Mr Oodish K Dahal
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Between November 2007 and April 2015, whilst employed as the head Biomedical Scientist for Blood Transfusion at North Middlesex Hospital, you:
1. Not proven.
2. Not proven.
3. Not proven.
4. Not proven.
5. Not proven.
6. Not proven.
7. Not proven.
8. Not proven.
9. Did not act upon one or more reports received between 2012 to 2014, advising that a fridge in the Blood Transfusion Department was operating outside of the specified temperature range.
10. Not proven.
11. Not proven.
12. The matters set out in paragraphs 1 to 11 constitute misconduct and/or lack of competence.
13. By reason of your misconduct and/or lack of competence your fitness to practise is impaired.
- This matter arises out of a Serious Untoward Incident that occurred at North Middlesex University College Hospital (‘the hospital’) on 30 March 2015. The incident concerned the issuing of 3 units of incompatible blood to a patient with Sickle Cell disease by a Biomedical scientist.
- An investigation into the said Serious Untoward Incident was undertaken Transfusion Practitioner and a Consultant Haematologist at the hospital. Their findings were that:
"The Laboratory Information Management System (LIMS) … permitted 3 units of B RH D Negative red blood cells to be issued to a patient who was O RH D Positive. Correct implementation of electronic issue via the LIMS could have prevented the allocation and administration of the incompatible blood to the patient.
The ISOFT MGXR notification document had been received by this hospital but then inadequate implementation process for software upgrades was found to be the root cause within the BT laboratory …”
- Further audits were then undertaken in April 2015 and September 2015. Those audits identified shortcomings in certain procedures in the Blood Transfusion Laboratory. An investigation was then conducted and completed on 23 December 2015 by the Central London Operations Manager.
- The Transfusion Practitioner who carried out the investigation into the Serious Untoward Incident referred the Registrant to the HCPC on 13 October 2015. Her referral stated that there were two matters of concern, namely:
- The Laboratory Information Management System was incorrectly setup and allowed the issue of incompatible B units …
- A temperature mapping report indicated that a Blood Bank had a significant cold spot had been ignored with no action taken even though evidence was provided that [the Registrant] had been informed
- These matters were investigated by the HCPC, which resulted in the above allegations against the Registrant. The panel hearing the substantive matters found the above allegations proved and also determined that the matters are so serious that they amounted to misconduct on the part of the Registrant. In coming to its decision, the panel noted that the temperature ranges for the storage of blood are set by statutory regulations, which highlighted their importance. They also found that the Registrant's failure to address the concerns arising out of two blood mapping reports was sustained over a significant period of time. The panel recognised that the failure to ensure that the fridges were operating at the required temperatures could potentially lead to deterioration in the quality of blood and blood products stored in the affected areas with consequent risks to patient safety.
- The substantive hearing panel also determined that the Registrant was an experienced Chief Biomedical Scientist and was very competent in such technical matters. Therefore, the Registrant's failure to take action in response to the temperature mapping report was not down to lack of competence.
- In coming to its determination on whether the Registrant's fitness to practise was impaired, the substantive hearing panel noted that it did not have any evidence of insight or remediation on the part of the Registrant with respect to the shortcomings in his practice demonstrated by his failures. This was because the Registered did not engage with the regulatory process nor attend the substantive hearing. As a result, the substantive hearing panel concluded that there was a real risk of repetition of the misconduct by the Registrant, and therefore his fitness to practise was impaired.
- The substantive hearing panel took into account all the relevant information when considering what sanction would be appropriate in the circumstances. They considered that the following were aggravating features:
- the misconduct involves serious failings over a significant period of time;
- the safe storage of blood was fundamental to the Registrant's role as the Chief Biomedical Scientist at the hospital;
- no insight in the remediation had been demonstrated by the Registrant.
- The substantive hearing panel considered the fact the evidence demonstrated that the Registrant was an outstanding practitioner in most respects to be a mitigating factor.
- The substantive hearing panel considered the available sanctions in ascending order in determined that a Suspension Order for a period of 12 months was necessary in the circumstances to protect the public and also the public interest. It also determined that a Striking-Off Order would be appropriate but that to impose one at that stage would be disproportionate.
- Ms Simpson, outlined the background of the case and submitted, that in the light of the lack of substantive engagement on the part of the Registrant, he remains impaired. She also submitted that an extension of the Suspension Order would serve no useful purpose and would not further the public interest. Ms Simpson submitted that the Registrant’s name should be struck off the HCPC Register in the circumstances.
- The Legal Assessor reminded the Panel that its purpose today was to conduct a comprehensive review to determine if the Registrant is fit to return to unrestricted practice. Its role was not to conduct a rehearing of the allegations nor was it to go behind the previous findings. He advised that in carrying out this assessment, the Panel must exercise its own independent judgment.
