Mrs Diane L Lucas

Profession: Radiographer

Registration Number: RA22480

Hearing Type: Consent Order Hearing

Date and Time of hearing: 10:00 25/01/2021 End: 17:00 25/01/2021

Location: Virtual via Video Conference

Panel: Conduct and Competence Committee
Outcome: Conditions of Practice

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Allegation

Whilst registered as a Radiographer with the Health and Care Professions Council, you:

1. On 9 June 2017, while employed by Ramsay Health Care UK did not
undertake the correct checks to ensure the identity of Patient B, and:
a. Incorrectly performed an XRay on Patient B, using the patient identification details for Patient A; and/or
b. Incorrectly matched Patient B’s X-ray images with Patient A; and/or
c. Exposed Patient B to unnecessary radiation.

2. While employed by Ramsay Health Care UK, did not report an error following an inpatient examination that had occurred on 22 May 2017, on Riskman and/or to the appropriate person/s.

3. On 12 June 2017, while employed by Ramsay Health Care UK, examined Patient C and:
a. Labelled and stored patient images under Patient D’s identification details; and/or
b. Did not ensure that Patient C’s diagnostic images were available for clinical review; and/or
c. Did not report your error on Riskman and/or to the appropriate person(s).

4. On 11 July 2017, while employed by Ramsay Health Care UK, deleted patient theatre images without a justification for doing so and/or without following the appropriate process.

5. On 26 July 2018, attempted to access Ramsay Health Care UK’s computer system after you had been dismissed by them.

6. On 26 September 2018, attempted to access Ramsay Health Care UK’s computer system after you had been dismissed by them.

7. The matters as set out in paragraphs 1 to 6 constitutes misconduct and/or lack of competence.

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

Finding

The Application
1. The HCPC and the Registrant seek a disposal by consent of the case brought against the Registrant. The order proposed is a Conditions of Practice Order for a period of 12 months.

Background
2. The Registrant is a registered Radiographer. She was employed by Ramsay Health Care UK at New Hall Hospital (‘New Hall Hospital’) as a Senior Radiographer and Radiation Protection Supervisor until her dismissal in March 2018. An investigation was conducted in June 2017 following an incident where the Registrant had conducted an X Ray on a patient who did not need one.

3. In January 2018, further concerns relating to the Registrant’s practice came to light following a number of automated alerts on the computer software systems used for radiography at New Hall Hospital.

4. On 26 March 2018, following the Registrant’s dismissal, the HCPC received a referral from New Hall Hospital.

5. On 9 August 2019 a panel of the Investigating Committee considered the allegation drafted by the HCPC and found that there was a case to answer in relation to the following allegation:

Whilst registered as a Radiographer with the Health and Care Professions Council, you:
1. On 9 June 2017, while employed by Ramsey Health Care UK did not undertake the correct checks to ensure the identity of Patient B, and:
a. Incorrectly performed an X Ray on Patient B, using the patient identification details for Patient A;
b. Incorrectly matched Patient B’s X-ray images with Patient A;
c. Exposed Patient B to unnecessary radiation;
2. On 22 May 2017, while employed by Ramsey Health Care UK, did not report an error following an inpatient examination that had occurred on Radiological Information System, to the appropriate person/s.
3. On 12 June 2017, while employed by Ramsey Health Care UK, examined Patient C and:
a. Labelled and stored patient images under Patient D’s identification details;
b. Did not ensure that Patient C’s diagnostic images were available for clinical review;
c. Did not report your error to the appropriate person(s).
4. On 11 July 2017, while employed by Ramsey Health Care UK, deleted patient theatre images without a clinical justification for doing so.
5. On 26 July 2018, attempted to access Ramsey Health Care UK’s system after you had been dismissed by them.
6. On 3 October 2018, attempted to access Ramsey Health Care UK’s system after you had been dismissed by them.
7. The matters as set out in paragraphs 1 to 6 constitutes misconduct and/or lack of competence.
8. By reason of your misconduct and/or lack of competence, your fitness to practise is impaired.

