Miss Camilla L Hewitt

Profession: Radiographer

Registration Number: RA49567

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 09/11/2020 End: 17:00 11/11/2020

Location: Virtual Hearing

Panel: Conduct and Competence Committee
Outcome: Suspended

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Allegation

Whilst registered as a Radiographer and working as an agency radiographer at Walsall Manor Hospital you:

1. On one or more of the dates set out in Schedule 1 exposed paediatric patients to excessive radiation in that you exposed them to an adult dose of radiation.

2. On or about 27 November 2018 exposed Patient C to excessive radiation in that you imaged the left ankle as opposed to the right ankle during a follow up of a previous right ankle fracture.

3. Your actions at particulars 1 and / or 2 constitute misconduct.

4. By reason of your misconduct, your fitness to practise as a radiographer is impaired.

Schedule 1

16 October 2018 – Patient A

20 November 2018 – Patient B

Finding

Preliminary Matters

Notice of Service

1. The Panel was provided with confirmation that the Notice of Hearing had been sent by e-mail to the Registrant’s registered e-mail address on 16 September 2020. Accordingly, the Panel concluded that service had been complied with in accordance with Rule 3 of the HCPC (Conduct and Competence Committee) (Procedure) Rules 2012 (“the Rules”).

Proceeding in absence

2. The Panel noted that the Registrant had been served with notice of today’s hearing and that she had responded by her e-mail dated 2 November 2020 to a Hearings Officer of the HCPTS in which she stated “After a great deal of deliberation I have decided I won't be in attendance of [sic] the hearing.”

3. Mr Millin, on behalf of the HCPC, made an application to proceed in the Registrant’s absence. He submitted that: the Registrant had voluntarily absented herself from the hearing and had indicated that she had no intention of attending; she not made any application for an adjournment of the hearing; there was a public interest in proceeding to hear the allegation expeditiously, given that it involved relatively serious matters; and two witnesses were on hand in anticipation of giving evidence.  

4. The Panel heard and accepted the advice of the Legal Assessor. The Panel was aware, in accordance with the HCPC’s Practice Note entitled “Proceeding in the Absence of the Registrant”, that it is only in rare and exceptional circumstances that the Panel should proceed to hear a case in the absence of a Registrant and then only if it is in the interests of justice.

5. The Panel noted that the Registrant had indicated in no uncertain terms that, having given the matter considerable thought, she had decided not to attend the hearing.  The Panel was aware that it could not force a Registrant to attend.  Moreover, there was no application for any adjournment before it.  In addition, the allegation concerned events which had taken place some two years earlier and, accordingly, there was a public interest in having such a relatively long-outstanding allegation dealt with as soon as possible.  Finally, there were two witnesses, who had made time to attend the hearing, waiting to give evidence.  In those circumstances, the Panel concluded that the Registrant had voluntarily absented herself from today’s hearing and determined that it was appropriate to proceed in her absence as it was in the interests of justice to do so.

Background and summary of evidence

6. In brief, the Registrant worked at the Walsall Healthcare NHS Trust (“the Trust”) between June and November 2018 as an Agency Radiographer in the Imaging Services Unit. She was employed through an agency, RIG Healthcare. On 16 October and 20 November 2018, the Registrant exposed paediatric patients to adult levels of exposure to radiation. After the first incident, the Registrant met with AC the Governance and Quality Lead Radiographer at the Trust, to discuss what had happened and to draw up an Action Plan to prevent a further occurrence. On 27 November 2018, the Registrant x-rayed the incorrect ankle of an adult patient. The Registrant’s contract was terminated by the Trust, which then referred the Registrant to the HCPC. 

The incident of 16 October 2018

7. The Panel notes, from the description of the incident provided by AC in the Medical Physics Incident Report dated 18 October 2018, that the “Patient attended for an abdominal x-ray. An adult exposure was selected rather than a paediatric setting.  Therefore, the patient received an exposure greater than intended...”  In his oral evidence AC confirmed that the x-ray image which resulted had “burned out” and could not be analysed so a second x-ray had to be carried out.

8. The Incident Report went on to say:

• “The effective dose from the unnecessary exposure is: I mSv…

• The effective dose from the required exposure is: 0.02 mSv. 

• The total effective dose from all the exposures are: 1.02 mSv of which 1 mSv was unnecessary. 

• The total lifetime cancer risk using 12% per mSv from the unintended effective dose of 1 mSv is estimated as: 1 in 8300.

• The additional dose to the patient was excess exposure due to radiographer error. The patient received approximately 50 times greater than expected and therefore exceeds the 20 X reportable level…This incident therefore needs externally reporting to the CQC.

• The average background radiation received in one year in the United Kingdom is 2.2 mSv…The dose received from the unnecessary exposure is equivalent to approximately…5 Months of background radiation.  The additional risk of 1 in 8300 is classified as low risk [when] compared to the cancer induction rate in the general population of about one case in every two people (Cancer Research UK online 2017). 

• A full investigation should be performed to identify why the incident happened to reduce the likelihood of a recurrence and training should be provided to the staff involved.

• The low risk nature of this exam should be communicated (if not already done so) to the patient and it should be made clear to the patient not to be concerned by the radiation risk.”  

9. Following this incident, AC set up a meeting with the Registrant and HM, the Head Paediatric Radiographer, to discuss what had happened and what steps could be taken to prevent a future recurrence. An Action Plan was agreed upon, the overall objective of which was stated as “For Milly [the Registrant] to produce diagnostic paediatric images consistently adhering to protocols and adhering to the two-stage process of exposure factor settings”. There were three individual stages in the plan. 

