Mr Christopher Milton

Profession: Biomedical scientist

Registration Number: BS70104

Hearing Type: Review Hearing

Date and Time of hearing: 10:00 07/09/2020 End: 17:00 07/09/2020

Location: Hearing taking place virtually

Panel: Conduct and Competence Committee
Outcome: Conditions of Practice

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Allegation

Allegations as found proven at the Final Hearing 


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

c) Did not complete the third prescription sheet

2. On the 13 April 2017 you recorded the wrong expiry date on Telepath for a Fresh Frozen Plasma unit

3. On the 4 May 2017 you booked in a sample for Patient E under “Patient E’s mother’s” Telepath record, instead of the infant’s own Telepath record

4. On the 15 May 2017:

a) Recorded the results of Patient C’s and Patient D’s blood tests under the incorrect specimen numbers

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

c) Recorded the blood group of Patient D’s Blood as O Positive when the results found the blood group to be B positive

5. On the 16 July 2017, did not update Patient B’s antibody file in Telepath to confirm that a Non Specific Antibody had been detected.

6. On the 25 July 2017:

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

b) Did not record Patient A’s phenotype on:

i) Telepath and/or

ii) Patient A’s request form

7. The matters set out in paragraphs 1 - 6 constitute misconduct and/or lack of competence.

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

Finding

Preliminary Matters:

Service

1. The Registrant was served with Notice of Hearing by email on 10 August 2020, in accordance with the requirements. The Registrant replied to this email on 13 August 2020 and has served a bundle for today’s hearing dated 27 August 2020. The Panel is satisfied that there has been good service.

Proceeding in the absence of the Registrant

2. The HCPC applied to proceed in the absence of the Registrant. Mr D’Alton submitted that the Notice of Hearing invited the Registrant to attend the hearing by video link. The Registrant had responded by indicating that he would be preparing written representations. He submitted that the Registrant had voluntarily absented himself. This was a mandatory hearing and the Registrant would be able to apply for an early review.

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

4. The Panel determined that it should proceed to hear the application in the Registrant’s absence. Whilst the Registrant has engaged in the process, he had elected not to appear in person. He had therefore voluntarily absented himself. He had submitted lengthy documents, which the Panel have read carefully. The Panel concluded that it would attach weight to the documents and consider carefully the submissions prepared by the Registrant before reaching a decision. The Panel noted that this was a mandatory review and that it was in the interests of justice to proceed. The Registrant had decided not to attend the hearing and will be able to apply for an early review should he wish to do so.

Background

5. 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.

6. In July 2017, it came to the Trust’s attention that the Registrant was making errors. Particular 1(a) related 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) related to the failure to adequately record the results.

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

8. Particular 6 related 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 were the basis of Particular 6. The allegations were the subject of a disciplinary investigation.

Decision of panel at substantive hearing

9. At the substantive hearing, the Registrant accepted the particulars of the allegations save for Particular 2. The panel at the substantive hearing, found Particulars 2, 4 and 5, proved, but did not find that they amounted 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.

10.The panel found that the following Particulars 1a), 1b), 3 and 6 amounted 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 represented a serious departure from the standards of conduct expected of a newly qualified Biomedical Scientist. 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. 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. 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.

11.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 was impaired. On the personal component, the panel accepted that the Registrant had some insight. He had accepted the factual Particulars of the allegations, with the exception of Particular 2. He did not try to hide his mistakes. The mitigating factors as identified by the panel at the substantive hearing 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 prepared for the sanction stage of the hearing showed that he was developing insight and that he had taken on board the panel’s findings. He had demonstrated remorse for his conduct. The incidents which led to the proceedings occurred over a short period of time and related 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. The Registrant had written a reflective piece and in his oral evidence he had acknowledged that he remained impaired. The panel found that the Registrant’s reflections did 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 the Registrant had “limited insight into the potential impact of his failings on patients”. The panel found that these were “careless mistakes which were not caused by a lack of scientific knowledge”.