6. By letters dated 16 April 2020 and 26 August 2020 the HCPC gave notice to the Registrant that it proposed to seek permission to amend the allegation at the final hearing.

7. The HCPC instructed solicitors, Kingsley Napley, to complete further investigations and prepare the case for a substantive hearing. Those solicitors conducted witness interviews, obtained statements and prepared a bundle of documentary evidence.

8. On 14 August 2020 the HCPC notified the Registrant’s representative that they considered this matter potentially suitable for disposal by consent. On 26 August 2020 the Registrant indicated that she would consider a consensual outcome. On 3 September 2020 the HCPC requested that the Registrant and her representative review the HCPC’s bundle and make submissions with a view to a disposal of the case by consent.

9. Those submissions were received by the HCPC on 9 November 2020, together with a reflective piece and references on behalf of the Registrant’s current employer, BMI Healthcare for whom she has been working at Winterbourne Hospital, in Dorchester (‘Winterbourne Hospital’).

10. The HCPC sought written confirmation that the Registrant admits that her fitness to practise is impaired and this was provided on 16 November 2020. On 9 December 2020 the HCPC proposed a Conditions of Practice Order in the place of a Caution which the Registrant had put forward in her submissions. However, on 16 December 2020 the Registrant confirmed to the HCPC that she was willing and able to comply with proposed Conditions of Practice. She confirmed that her manager is willing to act as the Workplace Supervisor, as contemplated by the proposed Conditions of Practice.

11. The HCPC received a signed Order from the Registrant on 23 December 2020, which was provided in revised form today in order to reflect the amended allegation proposed by the HCPC.

Amendment of the Allegation
12. Ms Sheridan applied to this Panel to amend the allegation in the form set out on page 2 of this decision. She explained the reasons for the amendments, which were to reflect the substance of the investigation and, where necessary, to clarify aspects of the allegation. Mr Higgs submitted that the amendments would be appropriate because the consensual disposal of the case had been prepared by the Registrant on the basis of the amended allegation proposed. The Legal Assessor advised that the amendments sought were appropriate in the circumstances.

Decision
13. The documents placed before the Panel include the bundle prepared for the final hearing and documents relevant to the present application.

14. The HCPC set out its application in a written Skeleton Argument, as supplemented by submissions made by Ms Sheridan. She submitted that the case was suitable for disposal by consent. Mr Higgs made submissions to the same effect.

15. The Panel has considered the evidence placed before it, has taken into account the submissions of Ms Sheridan and Mr Higgs and has directed itself in accordance with the advice given by the Legal Assessor.

16. The principles and policies for disposal of a case by consent are set out in a Practice Note of the HCPTS, Disposal of Cases by Consent. In summary, a panel should not agree to a case being disposed of by consent unless it is satisfied that:
• the appropriate level of public protection is being secured; and
• doing so would not be detrimental to the wider public interest.

17. A disposal by consent also requires that a registrant is willing to admit both the substance of the allegation and that his or her fitness to practise is impaired, and that the remedial action proposed is consistent with the expected outcome if the case were to proceed to a contested hearing.

18. In summary, the factual allegations against the Registrant were that in two instances (paragraphs 1 and 3 of the amended allegation), the Registrant made errors with reference to her work with patients. In the one case on 9 June 2017 (paragraph 1), that she did not carry out the identification checks required by the applicable written policies, which resulted in her x-raying the wrong patient, exposed him to an unnecessary x-ray and incorrectly matched the images taken to the other patient. In the second case, on 12 June 2017 it is alleged that she filed the images taken by her of one patient against the electronic record for another patient and did not report what had occurred as she should have done both on the electronic system used and to a supervisor.

