Holly Tetlow

Profession: Occupational therapist

Registration Number: OT76472

Interim Order: Imposed on 16 Feb 2022

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 10/02/2022 End: 17:00 17/02/2022

Location: Virtual via video conference

Panel: Conduct and Competence Committee
Outcome: Suspended

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Allegation

The allegation against you is as follows:

 

As a registered Occupational Therapist (OT76472) your fitness to practise is impaired by reason of your misconduct and/or lack of competence. In that;

 

1. Between 12 July 2018 and 26 October 2018, in relation to Patient A, you;

  • a) Did not fully assess and/or document your assessment of Patient A’s toileting requirements
  • b) Did not provide Patient A with the appropriate equipment for discharge home

 

2. Between 14 June 2018 and 27 July 2018, in relation to Patient B, you;

  • a) Did not complete follow up actions until prompted in supervision
  • b) Did not maintain adequate records
  • c) Did not demonstrate adequate clinical reasoning

 

3. Between 20 July 2018 and 3 October 2018, in relation to Patient C, you;

  • a) Did not maintain adequate records
  • b) Did not demonstrate adequate clinical reasoning
  • c) Did not complete follow up actions until prompted in supervision

 

4. Between 20 July 2018 and 3 October 2018, in relation to Patient D, you;

  • a) Did not maintain adequate records
  • b) Did not demonstrate adequate clinical reasoning
  • c) Did not complete follow up actions until prompted in supervision

 

5. Between 9 October 2018 and 7 November 2018, in relation to Patient E, you;

  • a) Did not maintain adequate records
  • b) Did not effectively communicate with others involved in Patient E’s care and/or Patient E
  • c) Did not complete follow up actions until prompted in supervision
  • d) Were unable to carry out therapeutic interventions without prompting
  • e) Demonstrated a lack of knowledge in the area of moving and handling

 

6. Between 19 October 18 to 14 November 2018, in relation to Patient F, you;

  • a) Did not demonstrate adequate clinical reasoning
  • b) Did not maintain adequate records
  • c) Were unable to carry out therapeutic interventions
  • d) Did not effectively communicate with others involved in Patient F’s care and/or Patient F

 

7. Between 10 November 2018 to 23 November 2018, in relation to Patient G, you

  • a) Did not effectively communicate with others involved in Patient G’s care and/ or Patient G
  • b) Were unable to carry out therapeutic interventions and/or assessments without prompting
  • c) Were unable to complete appropriate discharge planning
  • d) Did not demonstrate adequate clinical reasoning
  • e) Did not maintain adequate records

 

8. Between 24 January 2019 to 18 February 2019, in relation to Patient H, you

  • a) Were unable to carry out therapeutic interventions and/or assessments without prompting
  • b) Did not maintain adequate records
  • c) Did not effectively communicate with others involved in Patient H’s care and/ or Patient H
  • d) Did not demonstrate adequate clinical reasoning

 

9. Between 31 January 2019 to 6 March 2019, in relation to Patient I, you

  • a) Were unable to carry out therapeutic interventions and/or assessments without prompting
  • b) Did not demonstrate adequate clinical reasoning
  • c) Did not request assistance when practising outside of knowledge area
  • d) Did not effectively communicate with Patient I
  • e) Did not maintain adequate records
  • f) Demonstrated a lack of knowledge in the areas of posture and positioning during use of rotunda

 

10. Between 5 February 2019 and 1 March 2019, in relation to Patient J, you

  • a) Were unable to carry out therapeutic interventions and/or assessments without prompting
  • b) Did not request assistance when practising outside of knowledge area
  • c) Did not maintain adequate records

 

11. Between 6 February 2019 and 22 February 2019, in relation to Patient K, you

  • a) Were unable to carry out therapeutic interventions and/or assessments without prompting
  • b) Did not demonstrate adequate clinical reasoning

 

12. Your actions in paragraphs 1-11 constitute misconduct and/or a lack of competence

 

13. By reason of your lack of competence your fitness to practice is impaired.

Finding

Preliminary Matters

1. The Panel has been convened to undertake the hearing into the HCPC’s allegations against the Registrant, Ms Holly Tetlow, an Occupational Therapist.

