Mrs Malgorzata Kochanek

Preliminary Matters

Service of Notice of Hearing

1. On the 1 October 2021 the HCPC served Notice of Hearing on the Registrant. The Registrant attended the Hearing via video-link.

Decision on conducting the hearing in Private

2. Ms Khorassani, who appeared for the HCPC, invited the Panel to hear parts of the hearing in private because there were areas of information which were sensitive and related to the Registrant’s health.

3. Ms Kochanek expressed her agreement with this approach.

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

5. The Panel bore in mind the principle of open justice and weighed against it the interests of the Registrant and the protection of her private life. It determined that it should hear those parts of the case which touched on the Registrant’s private life in private.

Background

6. The Registrant is a Biomedical Scientist who was employed by Medical Diagnosis Limited ("the Company"), a private clinical pathology laboratory, between December 2007 and July 2018.

7. Between 29-31 March 2021, a Panel of the Conduct and Competence Committee considered an Allegation that the Registrant’s fitness to practise was impaired in relation to three incidents which occurred between January 2018 and June 2018, involving the Registrant’s failure to record and report laboratory results accurately and in one instance amending a result from a correct to an incorrect recording.

8. Following the first incident in January 2018, the Registrant offered a written apology by email to the clinic to whom the incorrect laboratory results had been conveyed.

9. After the second incident in March 2018, the Registrant attended a meeting to discuss matters and offered a written apology to the Company.

10. After the third incident in June 2018, the Registrant was suspended and an investigation and disciplinary process was undertaken. She was dismissed in July 2018. On this occasion, the relevant error was identified by the referring clinic, after the patient in question, had been provided with hormonal treatment based on the erroneous result which had produced an unexpected clinical response.

Substantive Hearing

11. The Registrant did not attend the hearing but indicated in her Response Pro-Forma and Pre-Hearing Information Form dated 2 October 2020 that she admitted all the factual allegations.

12. The panel at the substantive hearing found that each of the mistakes was so serious as to amount to misconduct. In relation to allegation 1a, the Panel found the Registrant’s failure to check her work had led to a transcription error. The consequence of the error was that an inaccurate result had been sent to the clinic which could have been communicated to the patient in question, who would have undoubtedly suffered anxiety in being told that an infection was present.

13. With respect to allegation 1b, the Panel determined that the alteration that the Registrant made to the karyotype test results, from a correct result to an incorrect result, without explanation or rationale, was serious in that it resulted in wrong information being delivered to the referring clinic. It was not possible to infer that the Registrant had, in this instance, made a simple transcription error because the result had been entered correctly by her colleague, and she must deliberately have decided to amend it for no evident reason.

14. With respect to allegation 1c, the panel found that the Registrant's failure to multiply the hormone titre result by the appropriate factor had in fact resulted in a patient receiving incorrect hormonal treatment and resulted in a response that was quadruple that which her treating clinician had anticipated.

15. The panel at the substantive hearing found that the Registrant’s fitness to practise was impaired. The Registrant did not attend the substantive hearing and there was very limited engagement with the regulatory process which meant the panel had limited evidence of insight and remediation. She had not submitted a reflective piece or provided evidence of any specific and relevant targeted professional development.

16. The substantive hearing panel decided that the appropriate and proportionate order was a Suspension Order for a period of 6 months.

17. The Panel considered that any panel conducting a review hearing would be assisted by the following:

• The Registrant's full engagement in the review process and attendance at any hearing;
• The Registrant providing a reflective piece addressing her misconduct;
• The Registrant providing up-to-date information about her continuing professional development; and in particular any targeted professional development and training that addresses the deficiencies in her practice identified by this Panel;
• Evidence of the Registrant seeking to maintain and enhance her skills in a laboratory environment in a capacity that does not require professional registration.

The Hearing

18. The Registrant sent an email on the morning of the Hearing. It included a short reflective piece, a recent appraisal and evidence of courses that she has undertaken as part of her current employment.

19. During the course of the Hearing two further letters were placed before the Panel which the Registrant had written to her previous employer at the time of these incidents.

20. The Registrant gave evidence. The Registrant was asked a number of questions relating to the three incidents. She told the Panel that she had worked as a Biomedical scientist for 20 years, of which 10 were in this country for Medical Diagnosis Ltd and that these incidents were the only incidents in an otherwise unblemished career.

21. The Registrant told the Panel she had been struggling in 2018 and she stated that this impacted on her concentration. She now copes by taking natural remedies and practising yoga. She stated that she had tried to talk about her health difficulties with her former employer but she was not taken seriously.

22. The Registrant relied on her most recent appraisal to support the fact that she is doing well in her current role. At the moment she collects samples and information for DNA analysis (urine, hair, blood). The samples must be in a specific order and must be accurately labelled.