10. First, the Registrant was “to complete [a] reflective statement regarding failure of 2 stage process of exposure factors”. On 25 October 2018 the Registrant completed and signed an Incident Reflection Form. In it, under the heading “Can you identify any Root Causes (Why did it happen?)” she wrote: “I didn’t check the exposure factors.  I was clear I’d selected the free detector and didn’t need a grid for this patient and didn’t select the paed. option on the drop-down menu.  I was rushing as the paed. was wriggling and crying and I wanted to ensure I exposed when they were still”. Under the heading “What could you have done differently?” the Registrant wrote “I should have checked the exposure factors before positioning the patient and then before exposing. I could have asked for a pair of hands – one person positioning and one person behind the control panel ready to prep. and two pairs of hands with a crying paed., nurse and relative is probably a good idea”. Finally, under the heading “Future prevention” she wrote “I may ask for help from colleagues in the future with paed. I must always check twice exposure factors with DR [Digital Radiography] – as I would with CR [Computed Radiography] to not get caught out again like this.  Upon reflection of this incident this will never happen again…”.

11. The second stage of the Action Plan required, by 29 October 2018, that: “Incident and action plan to be shared with all members of the imaging department to inform lessons learned and avoid re-occurrence of exposure factor related incidents…Imaging weekly incident review to be published and focus on paediatric exposure settings in lessons learned shared with all members of the imaging department.”

12. The third and final stage of the Action Plan required the Registrant, by 8 November 2018, “to meet with Paediatric Lead [Radiographer] to discuss [optimisation] of exposure factors for paediatric patients…Formal meeting to be held, and documentation on discussion to be uploaded and evidenced.”

13. In his statement dated 10 December 2019 and in his oral evidence, AC confirmed that the Registrant’s previous experience at other hospitals was on a slightly different system, but the principles, particularly that of “double checking” (which required the radiographer to check the exposure both before and after positioning the patient) still applied.  In the Trust they used a system of Digital Radiography, which contained pre-set exposures on the machines, including pre-set paediatric exposures.

14. However, whilst the Registrant was working through the Action Plan, a further incident occurred on 20 November 2018 when again the Registrant x-rayed a child using an adult setting.

The incident of 20 November 2018

15. The Panel notes, from the description of the incident provided by AC in the Medical Physics Incident Report dated 24 November 2018, that the:

• “Patient attended for x-ray - swallowed metal pin…An adult exposure was selected rather than a paediatric exposure.

• 80KV/1.7mAs dose 8.02 ugycm2. Exposed area: Lower mandible to Iliac crests. Exposure field size: 24.5cm x34.5cm EXI: 1327

• X-ray was not repeated as image was successfully manipulated to gain a diagnosis.

• Pre-populated paediatric exposure which should have been selected would have given 60 Kv and 2 mAs.

• The additional dose to the patient was excess exposure due to radiographer error. It is not reportable to the CQC under IRMER as it is not "much greater than intended"…The patient received approximately 2 times more than they should have received based on the information supplied by the radiographers.

• The average background radiation received in one year in the United Kingdom is 2.2 mSv. The dose received from the unnecessary exposure is equivalent to approximately…10 Days of background radiation.

• The additional risk of 1 in 100000 is classified as negligible risk…when compared to the cancer induction rate in the general population of about one case in every two people...

• A full investigation should be performed to identify why the incident happened to reduce the likelihood of a recurrence and training should be provided to the staff involved.

• The negligible risk nature of this exam should be communicated (if not already done so) to the patient's parents and it should be made clear to the parents not to be concerned by the radiation risk”.

16. The Registrant once again prepared and signed an Incident Reflection Form about this incident on 27 November 2018. She wrote, when describing the incident, that a 3½ year old child had arrived from A&E with a foreign body but when she “selected the patient the system couldn’t recognise what I was x-raying due to how it had been booked in on CRIS so there was a list of all projections/body parts to pick – hadn’t seen this before.  As I was going to be x-raying the patient’s chest and half of her abdomen I figured as she’s a paed. I wouldn’t need[?] to up the exposure allowing for the fact the abdo. was being imaged so was thinking along these lines, ensuring I was selecting on the detector tab, I obviously proceeded to use the incorrect exposure – for an adult.”

17. When asked to say why the incident happened, the Registrant wrote: “There is obviously a mental block with me and DR exposures.  I noted what exposure values I was using yet it obviously didn’t register in my brain that this was an adult setting.  Perhaps seeing the tabs of setting an exam phased [sic][fazed?] me – hadn’t seen this before, so perhaps this is significant?  Previous incident differs from this in that respect”.

18. When asked what she would have done differently, the Registrant wrote: “Not wanting to be put off from my previous incident and avoiding paeds, I should have asked a colleague to be a second pair of eyes however. Until my confidence increases and I am totally comfortable x-raying them as opposed to any other category of patient”.

19. Finally, under the heading “Future prevention” the Registrant wrote: “I have decided that prior to x-raying a paed. I will write on the request card the setting I have chosen…free detector and the kVp and mAs before I expose. This will serve as a visual check and an active one too as I will be writing it down. This I’m hoping is a change I can make relatively easy that will ensure I am never caught out again with paeds and DR.”