Service of the notice of hearing.

2. In view of the fact that the Registrant did not attend the hearing, the Panel initially considered whether she had been served with a valid notice of hearing. The Panel was provided with a copy of an email dated 12 January 2022 sent to the email address recorded in the HCPC Registrar as that of the Registrant. The email informed the Registrant of the dates and times of this hearing and that it was to be conducted remotely by video conferencing. The Panel acknowledged that the requirement with regard to service is the sending of the notice, rather that proof of receipt of it, but it was nevertheless reassured that the email address was that of the Registrant by the fact the day following the sending, the Registrant replied to it in terms that will be referred to below. The Panel was satisfied that there had been good service of the notice of hearing.

Application to proceed with the hearing in the absence of the Registrant.

3. After the Panel stated that it was satisfied that there had been good service of the notice of hearing, the Presenting Officer applied for a direction that the hearing should proceed in the absence of the Registrant.

4. The Panel heeded the advice it received that the finding of good service of the notice of hearing was a necessary but not sufficient factor in determining whether the hearing should proceed in the absence of the Registrant. A Panel is required to be satisfied that such a direction must be fair taking all relevant factors into account. The Panel considered the factors outlined in the relevant HCPTS Practice Note and concluded that the hearing should proceed in the Registrant’s absence. The reasons for this decision were as follows:

• In replying to the emailed notice of hearing, on 13 January 2022, the Registrant stated, “I will not be attending this hearing and there isn’t anyone representing me. I understand the allegations being made against me and have no further evidence.” She gave a summary of the work she was then doing and added, “…. I am no longer working within the occupational therapy area of work.”

• There was no application for an adjournment, no suggestion by the Registrant that her decision to attend was made because of the particular dates of the scheduled hearing, and no suggestion that she would participate to a greater extent if the hearing took place at another time.

• It followed that there was no information on which the Panel could conclude that there was a realistic possibility that the Registrant’s engagement would be greater if the present hearing were to be adjourned. Added to this were the facts that it was already more than three years since the events alleged by the HCPC, and four witnesses had been scheduled to give evidence before the Panel over a number of days.

• In all the circumstances the Panel was satisfied that public interest in proceeding with the hearing outweighed any disadvantages arising from the absence of the Registrant.

Application to amend the allegation.

5. Before the Presenting Officer opened the HCPC’s case, a minor amendment was made to paragraph 13 of the allegation. As referred by the Investigating Committee to this Panel, that paragraph alleged that the impairment of fitness to practise arose from lack of competence alone. That was clearly an unintentional error as misconduct was clearly alleged in the preceding paragraph, and the stem to the allegation contended that the impairment of fitness to practise resulted from misconduct and/or lack of competence. The Panel directed that paragraph 13 should be amended to reflect the clear intention of the Investigating Committee, finding that no prejudice could result to the Registrant by the error being corrected.

Application to hold part of the hearing in private.

6. Another application considered by the Panel before the case was opened was that made by the Presenting Officer that any part of the hearing when the Registrant’s health was considered should be held in private. The Panel acceded to this application finding that the direction sought would be necessary to protect the private life of the Registrant.

Background


7. The matters alleged by the HCPC against the Registrant occurred during her employment by Solent NHS Trust (“the Trust”) as a Band 5 Occupational Therapist. She was employed in that capacity as a Rotational Occupational Therapist from 1 December 2017, that being her first employment after qualification. She initially worked in the Community Team, but on 14 May 2018 she moved to work on the Spinnaker Ward, and it was her performance following that move that founds the basis of the HCPC’s complaints. The Registrant’s employment by the Trust ended in early April 2019.

