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Allegations against the Registrant are as follows:
As a registered Biomedical Scientist (BS16884) your fitness to practice is impaired by reason of misconduct and/or lack of competence in that:
1. On or around 27 March 2018 you did not notify a positive Troponin test result for Service User 1 to their GP.
2. On or around 12 May 2018 you authorised and/or reported incorrect full blood count results for service user 2, without;
a. conducting further investigations in light of the low results; and/or
b. notifying the low results to the relevant clinician(s) by telephone and/or otherwise seeking advice.
3. On or around 16 and/or 21 May 2018, you reported Service User 3’s specimens as being out of date, without:
i) reporting the potassium result(s) to the relevant clinician(s); and/or
ii) checking the age and time the specimen(s) were taken and/or separated; and/or
iii) observing the specimen(s) to check for haemolysis; and/or
iv) adequately recording your reasons for rejecting the potassium results.
4. On or around 13 November 2018, following the discovery of an error in the calibration of a biochemistry analyser, you did not:
a. ensure that the analyser was taken out of service until the calibration error had been rectified; and/or
b. adequately oversee the process of reviewing and/or re-analysing and/or reporting the samples that had been affected by the calibration error
5. Between January and December 2018, you did not:
a. process specimens on your outstanding work lists in a timely and/or adequate manner; and/or
b. maintain adequate telephone logs; and/or
c. report incidents in a timely manner; and/or
d. ensure adequate internal quality controls and/or that laboratory equipment was adequately maintained; and/or
e. review and/or appropriately act upon external quality controls
6. The matters set out in paragraphs 1 to 5 above constitute misconduct and/or lack of competence.
7. By reason of your misconduct and/or lack of competence your fitness to practice is impaired.
1. Due to the current Covid-19 pandemic and the Government’s advice in response to it, the Panel met to consider this matter via remote conferencing facilities.
2. Notice of this Hearing was sent by email on 18 August 2021 to the Registrant’s registered email address, more than 28 days before the date of Hearing. The Panel was satisfied that Notice of Hearing had been served in compliance with the HCPC Conduct and Competence Committee (Procedure) Rules 2003, (“the Rules”).
Proceeding in absence of the Registrant
3. Mr D’Alton, on behalf of the HCPC, invited the Panel to proceed in the absence of the Registrant. He referred the Panel to the guidance contained in the HCPTS Practice Note on Proceeding in the Absence of the Registrant and drew the Panel’s attention to an email dated 29 September 2021 from the Registrant’s solicitors which stated:
“I confirm that neither [the Registrant] nor I will be attending the hearing on 1 October. I look forward to receiving confirmation that the Panel has approved the Voluntary Removal Agreement, that [the Registrant’s] name has been removed from the Register and that the matter is at an end.”
4. Mr D’Alton submitted that it was appropriate for the Panel to exercise its discretion to proceed on the basis that the Registrant had chosen not to attend the hearing and had waived the right to appear. He pointed out that there had been no request from the Registrant for an adjournment, he had set out his detailed account of matters for the benefit of the Panel, which the Panel could take into consideration if it proceeded in his absence. Mr D’Alton submitted that the public interest in expeditious disposal of the matter outweighed any disadvantage to the Registrant in proceeding in his absence.
5. The Panel heard and accepted the advice of the Legal Assessor who reminded it of the guidance provided in the cases of R v Jones  UKHL5, Adeogba v the General Medical Council  EWCA Civ 162 and Davies v HCPC  EWHC 1593 (Admin).
6. The Panel recognised that the discretion to proceed in the absence of a Registrant is one which must be exercised with the utmost care and caution and that its decision should be guided by the overarching objective to protect the public.
7. In reaching its decision, the Panel had regard to the fact that the purpose of today’s remote hearing is to consider the Voluntary Removal Agreement (VRA) made between the Parties and signed by the Registrant on 25 September 2021. The Panel had careful regard to the nature and circumstances of the Registrant’s behaviour in absenting himself. It was clear to the Panel that the Registrant is aware of today’s remote hearing, has chosen not to attend, has not requested an adjournment and is content for the hearing to proceed in his absence. In these circumstances, the Panel concluded that the Registrant has voluntarily absented himself and waived his right to be present.
8. The Panel balanced the public interest in the timely disposal of the Allegation with any disadvantage to the Registrant should the hearing proceed in his absence. It had no reason to believe that, if it were to adjourn the hearing, the Registrant would attend on the next occasion.
9. For the reasons set out above, the Panel concluded that it would be fair and in the interests of justice to proceed in the absence of the Registrant.
Voluntary Removal Agreement
10. The Panel had careful regard to the VRA between the Registrant and the HCPC. The agreement is to the effect that the HCPC will not take any further action against the Registrant in relation to this matter on the understanding that he will remove himself from the Register, cease from practising as a Biomedical Scientist and not attempt to re-join the register. If the Registrant were to apply to come back on to the Register, his application would be treated in the same way as someone who had been struck off.
11. The Registrant is the subject of an allegation (set out in Schedule A to the agreement) to the effect that his fitness to practise is impaired due to misconduct and/or lack of competence regarding a failure to follow Standard Operating Procedures expected within the laboratory.