20. The Panel also noted that the Registrant added “Additional notes” on the reverse of the Incident Reflection Form as follows: “I realise now that all rooms have a paed. setting for every examination we do. In my early career days (when I x-rayed a lot) paed. settings on the CR kit wasn’t [sic] set up correctly so we were discouraged to use them – rather pick an adult exposure and alter it accordingly. This old-style practice is obviously ingrained in my head.  Also – DR exposures do differ from CR, ie it wasn’t advisable to ever x-ray anything below 60 kVp – some DR exams are as low as 55.  1.6 mAs for an adult chest x-ray on a CR kit would be far too low etc, as an example or two. Just wanted to add my thoughts above, to try to understand why I’ve made this error twice now. Reflection is definitely the word to use to describe what I’ve been doing since this second incident”. 

The incident of 27 November 2018

21. The Panel noted that the third incident occurred on 27 November 2018, which was the date the Registrant wrote her second reflective piece. The Medical Physics Incident Report dated 4 December 2018, states that the “Patient arrived at A&E via ambulance for a follow up of a previous fracture of the Right ankle. All previous imaging was for the right ankle. The Dr in A&E requested follow up images of the right ankle. Upon attendance in the department, the radiographer questioned the patient (who was confused) and imaged the left ankle. Upon review with A&E there were no issues with the left ankle and no reason to image. Patient is due to return or [sic] images of the correct ankle.”  As a result, as well as having the left ankle x-rayed twice, the patient’s correct (right) ankle was x-rayed three times.

22. The Incident Report continued:

• “The effective dose from the unnecessary exposures are: 0.001 mSv.

• The effective dose from the required exposures are: 0.0015 mSv.

• The total effective dose from an the exposures are: 0.0025 mSv of which 0.001 mSv was [unnecessary].

• The total lifetime cancer risk using 1 % per Sv from the unintended effective dose of 0.001 mSv is estimated as: > 1 in 1000000 (One Million)…

• …The additional dose to the patient was excess exposure due to radiographer error. It is not reportable to the CQC…as it is not "much greater than intended"...

• The average background radiation received in one year in the United Kingdom is 2.2 mSv. The dose received from the unnecessary exposure is equivalent to approximately…4 Hours of background radiation.

• The additional risk of 1 in 1000000 is classified as negligible risk when compared to the cancer induction rate in the general population of about one case in every two people (Cancer Research UK online 2017).

• A full investigation should be performed to identify why the incident happened to reduce the likelihood of a recurrence and training should be provided to the staff involved.

• The negligible risk nature of this exam should be communicated (if not already done so) to the patient and it is should be made clear to the patient not to be concerned by the radiation risk.”.

23. After this third incident, AC and DW who was then the Professional Lead for the Imaging Services and Clinical Measurement Unit and the Registrant’s line manager, decided to terminate the Registrant’s agency contract (for which only one week’s notice was required). On 30 November 2018 AC reported the matter to the HCPC, using the “Raising a fitness to practise concern” form, in which it was stated:

“Camilla (Milly) was an agency Radiographer employed by RIG Healthcare, and worked for Walsall Healthcare NHS Trust between the period of June - November 2018.

During this time, she had three separate Radiation Incidents, one being reportable to the CQC.

1st - Incident 96653 - Patient attended for an abdominal x-ray. An adult exposure was selected rather than a paediatric setting. Therefore, the patient received an exposure greater than intended. CQC reportable.

2nd - Incident 98260 - Patient attended for x-ray - swallowed metal pin ?location. An adult exposure was selected rather than a paediatric exposure.

3rd - Incident 98573 - Left Ankle imaged in error, Right ankle should have been performed.

Following the first incident, Milly was asked to provide a reflective statement. We then supported her through an action plan which involved meeting with the Paediatric Lead, to discuss the importance of a 2 stage process for setting of exposure settings, and how to optimise exposures for paediatric patients.

Checking exposure factors should be a 2 stage process. Exposure factors should be assessed:

Before patient enters the room - Preliminary exposures

After positioning the patient, before exposure.

Despite extensive support, Milly continued to make multiple mistakes. Following the second incident a review of competence was being undertaken through 1:1 discussions however following an additional incident the decision was made to terminate Milly's contract.

It was decided that Milly was a risk to the safety of patients, and therefore we notified her agency provider (RIG Healthcare), stating we are following up with reporting to the HCPC.”

24. In his statement signed on 28 November 2019, DW stated that:

“I was Camilla Hewitt’s line manager when she worked at the Trust between June and November 2018. She worked as an Agency Radiographer in the Imaging Services Unit and was employed through RIG Healthcare. At the Trust we use agency workers when there are temporary staff shortages. The agency is responsible for completing pre-employment checks on their employees. It is common for agency staff to be more experienced than the level of role that they are hired for. Camilla Hewitt was a band 6, but was hired to perform a band 5 role. When she started working at the Trust, Camilla Hewitt went through induction training along with other agency recruits. During induction she had to complete a series of competency tests before being signed off for work.

Diagnostic imaging

Camilla Hewitt’s responsibility was to create diagnostic images, predominantly [x-rays], which can be used for clinical diagnosis. An x-ray is a form of controlled radiation which passes through the body, creating an image. From a practical perspective, performing an x-ray involves inviting a patient into the room where the radiographer will perform a series of identification checks in order to establish that the test they are about to perform is appropriate. They will then set the correct exposure using the control panel. The control panel consists of two computer screens, and a series of controls. One computer is for patient administration and the other is an image viewing screen, which has a panel that allows the radiographer to set exposures. There are a number of pre-set exposures based on the size of an average adult or child, which the radiographer can adjust according to the size of their patient. This is done through the digital control panel.