8. The Spinnaker Ward is an inpatient rehabilitation ward for older people. At the time the Registrant worked on the ward there were sixteen beds and the average length of stay was three weeks. An Occupational Therapist working on the ward would have a caseload of approximately six patients, and the Occupational Therapists would be responsible for a variety of assessments and interventions to support patients. They would be expected to work alongside a full multi-disciplinary team (“MDT”) to develop an onward plan for the patients included in their caseload.

9. The HCPC’s case is based upon alleged shortcomings in the performance of the Registrant with regard to eleven patients who were on Spinnaker Ward during the time the Registrant worked there.

Decision on Facts

10. The HCPC called four witnesses to give evidence before the Panel, each of them being Occupational Therapists. They were:

• Ms CC, at the time relevant to the events being considered by the Panel a Band 6 Occupational Therapist. From June 2018 she was the Registrant’s supervisor. Initially, Ms CC worked at two sites, one of them being the Spinnaker Ward. She was on leave for the months of July and August 2018, during which Ms CA temporarily took over supervision of the Registrant. By the time Ms CC returned from the period of leave concerns had started to be expressed about the Registrant’s performance, and from early September 2018 the supervision of the Registrant was conducted jointly by Ms CC and Ms CA, at this time Ms CC was still working at two sites. However, from about the end of September or early October 2018, Ms CC transferred to the Spinnaker Ward full time so she could provide one to one support for the Registrant, and from that time she worked jointly with the Registrant on all the latter’s cases.

• Ms CA was the Portsmouth Rehabilitation and Reablement Team Occupational Therapy Team Lead, and she also acted as the Inpatient Therapy Lead for Spinnaker Ward. She undertook joint supervision of the Registrant with Ms CC.

• Ms JR. Her role at the Trust was as a Clinical Advisor in Moving and Handling. Her first involvement with the Registrant was during the latter’s rotation in the Community Team when she attended a course run by Ms JR. However, her greater involvement commenced in late 2018 when she was asked by Ms CA to undertake one-to-one manual handling training with the Registrant. Ms JR conducted eight such sessions with the Registrant between December 2018 and February 2019. The HCPC’s case in relation to Patients I, J and K is based on the evidence of Ms JR.

• Ms RB is the Service and Quality Manager for Intermediate Care within Adult Services Portsmouth and also Allied Health Professions Professional Lead and Occupational Therapy Professional Lead for Adult Services Portsmouth. Concerns regarding the Registrant were escalated to her in about August 2018 and she was involved in the decision to provide further support to the Registrant and in the conduct of the Trust’s capability processes.

11. In addition to the oral evidence of the witnesses just described, the HCPC produced a very detailed bundle of documents. The documents included very full witness statements made by the witnesses who gave evidence before the Panel. The level of detail was such that the witness statement of the four witnesses extended over 116 pages, the statement of Ms CC alone being some 55 pages and 189 paragraphs long. In addition to the witness statements, the documentary exhibits extended to 641 pages. The exhibits included patient records, records of supervision sessions attended by the Registrant as well as documents relating to formal performance management measures taken by the Trust.

12. The Panel approached its decision-making on the facts by accepting that it is for the HCPC to prove matters against the Registrant, the standard to which they are required to be proved being the balance of probabilities. In reaching its decisions the Panel critically examined not only the oral evidence of the witnesses, but also measured that evidence against the documentary exhibits.

13. From the number of factual particulars and sub-particulars and the extent of the evidence that was presented to the Panel it can be seen that it would be possible to prepare a very long determination on the facts. However, the Panel considers that a shorter determination, explaining concisely what the findings are and why they have been made will enable a clearer and better understanding of the case and the findings.