19. The third event alleged to have taken place during her employment by Ramsay Health Care UK was that on 22 May 2017 she had failed to report an error following the examination of a patient (paragraph 2). The context of that matter was that the error was made by another radiographer and that the Registrant ought to have reported this in her role as Radiation Protection Supervisor. It is also alleged (paragraph 4) that the Registrant inappropriately deleted x-ray images from the department’s records on 11 July 2017, alternatively that she did so without following the appropriate procedure.

20. The allegations also address two attempts that were made by the Registrant to access the computer system of Ramsay Health Care UK after the termination of her employment (paragraphs 5 and 6).

21. In her written submissions the Registrant admits the allegation as amended and, with respect to paragraph 4 she did so by reference to the alternative case that she deleted the images without following the appropriate procedure. In essence, she failed to report her actions which had been based on deleting images in order to present an accurate record of patient x-rays.

22. The Registrant has admitted in her submissions that her fitness to practise is impaired and she has consented to a Conditions of Practice Order in the terms she has signed.

23. The Panel has taken particular account of the written submissions for the Registrant, the reflective piece provided and the short testimonials provided by the Clinical Services Manager with whom the Registrant has been working as a Radiographer since April 2018 in her employment by BMI Healthcare at Winterbourne Hospital.

24. The Registrant has shown substantial insight into, and reflection on, her admitted professional shortcomings. The Registrant has cut down on the number of hours she works and she no longer has the role of Radiation Protection Supervisor or any similar responsibilities. These two factors also demonstrate insight.

25. The testimonials from her Clinical Services Manager state that the Registrant was open about her fitness to practise issues when she was interviewed in April 2018. Those testimonials demonstrate that the Registrant has since proved to be hard-working, very reliable and conscientious. Her standard of work is excellent as is her work ethic and she ‘brings invaluable experience to the team’. In her submissions she accepted that she should not have attempted to access the computer system of her former employer and should have written to ask for copies of the documents relevant to fitness to practise concerns about her.

26. The Panel considers that the Conditions of Practice proposed are proportionate and workable and reflect the expected outcome if the case were to have proceeded to a final hearing. The Registrant has engaged fully with the fitness to practise process and she is likely to comply with those conditions, supported by her manager who has agreed to act as the Workplace Supervisor. An order of 12 months is also the appropriate period for the conditions to operate.

27. The Panel considered that the Registrant’s admissions and the putting in place of the Conditions of Practice Order proposed would not only protect members of the public, but also maintain public confidence in the profession and declare and uphold professional standards. In the circumstances, there is no reason why the disposal of the case on the terms proposed would be contrary to the wider public interest.

28. Therefore, for the reasons set out above the Panel has decided to approve the disposal of the case by consent on the terms proposed.

Order

That the Registrar be directed to annotate the Register to show that for a period of one year from the date that this Order comes into effect, 25 January 2021 (the Operative Date), Diane L Lucas must comply with the following conditions of practice:

1. You must place yourself and remain under the supervision of a workplace supervisor registered by the HCPC or other appropriate statutory regulator and supply details of your supervisor to the HCPC within one month of the Operative Date. You must attend upon that supervisor as required and follow their advice and recommendations for the period of one year from the Operative Date.
2. You must work with your supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice:
a. Adequate record keeping;
b. Reporting errors; and
c. Data protection
3. Within three months of the Operative Date you must forward a copy of your Personal Development Plan to the HCPC.
4. You must meet with your supervisor on a monthly basis to consider your progress towards achieving the aims set out in your Personal Development Plan.
5. You must allow you supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan.
6. You must maintain a reflective practice profile addressing challenging cases and areas of improvement; and must provide a copy of that profile to the HCPC every three months. The first profile to be provided within three months of the Operative Date.
7. Within three months of the Operative Date you must:
a. satisfactorily complete a training course on Information Governance; and
b. forward a copy of your results to the HCPC.

Notes

This order will be reviewed again before its expiry on 25 January 2022.

Hearing History

History of Hearings for Mrs Diane L Lucas

Date Panel Hearing type Outcomes / Status
25/01/2021 Conduct and Competence Committee Consent Order Hearing Conditions of Practice