- The Legal Assessor advised that the Panel might find the questions formulated in the case of CHRE v NMC and Grant (2011) EWHC 927 (Admin) of some assistance, albeit slightly modified for these proceedings:
Does the evidence before the Panel today show that the Registrant’s fitness to practice remains impaired by reason of his misconduct in the sense that he:
- is liable in the future to act so as to put a service user at unwarranted risk of harm; and/or
- is liable in the future to bring the Biomedical Scientist profession into disrepute; and/or
- is liable in the future to breach one of the fundamental tenets of the profession?
- The Legal Assessor advised the Panel that if it determined that the Registrant’s fitness to practise remained impaired then the Panel must go on to consider what sanction, if any, should be imposed. The Legal Assessor advised the Panel that if it determined that the Registrant’s fitness to practise remained impaired any the options under Article 30 of the 2001 Order could be exercised by the Panel. He also advised the Panel that it should bear in mind the principle of fairness and proportionality and to have regard to the Indicative Sanctions Policy document issued by the HCPC. He reminded the Panel that any order that it makes under Article 30 should not be punitive in purpose, and that it should be the least restrictive order that would suffice to protect the public and/or is otherwise in the public interest.
Panel’s considerations and decision
- Ms Simpson drew the Panel’s attention to the letter/email that she wrote to the Registrant on 18 May 2020, which gave him information as to the type of evidence that would assist him in demonstrating that his fitness to practise was no longer impaired. It drew his attention to the comments of the substantive hearing panel in relation to how the Registrant could demonstrate insight and remediation and the powers of the Panel today upon when reviewing the substantive order.
- Ms Simpson submitted that the Registrant's response to her letter/email stating ‘Please don’t bother me anymore you are mentally torturing me for the last 2 years’ [sic] was an indication that the Registrant was not engaging in process, was not interested in remaining the profession, and did not demonstrate any insight and remediation on the Registrant's part.
- Ms Simpson submitted the Registrant’s fitness to practise remained impaired and that it was now appropriate that a Striking-Off Order should be imposed in the circumstances as the Registrant has not demonstrated that he would engage in any meaningful way with efforts or opportunities given to him to demonstrate insight and remediation.
- The Panel accepted the advice of the Legal Assessor. The Panel first considered whether the Registrant’s fitness to practise is currently impaired. The Panel took into consideration all the documentation before it, and the submissions of Ms Simpson.
- In particular it noted the following factors:
- This is a case of misconduct and there is no suggestion that the Registrant lacked the requisite competence to carry out the role of a Biomedical Scientist.
- The lack of engagement of the Registrant with the process, resulting in the absence of any indication that the Registrant remained committed to the profession and any information regarding the Registrant or his current circumstances, including any continuing professional development since this matters arose.
- There is no evidence before the Panel today that could satisfy it that the Registrant’s fitness to practise is no longer impaired. He did not engage with the final hearing nor has he engaged in this review process. Therefore, the Panel does not have any information as to what were the underlying causes of the Registrant’s misconduct. In these circumstances, it could not be satisfied that those issues have been addressed and that there was a low risk of repetition.
- In the light of all the above, the Panel determined that the Registrant’s fitness to practise remains impaired.
- The Panel then went on to consider what the appropriate and proportionate sanction should be. It had regard to the Indicative Sanctions Policy issued by the HCPC and considered the available sanctions in order of severity, starting with the least restrictive. In the light of the Registrant’s lack of engagement the Panel determined that taking no further action or imposing a caution would not be sufficient to protect the public, nor would either be in the public interest.
- The Panel considered whether to impose a Conditions of Practice Order but concluded that it would neither been appropriate nor could it formulate adequate conditions that would properly address the root of the issue, as there was no information as to what caused the Registrant to ignore important reports and not take action on critical matters under his responsibility as a Biomedical Scientist. This is not a case where there are identified areas of the Registrant’s practice where he lacked competence and that could be easily addressed be conditions.
- In considering whether a suspension order would be appropriate in the circumstances, the Panel considered whether or not the registrant was likely to demonstrate insight and remediation on his part. The Panel considered that this was unlikely, bearing in mind the Registrant’s total non-engagement with these proceedings. The Panel determined that a further period of suspension would serve no useful purpose and would not further the public interest.
- Panel determined that the appropriate and proportionate sanction now is to remove the Registrant’s name off the Register.
Order: The Registrar is directed to strike the name of Mr Oodish K Dahal from the Register on the date this Order comes into effect.
The Order imposed today will apply from 10 July 2020
The Order imposed today will apply from 10 July 2020.
History of Hearings for Mr Oodish K Dahal
|Date||Panel||Hearing type||Outcomes / Status|
|04/06/2020||Conduct and Competence Committee||Review Hearing||Struck off|
|20/05/2019||Conduct and Competence Committee||Final Hearing||Suspended|