The radiographer has discretion about what exposure to use for each patient. There is also a guide on dose reference levels, which is alongside the control screen. It gives an indicative guide for how to optimise exposures for patient size…Once the image has been taken, the radiographer must review it to ensure that it has covered the areas of the body that are required. There is a viewing area where the radiographer can view images outside of the room so that they can discuss the case away from the patient and consult colleagues if necessary. Although errors do occur, it is unusual for a practitioner to have more than one or two per year, because of the measures in place to prevent them.

Excess exposure

The principle is that a patient should receive the lowest possible dose of radiation that will produce an image. Anything more than the lowest possible dose is considered unnecessary. Exposure to radiation can increase a person’s risk of cancer, which is why dosage should be kept as low as possible. Particular care is paid to paediatric cases, because children’s cells grow at a rapid rate, making an increase in their risk of cancer a more severe prospect. If a patient is subjected to a significant unnecessary exposure - more than 20 times the expected dose - the Trust is required to report this to the Care Quality Commission (CQC)…For this reason, there is a low tolerance for individuals who do not demonstrate that they have learnt from previous errors and adapt their practice. Excess exposure incidents also pose a reputational risk to the Trust.

Excess exposure incidents are entered into an electronic safeguarding system in the hospital. The best practice is for the individual involved to report the incident, otherwise the lead in the area will do so. Incidents will then be investigated, and remedial steps taken where appropriate.

Prior to October 2018, Camilla Hewitt seemed to be performing to standard in most aspects of the job. Although I did not work with Camilla Hewitt directly, I recall that AC was required to talk to her about her reluctance to go to theatre at some point. The concerns had been raised by other members of staff. To my knowledge there was no further engagement around this…

…After the third incident I made the decision to terminate Camilla Hewitt’s contract. I held a meeting with Camilla Hewitt and AC to find out whether there were extenuating circumstances that explained her mistakes, given that we had not identified any additional learning requirements that could assist. Camilla Hewitt declined to discuss this with us.”

25. Both AC and DW gave oral evidence before the Panel.  AC confirmed that the Registrant’s error in the first incident was that she had not checked the exposure factors, which he described as a “basic” and a “fundamental principle” which was taught at undergraduate level. He stated, as had DW, that over-exposure to radiation could cause cancerous cells to develop. In the Registrant’s case, after the first incident, as it was recognised that everyone made mistakes, the Trust “owed her a chance” to rectify her errors as it was “silly” to terminate her contract after just one mistake.  After the second incident, although two such identical incidents amounted to a “fundamental error in practice”, they gave her an additional chance to put things right but after the third considered that they could not keep her.

26. AC was not aware of how many children the Registrant had dealt with between June (when she was first engaged by the Trust on a full time contract) and October 2018 (when the first incident occurred) but it was a “fundamental principle” for undergraduates to be taught about how to deal with both adults and children. A Radiographer would take about 50 images a day so he presumed that she would have dealt with some paediatric patients in that period of time.

27. AC confirmed that he was not aware of anything in the Registrant’s personal life which could have explained why she made these errors.  He had attempted to obtain such information, but the Registrant had not disclosed anything.

28. In his oral evidence, DW confirmed that, as the Registrant was recruited with experience as a Band 6 radiographer (even though the vacancy was for a Band 5 – however, the Trust was short-staffed at the time) it was expected that she was able to work independently.  However, there was always a Team Leader on each shift.  He confirmed that radiology equipment varied from Trust to Trust and this was why there was an induction process, which the Registrant had undertaken and in respect of which she had been signed off as competent.  Nonetheless, it was very unusual for a radiographer to make three errors a year, let alone in such a short period of just over a month – he had not seen that before.  He went on to say that he did not know why, after working without any apparent problems for four months, the Registrant’s performance suddenly deteriorated.  After the third incident when they met to advise her that they were terminating her contract, she had been asked if there were any background problems but she declined to answer and did not want to discuss the issue.  He did recall that she appeared to be defensive on that occasion, although he considered that it was probably difficult for her at that meeting given that they were telling her that they were ending her contract.

29. DW did say that the Registrant’s errors were remediable - they suggested a lack of understanding of the process and so could be rectified.  To that end it had been suggested that she undertook a reflective process but “obviously it was not happening”.  It was thought that she could “turn it around” after the second incident as she had worked there for a few months without any problems, so they put in what he described as “intensive” support. The feedback that he received from others said that she had been receptive and knew what needed to be done.

30. DW also confirmed that having to repeat x-rays meant that a patient would be exposed to more radiation than they should have been, and this increased the risk of cancer. It was his opinion that the Registrant’s actions therefore damaged the reputation of the profession, especially with regard to external reporting of some of those errors (such as to the CQC). As to what the Registrant went on to do following her departure from the Trust, DW had no information.

Decision on Facts

31. In considering this case the Panel bore in mind that the burden of proving the facts rests upon the HCPC and that the standard of proof is the civil standard of the balance of probabilities. It has taken account of all the evidence presented to it, namely the written and oral evidence of the witnesses detailed below, together with the documentary evidence provided by the HCPC. It has also considered the detailed submissions of Mr Millin and has accepted the advice of the Legal Assessor.

32. As indicated above, the Panel heard evidence from AC and DW. The Panel also received into evidence a statement and exhibit bundle from the HCPC of 155 pages.

Witness assessment

33. The Panel made the following assessments of the witnesses: it found both the HCPC witnesses to be very credible; impartial and balanced; and consistent and clear in their recollections.

Decisions on the Individual Particulars

Whilst registered as a Radiographer and working as an agency radiographer at Walsall Manor Hospital you:

Found Proved

34. There is no dispute that the Registrant was, at all material times, employed as a Radiographer by the named Trust.  Both AC and DW confirmed that she was taken on in June 2018 as a Band 6 agency worker in a Band 5 post and that she worked full time until November 2018.

