Mrs Louise J Middleton

Profession: Dietitian

Registration Number: DT6126

Hearing Type: Review Hearing

Date and Time of hearing: 10:00 13/01/2021 End: 17:00 13/01/2021

Location: Virtual hearing - Video conference

Panel: Conduct and Competence Committee
Outcome: Conditions of Practice

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Allegation

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

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

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

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

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

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

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

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

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

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

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

i. [Not proven] 

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

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

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

ii. [Not proven] 

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

iv. Identified 4 feeds a day as being adequate  

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

(d) [Not proven] 

4. In relation to Case 4:  

(a) [Not proven] 

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

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

i. did not plot the growth chart correctly.  

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

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

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

a. timing of feeds, and/or  

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

c. sucking ability, and/or  

d. feed losses  

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

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

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

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

(a) did not follow the medical management plan;  

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

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

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

ii. [Not proven] 

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

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

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

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

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

(e) [Not proven] 

(f) [Not proven] 

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

(h) [Withdrawn by HCPC] 

6. In respect of Case 6, you:  

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

(b) [Not proven] 

(c) [Not proven] 

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

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

7. In respect of Case 7, you:  

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

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

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

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

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

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

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

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

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

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

(b) [Not proven] 

(c) [Not proven] 

i. [Not proven]

ii. [Not proven]

iii. [Not proven] 

iv. [Not proven]

v. [Not proven] 

10. In respect to Case 9, you:  

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

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

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

11. In respect of Case 10, you:  

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

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

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

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

ii. eating environment; and/or

iii. number of children in the household;  

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

12. [Not proven] 

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

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

 

 

Finding

Background


1.    The Registrant commenced employment as a Band 7 Dietitian at Kirkcaldy and Levenmouth Community Health Partnership in December 2009. On 19 January 2019, a panel of the Conduct and Competence Committee found that the Registrant’s fitness to practise was impaired by reason of her lack of competence, having found a breadth of failings across a wide range of skills expected of a Band 7 dietitian and in relation to ten patients as set out in the allegation above. These occurred in the course of a twelve week return to work plan following a period of sick leave from May 2010 until February 2011. Prior to the period of sick leave, the Registrant had been under supervision due to perceived concerns about her ability to carry out the duties of a Band 7 Dietitian.


2.    On 19 January 2018 the Panel imposed a twenty-four month Conditions of Practice Order, having found that the Registrant had the required level of insight and understanding to indicate that a Conditions of Practice Order would be adhered to and that such an order would minimise the risk of future harm to patients.


3.    At the review hearing on 15 January 2020, the Registrant informed the Panel that she had been unable to obtain employment as a Dietitian because her prospective employers found the conditions to be too onerous to be workable. The reviewing panel therefore found that there was no evidence before it that the Registrant had complied with the conditions and therefore remedied the lack of competence found proved. The reviewing panel therefore found that the Registrant’s fitness to practise remained impaired. It therefore extended the Conditions of Practice order for a further period of 12 months in order to give the Registrant a further opportunity to seek employment and to comply with the conditions.
Decision


4.    In reaching its decision at this review, the Panel has considered all the information before it, together with the submissions of Ms Sampson and Mr Toms, the evidence of the Registrant and the documentary material she had provided. It has exercised the principle of proportionality at all times. It has accepted the advice of the Legal Assessor.


5.    Ms Sampson on behalf of the HCPC submitted that the Registrant’s fitness to practise remains impaired. She said that although the HCPC accepted that the Registrant had made efforts to obtain employment, she had been thwarted by the effects of the Covid-19 pandemic which had limited employment opportunities as a Dietitian. Her submission was that despite the significant efforts the Registrant had made to maintain her skills and knowledge she had been unable to demonstrate that she could return to practice unrestricted.


6.    Ms Sampson’s submission was that the current conditions of practice order should remain in place for a further 12 months to afford the Registrant the opportunity to demonstrate that she could engage in safe practice as a Dietitian.


7.    The Registrant gave evidence. She reiterated the matters set out in the documents she had placed before the Panel in regard to her efforts to obtain employment as a Dietitian and the difficulties that she had encountered. She expanded upon what she had said about her activities in the public health field and the practical experience she had gained, with particular regard to record-keeping, time-management and liaising with colleagues.


8.    Mr Toms on behalf of the Registrant referred to the matters described by the Registrant in the bundle she has placed before the Panel. He observed that she had been unable to obtain employment as a Dietitian in the light of the restrictive nature of the current conditions and also the effects of the Covid-19 pandemic. He made particular reference to what the Registrant has described as the efforts she has made to comply with the conditions despite being unable to obtain clinical employment. In this context he submitted that the Registrant had complied with the conditions relating to the three matters to which she made particular reference; namely, record-keeping, time-management and liaising with colleagues. He submitted that although not in a clinical setting this was indicative of competence in these fields.