12. Under the terms of the VRA, the HCPC is obliged, at this 1 October 2021 VRA Hearing, to apply to withdraw the Allegation.
13. Under the terms of the VRA, the Registrant is obliged:
i. On or before 1 October 2021, to execute a letter in the form set out in Schedule B to the agreement, requesting the Registrar to remove his name from the HCPC Register, and confirming both his admission of the Allegation and the HCPC’s withdrawal of the Allegation to enable his removal from the Register.
ii. From 1 October 2021, and absent a successful application to be restored to the Register, to cease and desist from practise as a Biomedical Scientist, to cease and desist from the use of any protected title in relation to the profession or any title which implies that the Registrant is registered in the Register, and not at any time before five years from 1 October 2021 to seek restoration to the Register.
14. The Registrant is a registered Biomedical Scientist.
15. On 20 December 2018, the HCPC received a fitness to practise referral from the Laboratory Manager at Oban General Hospital, NHS Highland (‘the Complainant’) raising numerous concerns in relation to the Registrant. At the time of the referral, the Registrant had been working as Biochemistry Section Lead for ten years.
16. The referral form documents a number of incidents in which the Registrant had been involved whilst working in the Haematology Unit in 2018:
17. Incident 1: On 27 March 2018 the Registrant allegedly did not provide a positive Troponin test result to the patient’s GP by telephone, as required by internal protocol.
18. Incident 2: On 12 May 2018 the Registrant performed a full blood count in Haematology. The results were not compatible with life and showed up with warning flags. The sample was processed twice by the Registrant, both as a partial aspirate, showing the same result. The Registrant purportedly did not understand the reason behind the error and made no phone calls to alert the relevant clinician(s) of the low results or to seek advice. A similar error could produce more believable but incorrect low results that could lead to inappropriate treatment such as transfusion.
19. Incident 3: On 16 and 21 May 2018 the Registrant allegedly found that potassium levels were high in some samples and assumed that they were old and deleted the results. The Patient had chronic heart failure. A high potassium level, as the one found by the Registrant, could put a patient’s life at risk. The patient’s GP telephoned the Registrant as she was concerned that not all precautions had been taken with the biochemistry samples; the GP wanted the Registrant to find the results and investigate what was written on the forms and the ages of the samples. The Registrant made no telephone note of this conversation and did not record any incident. The GP made a third attempt to have another sample tested, marking these as urgent. The results were not complete or reported by the Registrant that day.
20. Incident 4: Relates to a number of outstanding work sheets, which showed that the Registrant had not analysed samples in a timely manner and/or discarded them, which may have resulted in delays in patient care.
21. The referral form mentions a further incident, which occurred on 13 November 2018 and appears to have been categorised as a serious incident requiring a Significant Adverse Event Review (‘SAER’). The incident involved an error in the calibration of a biochemistry analyser, whereby during a short period it was producing inaccurate falsely elevated ALT results. During the time that the analyser was not correctly calibrated, the analyser should have been taken out service, however, calibrations and internal quality controls were run at the same time as patient samples. Locum staff, one of whom was new to the department and not competency assessed, had requested the Registrant for his support to oversee the process of looking back/repeating analysis and over-writing, however the Registrant, who himself was subject to a capability process at the time, is said to have provided insufficient oversight during the process. The Registrant, moreover, did not initially report the incident as would have been expected according to internal procedures. Seven patient results were affected and reported incorrectly. Two of the patients were receiving chemotherapy at the time and their treatments were altered / impacted as a result of the incorrect results. There appears to have been no harm or consequences caused to the other five patients as a result of these errors.
22. A capability meeting appears to have been held on 25 July 2018, where a Capability Development Plan was formulated. Four more areas of improvement were identified:
i) The water system supplying the biochemistry analysers were overdue for replacement. The results were being affected. There was no procedure or record of this process of filter change. No planned preventative maintenance.
ii) There were inconsistencies in the preparation and storage of quality control material and calibration material.
iii) Locum staff were working in the department without appropriate training and sign off.
iv) The external quality control was not being analysed and reported within the required timescales.
23. Two reviews of this plan were subsequently undertaken in October and November 2018. However, the employer was of the view that the Registrant was not making progress.
24. On 06 December 2018, a meeting appears to have taken place to consider the Capability Improvement Plan. Due to the serious nature of the concerns and the potential risk to patient care, the Registrant was informed that he would be removed from his role as Section Head for Biochemistry to more restrictive duties in order to mitigate any potential risks. The Registrant decided to leave the meeting and declined to return. The HCPC is not in receipt of the minutes of this meeting but has been provided with a letter that was sent to the Registrant following the meeting.
25. The Registrant resigned from his role at Oban General Hospital, NHS Highland on 7 June 2019.
26. The HCPC attempted to obtain further information in relation to the Registrant’s health, however, the Registrant did not consent to his employer releasing his Occupational Health reports to the HCPC.
27. The Registrant emailed the HCPC on 27 March 2019 advising that he had retired and had no intention of returning to work in the NHS.