1. On one or more of the dates set out in Schedule 1 exposed paediatric patients to excessive radiation in that you exposed them to an adult dose of radiation.

16 October 2018 – Patient A

20 November 2018 – Patient B

Found Proved

35.  The Panel relied upon the credible evidence of AC and DW, who both confirmed that the Registrant was the radiographer  responsible for exposing both the children Patient A and Patient B to excessive radiation since she x-rayed them both on adult settings and, in Patient A’s case, necessitated a further x-ray since the original x-ray could not be manipulated. In addition it relied upon the unchallenged documentary evidence detailed above of the Incident Reports and the Registrant’s own written reflections upon the incidents set out in the Incident Reflection Forms, in which she made admissions and accepted responsibility for her actions in relation to these Patients.

2. On or about 27 November 2018 exposed Patient C to excessive radiation in that you imaged the left ankle as opposed to the right ankle during a follow up of a previous right ankle fracture.

Found Proved

36. The Panel relied upon the credible evidence of AC and DW, who both confirmed that the Registrant was the radiographer responsible for exposing Patient C, who was an adult, to excessive radiation by imaging the incorrect ankle thereby necessitating an additional three x-rays on the correct ankle.  In addition, it relied upon the unchallenged documentary evidence of the Incident Report detailed above.
 
Decision on Grounds

37. Having found facts proved in this matter, the Panel went on to consider whether the facts found proved, individually or collectively, amounted to the statutory ground of Misconduct.

38. In relation to Misconduct, the Panel noted the advice of the Legal Assessor who referred to the cases of Roylance v General Medical Council [2000] 1 A.C. 311, Cheatle v General Medical Council [2009] EWHC 645 (Admin), Nandi v. General Medical Council [2004] EWHC 2317, Spencer v General Osteopathic Council [2012] EWHC 3147 (Admin) and R v. Nursing and Midwifery Council (ex parte Johnson and Maggs) (No 2) [2013] EWHC 2140 (Admin). The Panel noted that misconduct must be serious and amount to a registrant’s conduct falling far below the standards expected of a registered radiographer in such a way that fellow practitioners would find her behaviour “deplorable”.

39. The Panel noted Mr Millin’s submissions that a number of standards in both the HCPC’s Standards of conduct, performance and ethics had potentially been breached, namely standards 3 and 6.

40. The Panel finds that the following standards of the HCPC’s Standards of Proficiency of Social Workers (2016 version) have been breached by the Registrant’s actions or failings:

• 1 (To promote and protect the interest of service users and carers by treating service users and carers with respect);

• 3 (Work within the limits of your knowledge and skills by keeping within your scope of practice and by maintaining and developing your knowledge and skills);

• 6 (Manage Risk by identifying and minimising risk). 

41. In addition, it found that standard 2.6 of Standards of Proficiency for Radiographers (be able to practise in accordance with current legislation governing the use of ionising and non-ionising radiation for medical and other purposes) had potentially been breached.

42. However, the Panel reminds itself that a mere breach of standards does not, in itself, amount to misconduct.

43. The Panel considers that the facts found proved in relation to all three incidents individually and collectively amount to Misconduct.

44.  The Panel takes particular account of the fact that, in relation to Particular 1, the Registrant administered adult doses of radiation to children, which had the effect of increasing their potential to develop cancer; further, in relation to the incident of 16 October 2018, a second x-ray, albeit at the correct child setting, had to be taken.  The Panel appreciates that (upon analysis of the amount of overexposure to radiation contained in the Incident Reports) the risk of both Patients A and B developing cancer in the future was stated to be relatively minimal, but the fact remains that the patients were put at risk of harm. Moreover, the Panel notes that, in relation to Patient A, the dose was 50 times greater than required and accordingly had to be reported to the CQC, thereby causing reputational damage to the Trust.

45. In relation to Particular 2, although the overexposure to radiation was stated to be minimal, nonetheless the fact remains that Patient C was put at risk of harm by having to have the correct ankle x-rayed three times.  Moreover, there was the danger, in x-raying the incorrect ankle, that the injury to the other ankle could have gone undiagnosed. 

46. Finally, the Panel notes that these incidents occurred over a very short period of time (about five weeks) and no real explanation has been provided by the Registrant for what have been described as “fundamental errors of practice”.  Accordingly, the Panel is drawn to the inevitable conclusion that the Registrant’s actions were serious and that her conduct fell far below the standards expected of a registered radiographer in such a way that fellow practitioners would find her behaviour “deplorable”. 

Decision on Impairment 

47. In reaching its decision on impairment, the Panel has taken account of the submissions of Mr Millin and the oral testimony of AC and DW, and the advice of the Legal Assessor. It has also taken account of the HCPC Practice Note “Finding that Fitness to Practise is Impaired”.

48. The Panel is aware that, in determining whether fitness to practise is impaired, it must take account of a range of issues which, in essence, comprise two components, namely the ‘personal’ component (the current competence and behaviour of the individual Registrant) and the ‘public’ component (the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession). It appreciates that not every finding of misconduct will automatically result in a Panel concluding that fitness to practice is impaired. Moreover, it cannot adopt a simplistic view and conclude that fitness to practise is not impaired simply on the basis that, since the allegation arose, a Registrant has corrected matters or “learned his/her lesson”. Although the Panel’s task is not to punish past wrongdoings, it does need to take account of past acts or omissions in determining whether a Registrant’s present fitness to practise is impaired. In addition, when assessing the likelihood of a Registrant causing similar harm in the future, the Panel should take account of both the degree of harm if any, caused by a Registrant and that Registrant’s culpability for that harm. Finally, the Panel is to consider whether a Registrant has demonstrated insight into her attitude and failings.