14. Before it turned to consider the specific allegations made by the HCPC against the Registrant, the Panel made an assessment of the evidence with which it had been presented, including a general assessment of the four witnesses who were called by the HCPC to give evidence. The Panel considered that each of the witnesses gave evidence that could be relied upon. They were knowledgeable about the areas covered by their evidence, and, allowing for the passage of time since the relevant events, they had good recall of matters. It was clear that they were concerned about their perceptions that the Registrant was not practising to an acceptable standard, but it was equally clear that they were genuinely motivated to assist her in remedying her shortcomings, and to that end very considerable efforts were made. The Panel found no evidence of the witnesses having a negative agenda against the Registrant. Furthermore, the extent of the documentation that has already been referred to enabled the Panel to seek independent clarification from source documents of important elements of the evidence given by the witnesses. In short, the Panel found that, taken in the round, the evidence presented by the HCPC provided a solid basis on which it could base its decisions.

Particulars 1(a) & (b) concerning Patient A.

15. On 13 July 2018, the Registrant conducted an initial assessment of Patient A, at which time the patient was unable to walk or look after herself. On 20 July 2018, the Registrant conducted an Access Visit at Patient A’s home, the patient still being on the ward although the patient’s son attended. The Registrant took notes and recorded matters such as the height of the patient’s chair, toilet and bed. On the ward at this time Patient A was using a commode, and it was decided that she would require a commode when she returned to her home. On 7 August 2018, the patient’s son had a conversation with Ms CC, and the discussion included how the patient would move between rooms when she returned to her home. That day, Ms CC wrote in the patient’s notes that a “glide about” commode would be an appropriate option for her at home. On 14 August 2018, the Registrant requested an Occupational Therapy Associate Practitioner to order a glide about commode for Patient A. By this stage the Registrant had practised transfers with the patient, but she had not trialled transfers on and off a glide about commode. It followed that the Registrant could not have satisfied herself that Patient A would have been capable of transferring to and from a glide about commode safely. Glide about commodes are set at a fixed height, and it proved to be the case that the height was too low for Patient A. The Registrant should have satisfied herself of the appropriate, safe height for Patient A, and had she done so it would have been discovered that a glide about commode was not appropriate. In fact on 28 August 2018, Patient A was discharged from the ward and returned to her home. It was appreciated when an assessment was made that same day that the patient was unable to transfer onto and off the commode. A request was then made for a static commode, but unfortunately before it was provided Patient A suffered a fall when attempting to use the glide about commode which set in train a series of events that resulted in a very serious outcome.

16. The Panel finds that the Registrant did not fully assess and document her assessment of Patient A’s toileting requirements because the height of the glide about commode was not appropriate for Patient A as at the date of her discharge. As a result of that failure, Patient A was not provided with the appropriate equipment for her discharge to return to her home.

17. It follows from these findings that particulars 1(a) and (b) are proven.

Particulars 2(a), (b) & (c) concerning Patient B.

18. Patient B was admitted to the ward for rehabilitation following a fall resulting in a fractured right ankle with dislocation. The Registrant and a Band 6 Occupational Therapist, Ms SC, conducted a joint session with Patient B during which it was discovered that Patient B had enjoyed knitting before her admission to the ward and would like to return to it with appropriate support. Ms SC requested the Registrant to explore this further with the patient and to support her return to knitting. The Registrant was advised that the support would involve contacting the patient’s daughter to bring the knitting into the ward and that it would then be necessary for the Registrant to spend time with Patient B until she felt happy to do it alone. On 2 July 2018, the Registrant recorded in Patient B’s notes, “Patient sat by window and given knitting.” There was no indication that the Registrant had spent time with the patient or supported her, and no record that the Registrant considered what the therapeutic benefit of knitting would be.

19. The wording of particular 2(a) is such that not only does it involve an allegation that there was supervision, but also that follow-up action was undertaken after prompting given during supervision. In reviewing the evidence the Panel was unable to find any evidence of supervision relating to this incident beyond the fact that there had been a joint assessment undertaken with Ms SC. More fundamentally, the conclusion of the Panel was that the Registrant did not follow up actions, whether or not as a result of any prompting.
20. As to particulars 2(b) and (c), the Panel found that the records were inadequate, consisting solely of the short note already quoted, and the absence of any discussion of the rationale for knitting meant that adequate clinical reasoning was not demonstrated.