12.Whilst the panel found that the failings were remediable, it noted that the Registrant had not worked in biomedical science for almost two years and had only recently made enquiries about updating his professional knowledge. At the time the Registrant had enrolled on a mindfulness course. The panel found that the Registrant was in the early stages of remediation and insight and the risk of repetition and the consequent risk to service users remained high. The panel found that the public component had been met and that public confidence in the profession and the regulator would be undermined were a finding of impairment not made. The Panel therefore found that the Registrant’s fitness to practise was impaired on both the personal and public components.

The Hearing

13. Mr D’Alton for the HCPC submitted that the Registrant remained impaired. He acknowledged that the Registrant had engaged with the HCPC and had communicated with the HCPC. He however argued that it was now almost three years since the Registrant had worked in a laboratory and that there was no evidence before the Panel from which it could safely find that the Registrant was no longer impaired. He submitted that there were significant shortcomings in the Registrant’s reflective piece which amounted to little more than an academic explanation as to the consequences of mistakes in blood transfusion cases. The Registrant had not linked this with his own actions, nor had he demonstrated the practical steps that he would take to avoid a repetition of the mistakes which led to the proceedings. He argued that the Registrant he had not continued to develop insight and submitted that the risks have increased because the Registrant has now been out of a laboratory setting for longer.

14. The Registrant in his submissions provided a lengthy reflective piece and addendum containing some evidence of further training and recent job applications, and a reference from an employer in a role unrelated to Biomedical Science.

15.The Registrant also provided a letter setting out what had happened since the substantive hearing. Shortly after the substantive hearing in September 2019, the Registrant’s partner was given the opportunity to work in New Zealand. The Registrant elected to travel with her. At the time he envisaged that he would be in New Zealand for 1-2 years. In January 2020 the Registrant completed a course required by the New Zealand Medical Sciences Council (NZMSC) to transfer his qualification to enable him to seek registration in New Zealand. He wrote to the HCPC in March asking if he would be able to be supervised by a Biomedical Scientist registered with the NZMSC. However, he was never registered by the NZMSC because the Covid 19 pandemic took over and his partner’s secondment was cut short. He travelled back to the UK in April 2020 and has been applying for jobs in the UK since then. The Registrant provided a selection of applications and feedback from a job interview which noted interalia and that he presented well in interview, had come a close second. The employer noted that the supervision requirements of his conditions of practice would place an onerous burden on them. On 13 August 2020, the Registrant wrote to the HCPC asking whether he would be able to work as a Medical Laboratory Assistant or in a different field such as Biochemistry. The HCPC responded by stating that this would be a matter best addressed at the substantive review hearing.

16. In his reflective piece the Registrant accepted that had not worked in Biomedical Science since the Conditions of Practice Order. He stated that he had studied the SOP’s and had also studied the regulations behind transfusion protocols “Blood Safety & Quality Regulations 2005” as well as the handbook prepared by the “Joint UK Transfusion & Tissue Transplantation Services Professional Advisory Committee and the Blood Safety and Quality Commission. In his reflective piece the Registrant set out the risks associated with transfusion. He wrote “transfusion errors can cause catastrophic outcomes for patients and damage the profession in the public eye”. He also stated that “negative outcomes of errors are all serious and must be reported to the appropriate regulator” and that if all regulations are followed” error can be minimised to an absolute minimum”. He wrote that “It is with the utmost regret that I have previously made careless errors in this field and that these had the potential to cause ABO incompatibility and a delayed haemolytic reaction”.

17.The Panel accepted the advice of the Legal Assessor. As part of her advice, she advised the Panel of its powers at review under Article 30(1) of the Health Professions Order 2001. She advised the Panel that the review process is not a mechanism for appealing against or ‘going behind’ the original finding that the Registrant’s fitness to practise is impaired. The purpose of review is to consider whether the Registrant’s fitness to practise remains impaired; and if so, whether the existing order or another order needs to be in place to protect the public.

18.The task of this Panel was to conduct a thorough review of the evidence to determine if anything had changed since the current order was imposed.