28. In a letter dated 26 November 2020, the Registrant’s representative informed the HCPC that the Registrant was retired, had no intention of returning to practice and that “he does not oppose the case as referred to the CCC and wishes to avoid unnecessary process. He wishes to have the matter disposed of by way of a Voluntary Removal Agreement as provided for in Practice Note – Disposal of Cases by Consent”.
29. Following the Investigating Committee decision, the Registrant, via his representatives, requested voluntary removal from the Register.
30. On 11 December 2020, the Registrant, via his representatives, sent the HCPC documents pursuant to his request for removal. He accepted the failings alleged, stating that his failings occurred against a backdrop of health issues which impacted on his competence.
31. On 1 April 2021, the Registrant, via his representatives, sent the HCPC a letter dated 15 March 2021 from the Registrant’s GP. This stated that the Registrant: “...received 4 sick lines from the practice dating from 27 June 2018 – 08 March 2019. It is difficult for me to comment on how this may have affected his judgement. It would be difficult to imagine that the aforementioned issues would not have made his work more difficult.”
32. The Registrant has returned to the HCPC the signed VRA.
33. Mr D’Alton adopted the contents of the HCPC’s written skeleton argument in support of the VRA. He submitted that, in all the circumstances, voluntary removal from the Register would be an appropriate means of resolving the current matter.
34. Mr D’Alton reminded the Panel that is clear from the correspondence that the Registrant has no desire to practise as a Biomedical Scientist in the future. Further, he has accepted the Allegation, including that his fitness to practise is impaired. He has now retired.
35. Mr D’Alton said the Registrant has been provided with detailed information about the consent process and the effect of voluntary removal from the Register, should the application be granted. He submitted that the Registrant has had time to review this information and query its implications.
36. Mr D’Alton submitted that, should voluntary removal be permitted in this case, public protection would be ensured as the agreement is equivalent, in effect, to a Striking off Order. The Registrant would no longer be registered as a Biomedical Scientist. He has confirmed that he does not intend to practise as a Biomedical Scientist in the future. As a consequence, the public would be adequately protected from any potential risk posed by the Registrant’s practise.
37. In addition, Mr D’Alton submitted that the wider public interest would not be put at risk should this matter be disposed of by way of consent. He said the public would not be concerned, nor would public confidence in the profession be put at risk, should the Panel grant Voluntary Removal in circumstances where the Registrant has accepted the allegations made and accepts that his fitness to practise is impaired.
38. In conclusion, Mr D’Alton submitted that, in all the circumstances, it is appropriate to dispose of this matter in accordance with the terms of the VRA. He said it is the HCPC’s view that disposal by consent on these terms is a suitable, pragmatic and expeditious way of dealing with this matter.
39. The Panel gave careful consideration to all the material before it, including the main evidence bundle, the HCPC Skeleton Argument in support of the VRA, the correspondence between the Registrant and the HCPC on the subject of VRA and the signed VRA itself. It also had regard to Mr D’Alton’s oral submissions to the Panel today.
40. The Panel accepted the advice of the Legal Assessor and had careful regard to the content of the HCPTS Practice Note on Disposal of Cases by Consent. The Panel had particular regard to the following guidance contained in the Practice Note:
- “In cases where the HCPC is satisfied that it would be adequately protecting the public if the Registrant was permitted to resign from the Register it may enter into a Voluntary Removal Agreement allowing the registrant to do so, but on similar terms to those which would apply if the registrant had been struck off.”
41. The Panel noted from the documents that the Investigating Committee had concluded that there was a case to answer, and that the Registrant has admitted the Allegation as part of the VRA. The Registrant has also signed a Declaration that there is no other matter of which the Registrant is aware which might give rise to any other allegation.
42. In light of the Registrant’s correspondence with the HCPC, the Panel is satisfied that the Registrant fully understands the effect of the VRA and that the agreement represents a considered and informed decision on the part of the Registrant.
43. The Panel was mindful of the overarching objective of protection of the public and the public interest. It considered whether there were any factors that would make it undesirable to allow the Allegation to be concluded on the consensual basis set out in the VRA.
44. The Panel was satisfied that the public would be adequately protected if the Allegation is withdrawn and the Registrant is permitted to have his name removed from the Register and leave the Biomedical Science profession in accordance with the terms of the VRA. The Panel was also satisfied that there are no overriding public interest factors that would require this matter to go to a full substantive hearing. It was aware that if the Registrant sought to return to the HCPC Register at any time in the future, his application would be treated as if he had been struck off as a result of the Allegation.
45. For the reasons set out above, the Panel is satisfied that Voluntary Removal is appropriate and proportionate in this case, and is jointly in the interests of the public, the HCPC and the Registrant.
46. Accordingly, the Panel approves the VRA including the withdrawal of the Allegation and the discontinuance of the proceedings.
Order: The Registrar is directed to remove the name of Mr Neil Goulding from the HCPC Register with immediate effect.
No notes available
History of Hearings for Neil Goulding
|Date||Panel||Hearing type||Outcomes / Status|
|01/10/2021||Conduct and Competence Committee||Voluntary Removal Agreement||Voluntary Removal agreed|