21. It follows that particular 2(a) is not proven, but particulars 2(b) and (c) are proven.

Particulars 3(a), (b) & (c) concerning Patient C.

22. The records in relation to Patient C were deficient in more than one respect. In a discharge Summary written on 23 August 2018, the Registrant wrote that the patient had three steps that needed to be completed at home, that these had been practised on the ward and that the patient required stair rails as well as assistance to complete the stairs. In fact the three stairs in the patient’s home were at the top of a flight of steps that the patient would have needed to use a stair lift to ascend. There was no mention of this flight of stairs or the lift, and no mention of the patient’s ability to use the lift. The note made by the Registrant was also deficient with regard to the recording of Patient C’s expressed wishes with regard to whether he would prefer to return to his home, or whether he would prefer to be with his brother in a care home. The record should have, but did not, make it clear whether this was an expression of choice made by a patient with capacity to make that decision, or something that would be in the best interests of the patient as someone lacking capacity.

23. With regard to particular 3(b), an Access Visit was made to Patient C’s home by the Registrant and Ms C on 6 September 2018. The Registrant was leading the visit and was taking Patient C around each room. Patient C was using a three-wheeled walker, and it was necessary for Ms CC to intervene when Patient C sought to enter a toilet, guided by the Registrant, in which there was limited space. She intervened because if the Registrant had continued with the access for the patient she was attempting, it would have been necessary for the patient to walk backwards in order to exit. In the judgement of the Panel this incident occurred as a result of inadequate clinical reasoning on the part of the Registrant.

24. So far as particular 3(c) is concerned, in reviewing the evidence the Panel was unable to find material from which it could be said that the Registrant did not follow up actions until prompted in supervision. Indeed, in her witness statement Ms CC stated explicitly that she had no concerns in relation to follow-up actions relating to Patient C.

25. It follows that particulars 3(a) and (b) are proven. Particular 3(c) is not proven.

Particulars 4(a), (b) & (c) concerning Patient D.

26. Patient D had undergone a below knee amputation. On 10 September 2018, Ms CC assessed Patient D and explained to the patient and to the Registrant that in order to keep the knee extended and reduce muscle shortening and tension, the patient should use a stump board. Three days later, on 13 September 2018, the Registrant conducted a washing and dressing assessment when Patient D was not using the stump board. The assessment went well, but the Registrant was not able to explain the reasoning behind the advisability of using a stump board, despite the very recent explanation. Furthermore, the Registrant did not remind the patient of the importance of using the stump board. The Registrant saw Patient D on the ward again on 25 September 2018, when the patient was not using the stump board. The notes relating to that occasion do not state whether or not the Registrant reminded the patient of the importance of using it. The giving of advice to use the stump board and the reason why it was not being used were matters that should have been recorded in the patient’s notes. In addition, the Registrant had used the term BKA (below knee amputation) in the clinical records but admitted to Ms CC that she did not know what it stood for despite having treated a previous patient with a similar diagnosis. Ms CC also commented that the Registrant should have suggested a fixed floor toilet frame following the access visit due to the toilet height being different to the wheelchair.

27. The conclusion of the Panel is that the records were not adequately maintained, the Registrant did not demonstrate adequate clinical reasoning and she did not follow up actions until prompted in supervision. So far as particular 4(c) is concerned, in reviewing the evidence the Panel was unable to find material from which it could be said that the Registrant did not follow up actions until prompted in supervision

28. It follows that particulars 4(a) and (b) are proven. Particular 4(c) is not proven.

Particulars 5(a), (b), (c), (d) & (e) concerning Patient E.

29. Patient E was admitted to the ward following a fall in which she fractured her right clavicle and suffered pain in her right knee. The HCPC advances the case in relation to inadequate records concerning Patient E on the basis that the Registrant failed to record, as she was prompted to do by Ms CC, that the patient passed a black stool on the ward, and also that the Registrant mis-recorded the nature of the injury that had resulted in the patient being admitted to the ward. In the notes made by the Registrant relating to 29 October 2018 (the day when both the Registrant and Ms CC noted the black stool) the Registrant recorded, “BO type 3/4”, but did not note that the stool was black. In addition, in the discharge summary written on 6 November 2018, (it being noteworthy that this error was committed after her mistake as to the nature of the injury had been corrected at the MDT meeting on 16 October 2018) the Registrant wrote that Patient E had been admitted to the ward following a fall and a head injury.