9.    Mr Toms submitted that the Registrant’s fitness to practise is no longer impaired. He emphasised that, as she had said in her evidence, she had no intention in the future to practise in a clinical setting and that there was therefore no risk of repetition. However he said that if the Panel were to find that the Registrant’s fitness to practise remains impaired the appropriate sanction would be that of a Caution or an amendment to the Conditions of Practice order.


The Panel’s Findings


Impairment


10. The Panel has recognised the difficulties facing the Registrant since the last review, in obtaining employment as a Dietitian. It is impressed by the efforts that the Registrant has made by way of engaging in course material and reading in order to maintain her knowledge. Although she has demonstrated that she has achieved progress in record-keeping, time-management and liaising with colleagues, this has only been in relation to non-clinical matters. 


11. In summary there is nothing before the Panel to indicate compliance with the conditions imposed albeit this has not been due to any lack of endeavour by the Registrant. The Registrant has not been able to demonstrate that she can practise safely as a Dietitian. In these circumstances, although the Registrant has demonstrated significant insight there remains a risk of repetition. The Panel has therefore concluded that the Registrant’s fitness to practise remains impaired in terms of the personal component. In regard to the public component the Panel has concluded that the public would be concerned if the Registrant were able to practise unrestricted despite being unable to demonstrate that she could do so safely. Public confidence in the profession would be undermined if a finding of impairment were not made. 


Sanction


12. In reaching its decision the Panel considered all the information and evidence before it together with the submissions of Ms Sampson and Mr Toms. It had in mind the HCPC’s Sanctions Policy. It accepted the advice of the Legal Assessor.


13. The Panel first considered a Caution order but concluded that this would be insufficient to protect the public and to address public interest concerns.


14. The Panel then considered a Conditions of Practice order and concluded that the current Conditions of Practice order remains appropriate, proportionate and sufficient to protect the public and to address public interest concerns.  Further, it has determined that a further period of 12 months will afford the Registrant the opportunity to obtain employment as a Dietitian and to demonstrate compliance with the Conditions.

 
15. The Panel did consider imposing a Suspension Order but concluded that this would be disproportionate in the current circumstances. The lack of competence found proved is remediable and the Registrant has shown her willingness to comply with the conditions and she has shown a commitment to her profession

Order

ORDER: The Registrar is directed to extend the Conditions of Practice Order against the registration of Louise Middleton for a further period of 12 months on the expiry of the existing Order.


1.    You must inform the HCPC within 14 days of your start date if you take up any employment or other engagement as a Dietitian in a clinical role which includes the giving of advice or treatment to individuals.


2.    While working as a Dietitian, either in an employed or voluntary capacity, you must promptly place yourself and remain under the indirect supervision of a workplace supervisor at Band 6 or higher, who must be registered as a Dietitian by the HCPC, and you must supply full details of your supervisor to the HCPC within 14 days of their appointment. You must attend upon that supervisor as required and follow their advice and recommendations.


3.    You must work with your workplace supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice:


(i)           Record Keeping;
(ii)          Time Management;
(iii)        Clinical practice;
(iv)        Communication with dietetic, nursing and medical colleagues.


4.    Within three months of the Operative Date you must forward a copy of your Personal Development Plan to the HCPC.


5.    You must meet with your workplace supervisor on a monthly basis to consider your progress towards achieving the aims set out in your Personal Development Plan.


6.    You must allow your workplace supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan.


7.    You must provide a detailed report approved by your supervisor commenting on your practice as a Dietitian prior to every hearing to review this Order. That report must cover, at least, the follow matters:


(i)           Record Keeping;
(ii)          Time Management;
(iii)        Clinical practice;
(iv)        Communication with dietetic, nursing and medical colleagues.


8.    You must allow your supervisor to contact the HCPC to report any concerns with your practice as a Dietitian.


9.    You must comply with all requirements of the HCPC Registrations department regarding your return to practice.


10. You must promptly inform the HCPC if you cease to be employed as a Dietitian by any employer.


11. You must promptly inform the HCPC of any disciplinary proceedings taken against you by your employer.


12. You must inform the following parties that your registration is subject to these conditions:


A.   Any organisation or person employing or contracting with you to undertake professional work as a Dietitian, at the time of application;
B.   Any agency you are registered with or apply to be registered with as a Dietitian (at the time of application);
C.   Any prospective employer, seeking to employ you as a Dietitian, (at the time of your application).

Notes

This Order will be reviewed again before its expiry.

Hearing History

History of Hearings for Mrs Louise J Middleton

Date Panel Hearing type Outcomes / Status
13/01/2021 Conduct and Competence Committee Review Hearing Conditions of Practice
15/01/2020 Conduct and Competence Committee Review Hearing Conditions of Practice
15/01/2018 Conduct and Competence Committee Final Hearing Conditions of Practice