23. The Registrant told the Panel that she also works part-time as a phlebotomist. She has been working for 2 years and eight months for her current employer. She said she would like to go back to work in a pathology laboratory under supervision, in a less senior role. She stated she has considered looking for some voluntary work at Northwick Park Hospital or a laboratory role with her current employer.

24. She stated she would ensure that she did not repeat these types of errors and that she had learnt to prioritise accuracy over speed. She said the last two years had been difficult because of COVID-19. She had completed an online course on managing her health. She stated that she now manages her health difficulties. In terms of preventing future errors she will ensure she implements accuracy over speed and that she “always double checks everything”. She told the Panel that after the mistakes she felt huge shame. In terms of the implications of her mistakes on the public, she acknowledged that accurate reports were the foundation for diagnosis and treatment. The Registrant stated that she would like to go back to work in a laboratory at a lower grade and would wish to work under supervision.

Submissions

25. Ms Khorassani, on behalf of the HCPC, invited the Panel to impose a further Suspension Order for 6 months. She submitted that the Registrant remained impaired. The Registrant had not yet developed the required degree of insight, nor had she taken the necessary remedial steps to reduce the risk of repetition. The Registrant had not completed relevant and targeted CPD.

26. Ms Khorassani questioned whether a Conditions of Practice Order was practical and or workable as the Registrant would need to update her knowledge and find a supervisor who would supervise her in a laboratory role. She reminded the Panel of the serious nature of the errors.

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

28. The Panel was pleased that the Registrant attended the Hearing. The Panel found her to be a credible witness, who feels remorse and shame about the incidents that led to the referral to the Regulator. The Panel was also impressed by the steps which the Registrant has taken to cope with her health and accepts that she has found ways to manage the medical condition which she was finding so difficult to manage at the time of these incidents.

29. The Panel notes that these incidents were within a relatively short period in what was an otherwise unblemished career. The Panel noted that the Registrant’s current appraisal was excellent and that she was described as a valuable team member. She is clearly well regarded in her current job. Her current work requires organisation and accuracy but is not based in a laboratory and appears to be largely administrative.

30. The Panel noted that the reflective piece provided by the Registrant was superficial. It found that the Registrant has only just begun to understand the implications of her mistakes and to engage in the regulatory process. The Registrant does not appear to have done any real research into how she might return to work in a laboratory safely, nor has she undertaken targeted courses which she will need to make the transition back to laboratory work.

31. In summary, the Panel has concluded that the Registrant’s fitness to practise remains impaired. In coming to this conclusion, the Panel found that these were serious errors. One of the errors could have resulted in a patient suffering significant and needless anxiety and one of the errors resulted in a patient receiving inappropriate treatment based the Registrant’s error. The Panel could not be satisfied that the Registrant fully appreciated the gravity of the errors.

32. The Panel found that the Registrant is developing insight but does not have full insight. In addition, she has only just begun to engage with the HCPC and in the regulatory process. She has not understood the full impact of her behaviour on the public and on the profession and has not undertaken a targeted programme of relevant professional development to address the deficiencies previously identified.

33. The Panel therefore determined that a restriction on the Registrant’s ability to practise remains necessary in order to protect the public and also to maintain public confidence in the profession of Biomedical Science and in the HCPC as its Regulator.

34. Having determined that the Registrant’s fitness to practise remains impaired, the Panel next considered the appropriate sanction to impose. The Panel had regard to the Sanctions Policy published by the HCPC and to the need to act proportionately.

35. The Panel concluded that a Caution Order would not be sufficient. Such an outcome would permit the Registrant to return to unrestricted practice and would not meet the serious nature of the misconduct found, nor would it protect the public from repetition.

36. The Panel next had regard to the imposition of a Conditions of Practice Order having regard to the facts and the impairment identified, the Panel found that it could not formulate conditions of practice which would be workable, enforceable or verifiable and that which would adequately protect the public. The Panel reached this conclusion because the Registrant has not identified an employer within a laboratory who is willing to supervise her and she has not begun to do targeted CPD and/or education.

37. Accordingly, the Panel decided that it was proportionate to impose a further suspension order for a period of 6 months. Such an order would be proportionate and fair to the Registrant whilst providing protection to the public and upholding the public interest. The Panel reiterate the importance of providing the following information for the next review Panel:-

• The Registrant’s attendance at a future hearing;
• References, particularly from an employer or potential employer, who attests to the Registrant’s work;
• Evidence of targeted CPD to address the deficiencies previously identified, which will assist the Registrant should she return to work in a laboratory role;
• A fuller reflective statement explaining what the Registrant has learned from the incidents and the steps she has taken to avoid a repetition.

ORDER: The Registrar is directed to suspend the registration of Ms Malgorzata Kochanek for a further period of 6 months on the expiry of the existing order.

The Order imposed today will apply from 28 October 2021.

History of Hearings for Mrs Malgorzata Kochanek