30. Patient E was very hard of hearing, and an amplification device that involved the patient using a pair of headphones was used to communicate with her. The Registrant did not use this equipment, and when asked in a supervision session on 2 November 2018 why she did not, her reply was that she did not like using it, and when prompted why she did not like using it, she stated that other people on the ward could hear what she was saying. The result, however, was that her communication with the patient was compromised and the patient’s ability to consent was affected.

31. At a MDT meeting on 16 October 2018, the Registrant initially assumed that the patient’s injury had been a head injury and she required a lot of prompting from Ms CC to formulate a plan of activities that could improve her range of movements that had been restricted by the injury she actually suffered.

32. The Panel finds that the records relating to Patient E were not adequately maintained in relation to the mis-recording of the nature of the patient’s injury, and in relation to the failure to record that the bowel movement was black. The failure to use the amplification device meant that the Registrant did not communicate effectively with the patient and the mis-recording in the patient’s notes resulted in ineffective communication with others involved in the patient’s care. She did not follow up actions until prompted in supervision, and she was unable to carry out therapeutic interventions until prompted. An example of this was the failure of the Registrant to involve Patient E in the Wiihab sessions, something for which the Registrant herself had responsibility on the ward. However, the Panel did not find evidence upon which it could be said that in relation to Patient E, the Registrant demonstrated a lack of knowledge in the area of moving and handling because Ms CA stated that she had limited knowledge of this patient or incident. In addition, the clinical notes state the patient was independent on transferring to the rotunda, so there was no evidence to suggest the Registrant positioned herself incorrectly in using this equipment.

33. It follows that particulars 5(a), (b), (c) and (d) are proven. Particular 5(e) is not proven.

Particulars 6(a), (b), (c) & (d) concerning Patient F.

34. Patient F was admitted to the ward following a fall that resulted in a fracture of the neck of her right femur and a fracture of her right humerus. The Registrant conducted a Domestic Activity of Daily Living assessment on 6 November 2018, and two days later Ms CC asked the Registrant to conduct an Activity Analysis. An Activity Analysis is an exercise that identifies activities that are the most appropriate for the treatment of the patient. The Registrant submitted an Activity Analysis on 12 November 2018. The document submitted by the Registrant was deficient because it focused on upper limb exercises that would be more appropriate for a Physiotherapist to identify, and did not focus on factors that were important for Occupational Therapy input to advance the patient’s rehabilitation.

35. Other problems presented in relation to Patient F included the fact that the Registrant twice recorded the patient’s problems to be with her left arm, whereas it was her right arm. It was necessary for Ms CC to prompt the Registrant to consider the use of padded cutlery to mitigate problems the patient was experiencing. Furthermore, the fact that the patient had difficulties in raising their arm should have resulted in further activities (such as dressing and toileting) as being potentially difficult. On 25 October 2018, the Registrant conducted an Access Visit at Patient F’s home but did not identify a need for a second handrail for the stairs. On 6 November 2018, another colleague noted that a second handrail was required. The Registrant ordered the handrail but she had omitted to take measurements on her earlier visit. This necessitated asking the patient’s family to undertake the measurement. The measurement they took was incorrect so the ordered handrail had to be returned. The consequence was that Patient F’s discharge was delayed by a day.

36. The Panel finds that these matters demonstrated inadequate clinical reasoning, a failure to maintain adequate records, an inability to carry out therapeutic interventions and a failure to communicate effectively with others.

37. It follows that particulars 6(a), (b), (c) and (d) are proven.

Particulars 7(a), (b), (c), (d) & (e) concerning Patient G.

