as a Dietitian by the HCPC, and
you must supply full details of your supervisor to the HCPC within 14 days of their appointment. You must attend upon that supervisor as required and follow their advice and recommendations.
 
3. You must work with your workplace supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice:
(i) Record Keeping;
(ii) Time Management;
(iii) Clinical practice;
(iv) Communication with dietetic, nursing and medical colleagues.
 
4. Within three months of the Operative Date you must forward a copy of your Personal Development Plan to the HCPC.
 
5. You must meet with your workplace supervisor on a monthly basis to consider your progress towards achieving the aims set out in your Personal Development Plan.
 
6. You must allow your workplace supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan.
 
7. You must provide a detailed report approved by your supervisor commenting on your practice as a Dietitian prior to every hearing to review this Order. That report must cover, at least, the follow matters:
(i) Record Keeping;
(ii) Time Management;
(iii) Clinical practice;
(iv) Communication with dietetic, nursing and medical colleagues.
 
8. You must allow your supervisor to contact the HCPC to report any concerns with your practice as a Dietitian.
 
9. You must comply with all requirements of the HCPC Registrations department regarding your return to practice.
 
10. You must promptly inform the HCPC if you cease to be employed as a Dietitian by any employer.
 
11. You must promptly inform the HCPC of any disciplinary proceedings taken against you by your employer.
 
12. You must inform the following parties that your registration is subject to these conditions:
A. Any organisation or person employing or contracting with you to undertake professional work as a Dietitian, at the time of application;
B. Any agency you are registered with or apply to be registered with as a Dietitian (at the time of application);
C. Any prospective employer, seeking to employ you as a Dietitian, (at the time of your application).

Notes

No notes available

Hearing History

History of Hearings for Mrs Louise Middleton

Date Panel Hearing type Outcomes / Status
15/01/2020 Conduct and Competence Committee Review Hearing Conditions of Practice
15/01/2018 Conduct and Competence Committee Final Hearing Conditions of Practice