49. The Panel first of all considered the personal component. It noted that the Registrant had not engaged with the HCPC and had provided no information about her current circumstances or what she did following her departure from the Trust in November 2018. It was aware that she had worked as a radiographer for a few years and that she was occupying the Band 5 post as a relatively senior Band 6 Radiographer. Further, it took account of the fact that she apparently worked without any difficulty for three or four months at the Trust (where DW estimated that she might have carried out up to 50 x-rays a day).  It noted that she apparently had an aversion to working in theatre but DW indicated that it was not unusual for radiographers to express individual preferences and he read nothing unusual into this.  

50. The Panel also noted, from the evidence of both AC and DW, that her errors were remediable and that they could be eradicated by reflection and training.  However, the Panel had no evidence before it that the Registrant had remediated her practice.  Although she demonstrably reflected upon the first two incidents involving the child patients, her resolve in her first reflection never to make the same mistake again had a hollow ring to it since she repeated the error within a month.  Her further reflections, on the very day that she made the third error in relation to Patient C, were similarly undermined by that subsequent mistake and demonstrated that she had not really understood what caused her to make such fundamental errors.  The Panel also notes that both AC and DW indicated that they had asked the Registrant whether there were any extenuating circumstances and that she had refused to answer.  Finally, the Panel reminds itself that the Registrant had not engaged with the HCPC and had provided no information about her current circumstances or what she did following her departure from the Trust in November 2018.  There is, in addition, no indication from her that she has maintained her CPD.  Accordingly, not only is there no evidence that, as at today, the Registrant has remediated her conduct, but there is no evidence that she has developed any, or any meaningful, insight into her actions. Consequently, it follows that the Panel cannot be satisfied that the Registrant will not repeat these errors. 

51. The Panel therefore concludes that, in relation to the Personal component, the Registrant is and remains currently impaired.  

52. In relation to the Public component, the Panel concluded that the Registrant’s misconduct was such that the need to declare and uphold professional standards and maintain public confidence in the profession would be undermined if a finding of impairment were also not made in these circumstances. The Panel believes that a right-minded member of the public, with full knowledge of all of the circumstances, would be concerned if a finding of current impairment were not made. 

53. In particular, the Panel reminds itself that it had found that an apparently experienced and competent radiographer had overexposed three patients, two of which were children, to excessive radiation and had provided no cogent explanation for such actions.  Moreover, there was evidence from both AC and DW that reputational damage to both the Trust and to the profession had been caused, which again emphasised the need to consider the public interest in this case. 

54. The Panel also took account of the examples given by Dame Janet Smith in her Fifth Shipman Report which set out four reasons why a decision maker might conclude that a registrant was unfit to practise, or that her fitness to practise was impaired. The first three examples were:

a) has in the past acted and/or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and/or

b) has in the past brought and/or is liable in the future to bring the… profession into disrepute; and/or

c) has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the … profession;

55. The Panel considered that all three examples applied to the Registrant – she had acted in the past and there was no evidence that she would not do so in the future “so as to put a patient or patients at unwarranted risk of harm” by overexposing them to radiation; she had acted in the past and there was no evidence that she would not do so in the future “to bring the … profession into disrepute”; and she had acted in the past and there was no evidence that she would not do so in the future to “breach one of the fundamental tenets of the … profession” (namely, as submitted by Mr Millin, not to overexpose patients to radiation, which was taught at undergraduate level).

56. Finally, the Panel noted Mr Millin’s submissions which it considered neatly encapsulated the reasons for a finding on this point:

“The fact (if the Panel finds) that the [Registrant’s] actions were repeated, exposed vulnerable patients to risk of harm, and has not taken steps to remediate her misconduct makes a finding of impairment a necessity, both in order to protect the public as well as maintaining public confidence in the profession.”

57. Taking all these factors into account the Panel concludes that the public interest requires a finding of impairment against the Registrant.

58. In conclusion therefore, the Panel finds that the Registrant’s fitness to practise is impaired under both the personal and the public components.    

Decision on Sanction

59. In reaching its decision on sanction the Panel took account of the Sanctions Policy (“SP”) document and the advice of the Legal Assessor, which it accepted. The Panel was mindful that the purpose of sanctions is not to be punitive, although they may have that effect. It appreciated that the primary purpose of any sanction is to address public safety from the perspective of the risk which the Registrant concerned may pose to those who use or need her services. It noted, however, that in reaching its decision, panels must also give appropriate weight to the wider public interest, which includes: the deterrent effect to other registrants; the reputation of the profession concerned; and public confidence in the regulatory process. In addition, the Panel noted that it must act proportionately, which requires it to strike a balance between the interests of the public and those of the Registrant.

60. The Panel took account of Mr Millin’s submissions. It also took account of the various mitigating factors namely:

• The Registrant’s previous good character;

• She had co-operated with the Trust’s investigation into the first and second incidents and had made some attempts to comply with the Action Plan;

• She had engaged with the HCPC, albeit to a limited extent in that she has not provided any information for this hearing or attended;

• She had accepted responsibility for the first and second incidents in her reflective pieces (although she had not provided any real explanations for her actions in all three incidents);

• She had worked at the Trust without any concerns being raised for about four months prior to the first incident. 