Decision

19.The Panel considered the bundle provided by the HCPC and the Registrant. The Panel has also taken into account the submissions made by Mr D’Alton and the advice of the Legal Assessor.

20.After considering all of the evidence the Panel determined for the reasons set out below that the Registrant’s fitness to practise remains impaired.

21.Whilst the Registrant has engaged with the HCPC he has not shown that he has addressed the concerns raised by the panel at the substantive hearing. The Registrant was a newly qualified Biomedical Scientist at the time of the incidents which led to the Particulars. He therefore had little experience. The Registrant had very limited experience and now has not worked for three years. The Panel noted that there have been considerable developments in the field of biomedical science since he was last in a laboratory and that there was no evidence to show that he has kept abreast of these. This of itself means that the Panel have concluded that the Registrant remains impaired. His lengthy reflective piece was theoretical in nature and did not demonstrate that he would be safe to work in a laboratory. Although the Registrant acknowledged the serious consequences of his mistakes in blood transfusions, he did not really address the fact that his errors were careless errors. Similarly, the Registrant explained that he had completed CBT Mindfulness training and set out the areas that the course had covered but he did not link it to the mistakes he had made.

22. The Panel therefore finds that the Registrant has not shown that he has developed further insight into the issues that led to the findings of the substantive panel. In short, the Panel finds that the Registrant has made limited progress in remediating his failings and find that he remains impaired. The Panel determined that if the Registrant were to return to work in a laboratory unsupervised at the present time there would be a high risk of repetition and that this would lead to risks to the public. The Panel also considered that an order remains necessary in the public interest as it is important that the public has confidence in the regulatory process and in the high standards of the profession of Biomedical Science.

23.The Panel next considered the appropriate order. In reaching a decision on the type of order, the Panel took into account its overall duty to protect the public and the public interest as set out above. The Panel have also taken into account its duty to act proportionately. The Panel have determined that a further Conditions of Practice Order is the least restrictive order that can adequately protect the public and satisfy the public interest.

24.The Panel has updated the conditions to reflect the fact that the Registrant has been out of work for longer, but also to assist the Registrant to address the relevant issues at a future hearing. The Panel note that the Registrant has been open and honest with employers when he has applied for work. He has engaged with the HCPC and is now keen to return to work. The gap of three years means that he will have to update his knowledge and complete the mandatory 30 day return to practise training, as set out in the HCPC’s “Returning to Practice” booklet, when he returns to work. The Panel would like to emphasise that it is important that the Registrant continues to engage and that he should try to attend the next hearing whether or not he is represented. If the Registrant finds work as a Medical Laboratory Assistant or chooses to work as a scientist in a role which does not require him to be registered, he will not be subject to conditions of practice. Whether or not the Registrant takes up a role as a registered Biomedical Scientist or not, a future panel will be assisted by a thorough reflective piece which addresses in practical terms how his working methods have changed. It would also be assisted by references from his employer which refer back to the failings and evidence how the Registrant has addressed these. The Panel has imposed a further 12 months Conditions of Practice Order.

Order

ORDER: The Registrar is directed to vary the Conditions of Practice Order against the registration of Christopher Milton for a further period of 12 months on the expiry of the existing order. The Conditions are:

1. You must not work 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. You must complete the mandatory 30 day return to practise training as stipulated in the HCPC “Returning to Practice” booklet.

3. Whilst working as a Biomedical Scientist, you must place yourself and remain under the supervision of a workplace supervisor registered with the HCPC.

4. 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.

5. Within 3 months of obtaining employment as a Biomedical Scientist you must forward a copy of your PDP to the HCPC.

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

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

8. Once you obtain employment as a Biomedical Scientist, you must maintain a reflective piece and an evidenced based log to demonstrate the 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.

9. You must inform the HCPC within seven days if you take up employment as a Biomedical Scientist.

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

11. 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

This Order will be reviewed again before its expiry on 16 October 2021.

Hearing History

History of Hearings for Mr Christopher Milton

Date Panel Hearing type Outcomes / Status
07/09/2020 Conduct and Competence Committee Review Hearing Conditions of Practice
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