61. However, the Panel also notes the following aggravating features and in particular:

• The Registrant’s actions were serious and potentially could have caused significant harm to the patients;

• Her misconduct was repeated, albeit over a short period of time;

• There does not appear to have been any real expression of genuine or timely remorse or apology; none could be recalled by her line manager, DW, and none are contained within her written reflections;

• There is no evidence of any further reflection about these incidents since her departure from the Trust in November 2018 nor any subsequent indication that she would change her practice because of them;

• There is no evidence before the Panel that the Registrant has remediated her misconduct and, accordingly, there is a continuing risk of repetition; 

• The Registrant has not supplied any evidence of CPD or any relevant testimonials.

62. Given the seriousness of the misconduct and the aggravating factors, the Panel took the view that this was not a case that could be appropriately dealt with without a sanction.

63. The Panel first considered the sanction of mediation and concluded that it was not appropriate. There was no evidence before it that the Trust or the Registrant would co-operate in such a process, and in any event the matter was too serious to be resolved in this way.

64. The Panel next considered a Caution Order, which paragraph 101 of the SP deems to be appropriate where:

 “the issue is isolated, limited, or relatively minor in nature; there is a low risk of repetition; the registrant has shown good insight; and the registrant has undertaken appropriate remediation. ”

65. The Panel noted that, although these were apparently isolated lapses (spanning some five weeks in an otherwise unblemished career) the Particulars found proved were serious. Moreover, the Panel had found that there remained a real risk of repetition. Consequently, the Panel concluded that, especially given that the Panel believed that there remained significant issues in relation to the Registrant’s insight, such a sanction would be insufficient to address the Panel’s concerns in relation to public interest grounds or to provide adequate protection to the public.

66. The Panel then considered the next most serious sanction, that of a Conditions of Practice Order, and noted that paragraph 106 of the SP considered that this was appropriate where:

• “the registrant has insight;
• the failure or deficiency is capable of being remedied;
• there are no persistent or general failures which would prevent the registrant from remediating;
• appropriate, proportionate, realistic and verifiable conditions can be formulated;
• the panel is confident the registrant will comply with the conditions;
• a reviewing panel will be able to determine whether or not those conditions have or are being met; and
• the registrant does not pose a risk of harm by being in restricted practice.”

67. The Panel determined that, despite the breaches being serious, the Registrant’s failings were capable of being remedied – the evidence of AC and DW made this clear. Moreover, it took into account that she had co-operated with the Action Plan and, according to the evidence of DW, feedback to him had indicated that she was “receptive and knew what needed to be done”.  Consequently, it appeared that the Registrant might be willing to comply with conditions.

68. However, the Panel also took account of paragraph 107 of the SP, which states:
“Conditions will only be effective in cases where the registrant is genuinely committed to resolving the concerns raised and the panel is confident they will do so. Therefore, conditions of practice are unlikely to be suitable in cases in which the registrant has failed to engage with the fitness to practise process or where there are serious or persistent failings. ”

69. The difficulty that the Panel faced was that the Registrant had not engaged with these proceedings in any meaningful way so it had no information before it: as to her current situation; whether the Registrant was still working, or even intended to work in the future, as a radiographer; or whether she had reflected further upon these matters and/or had remediated her errors. Accordingly, the position remained that it appeared to the Panel that the Registrant continued to display little or no insight into her actions in this matter. On the evidence before it, the Panel could not be satisfied that the Registrant would not act in this way again; and that, consequently, there was no available evidence to reassure the Panel that there was the required level of insight and understanding to indicate that a Conditions of Practice Order was an appropriate and proportionate response.

70. Given the Registrant’s initial response to the Trust’s Action Plan, the Panel did give consideration to making a Conditions of Practice Order. However, based on the information, or indeed the lack of information, before it, the Panel felt that it was unable to draft workable, appropriate, realistic or verifiable Conditions of Practice. It concluded that there was insufficient evidence before it that the Registrant would be able or willing to comply with such an order.

71. The Panel next considered imposing a Suspension Order. It noted that paragraph 121 of the SP indicated that a suspension might 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.”

72. The Panel was satisfied that, for instance, the concerns represented a serious breach of the Standards. It appreciated that there was no evidence before it to indicate that the Registrant currently had sufficient, or any, insight and therefore it could not be said that the issues were unlikely to be repeated.  However, there was evidence to suggest that she might be able to resolve/remedy her failings, namely her initial positive reaction to the Trust’s Action Plan, which suggested an eagerness to remedy her failings and learn.  Once again, the difficulty the Panel had was that there was no significant engagement by the Registrant with these proceedings, so it was unable to ascertain her current situation, and therefore address her current requirements.

73. However, the Panel appreciated that the Registrant, for whatever reason, might have found it difficult to engage in these proceedings. Consequently, the Panel considered that a possible and proportionate response could be to give her an opportunity to show that she is willing to remedy her failings by imposing a short Suspension Order, commensurate with the gravity of her failings so as to mark the seriousness of those failings. Such an order would be reviewed before the end of the suspension period, which would provide an opportunity for the Registrant to demonstrate in the interim that she has gained insight into her errors and wishes to remedy them. The Panel was also satisfied that a Suspension Order would maintain public confidence in the Regulator and the profession.

74. The Panel did, as advised by the Legal Assessor, consider the next most onerous sanction, that of Striking Off.  It notes paragraphs 130 of the SP, which indicates that such an order:
“is a sanction of last resort for serious, persistent, deliberate or reckless acts involving (this list is not exhaustive):

• dishonesty…
• failure to raise concerns…
• failure to work in partnership…
• discrimination…
• abuse of professional position, including vulnerability…
• sexual misconduct …
• sexual abuse of children or indecent images of children…
• criminal convictions for serious offences…and
• violence.

75. The Panel paused there to comment that the Registrant’s failings do not fall into any of the above categories. It further notes paragraph 131 of the SP, which states:


“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; or
• is unwilling to resolve matters.

76. The Panel considered that, although little is known at this stage about the Registrant’s current situation, imposing such a draconian sanction without giving the Registrant an opportunity to engage further with the proceedings and demonstrate whether she is willing and/or able to remediate her failings would be disproportionate.  It therefore concluded that the stage has not been reached whereby it is appropriate to impose a “sanction of last resort”. It follows that the Panel considered that, at this stage, a Striking Off Order would be disproportionate.

77. Accordingly, the Panel concluded that the proportionate response is to make a Suspension Order for a period of 6 months, which would give the Registrant sufficient time to address and remedy her failings.

78. That Order will be reviewed towards the end of that period and the HCPC will arrange for a Review hearing to take place. At that hearing, at which of course the Registrant would be entitled to attend, the reviewing Panel may be assisted by:

• Evidence of reflection about this matter together with evidence of insight and remorse;
• Evidence that the Registrant has kept her skills and knowledge up to date, together with evidence of CPD;
• Evidence of the Registrant’s future intentions about practising as a radiographer and details of her plans, if any, for such a return;
• References and testimonials.

Order

Order: The Registrar is directed to suspend the registration of Camilla L Hewitt for a period of 6 months from the date this Order comes into effect.

Notes

Interim Order

Application for Interim Order

1. Having determined to conclude this case by imposing a Suspension Order for 6 months on the Registrant, the Panel heard an application by Mr Millin for an Interim Suspension Order for 18 months (to cover any appeal period). 

Application to proceed in absence

2. However, before asking the Panel to consider such an application Mr Millin asked whether he needed to make a further application to proceed in the Registrant’s absence.  He cited the case of Zanusi v GMC as authority for not needing to make such an application and reminded the Panel that the Notice of Hearing made it clear that if a Registrant did not attend the hearing a panel had powers not only to proceed in their absence but also to impose a sanction which could restrict their practice. Finally, he reminded the Panel that it had already decided to proceed in the Registrant’s absence, following which it had made findings that her ability to practise was impaired and that a Suspension Order was the appropriate and proportionate sanction.

3. The Panel heard advice from the Legal Assessor who agreed with Mr Millin that no such application was necessary as the Panel had already made such a decision at the commencement of the hearing.  Having heard such advice the Panel decided that no further application to proceed in the Registrant’s absence was necessary.
Application for Interim Suspension Order    

4. Mr Millin submitted that such an order was necessary on both public protection and public interest grounds on the basis that the Panel had found that the Registrant was currently impaired due to her Misconduct and had considered that she should be made subject to a Suspension Order for 6 months on the grounds that she posed an ongoing risk to the public and had acted in such a serious manner that such a sanction had to be imposed upon her. 

5. The Panel accepted the advice of the Legal Assessor, who referred it to paragraphs 133 to 135 of the SP, which state:

What is an interim order?

6. 133. If a panel imposes a conditions of practice order, suspension order, or striking off order, Article 31 of the Order provides the panel with the discretionary power to also impose an interim conditions of practice order or an interim suspension order. This will apply from the imposition of the substantive order, until the end of the appeal period, or where an appeal is made, the end of the appeal process. 

When is an interim order appropriate?

7. 134. The power to impose an interim order is discretionary, and so panels should not consider it to be an automatic outcome. The panel should carefully consider whether or not an interim order is necessary and should provide the parties with an opportunity to address the panel on whether an interim order is required.

8. 135. An interim order is likely to be required in cases where:

• there is a serious and ongoing risk to service users or the public from the registrant’s lack of professional knowledge or skills, conduct, or unmanaged health problems; or
• the allegation is so serious that public confidence in the profession would be seriously harmed if the registrant was allowed to remain in unrestricted practice.”

9. The Panel took account of the Practice Note on Interim Orders and first considered whether an interim order was necessary. It noted that it had no information as to whether the Registrant had practised as a Radiographer since leaving the Trust in November 2018.  Further, it noted that the Registrant had not been made subject to any Interim Suspension Order. It had, however, found that she was currently impaired due to her Misconduct. The Panel was therefore satisfied that there was a serious and on-going risk to service users or the public and that for the same reasons public confidence in the profession or the regulatory process would be seriously harmed if the Registrant was allowed to remain in unrestricted practice.

10. Having determined that an interim order was necessary, the Panel then considered the appropriate form of that order, beginning with the least restrictive. It first considered whether an Interim Conditions of Practice Order would be sufficient to protect the public, meet the wider public interest or be in the Registrant’s own interests.  For the same reasons as given when deciding not to impose a substantive Conditions of Practice Order on the Registrant (which included the Panel’s concerns about the her currently being willing or able to comply with such an order) the Panel decided that such an Interim Order would not be appropriate to manage the risks identified by the Panel and that it would be perverse to impose an order inconsistent with the substantive order of Suspension.  

11. The Panel therefore concluded that an Interim Suspension Order was the appropriate and proportionate order. It also determined that it should be for a period of 18 months since, if there was an appeal, the substantive order would not come into effect.

 

Hearing History

History of Hearings for Miss Camilla L Hewitt

Date Panel Hearing type Outcomes / Status
09/11/2020 Conduct and Competence Committee Final Hearing Suspended