38. Patient G was admitted to the ward for rehabilitation after suffering multiple falls. She had cognitive impairment and experienced difficulty with balance and gait. She had previously suffered a dislocated left shoulder. Her home was a first floor flat that could only be accessed by stairs.

39. When the Registrant saw Patient G she was using a four-wheeled walker to move. When at home, the patient would sit on the walker resting seat and propel herself around her flat by using her feet. This was not safe because the seat is intended only for resting, and if used during movement could result in the user tipping either forwards or backwards. During an Access Visit on 14 November 2018, when the Registrant was asked how the patient would move around, she stated that her son could help. However, it had to be explained to the Registrant that the patient’s son would not always be at the flat. After some prompting, the Registrant identified a self-propelled wheelchair as a suitable item of equipment, and the Registrant asked the patient’s son to request one from the patient’s G.P. This was not appropriate as the Registrant could have herself made a referral to the wheelchair service. During the access visit on 14 November 2018, Ms CC had to prompt the Registrant to consider whether the patient’s documented history of shoulder dislocation would make it safe for the patient to use a self-propelled wheelchair, and during a trial with a self-propelled wheelchair on 19 November 2018, Ms CC had to intervene to lower the foot plates on the wheelchair as the Registrant had not noted that they were not in place. Had they not been properly positioned there would have been a risk that the patient’s foot or leg might be injured. Eventually, when the measurements that were necessary for the provision of a wheelchair for Patient G were made, they were not taken until two days before the date scheduled for her discharge from the ward. Furthermore, in relation to assessments the Registrant entered “TBA as appropriate” in the notes, thereby indicating that the issue was to be assessed as appropriate. Finally, Ms CC confirmed that the Registrant’s typed notes contained multiple spelling mistakes and it appeared that she was not proof reading her work or using the spell check function on her computer as instructed.

40. In the judgement of the Panel these matters resulted in the communications with Patient G and those involved in her care not being effective, an inability to carry out therapeutic interventions and assessments without prompting, an inability to complete appropriate discharge planning, inadequate clinical reasoning and a failure to maintain adequate records.

41. It follows that particulars 7(a), (b), (c), (d) and (e) are proven.

Particulars 8(a), (b), (c) & (d) concerning Patient H.

42. Patient H was admitted to the ward for rehabilitation following a fractured left neck of femur, pneumonia, post-operative anaemia and delirium. On 25 January 2019 the Registrant commenced an initial assessment, and on 28 January 2019, Ms CC accompanied the Registrant to complete that assessment. When assessing the patient the Registrant did not move the bedside table out of the way, resulting in the Registrant lifting her chair over the table so that she could get closer to the patient. This was an unnecessary and unsafe action to perform in close proximity to the patient as the Registrant could have lost her balance thus putting her patient at risk of harm. On 15 February 2019 the Registrant was undertaking a washing and dressing assessment with regard to Patient H. Although the Registrant identified that the patient would require support due to a problem with the patient’s back, she required a lot of prompting before she realised that this problem could result in other difficulties. These included not considering who would provide a bowl of water for the patient to wash her feet, and whether there would be a problem and if so, one that could be addressed, in relation to pulling up lower items of clothing. When the Registrant prepared a discharge summary she incorrectly recorded that Patient H lived in a second floor flat, whereas the patient’s home was situated on the first floor. Even after this was pointed out to her, she then went on to repeat this error.

43. In the judgement of the Panel these issues resulted in the Registrant being unable to carry out therapeutic interventions and assessments without prompting, not maintaining adequate records, not communicating effectively with Patient H and failing to demonstrate adequate clinical reasoning.

44. It follows that particulars 8(a), (b), (c) and (d) are proven.

Particulars 9(a), (b), (c), (d), (e) & (f) concerning Patient I.

45. Patient I had undergone a left total hip replacement procedure and she also had pressure ulcers on both heels. This patient was seen by the Registrant during one of the one-to-one sessions with Ms JR who had been asked to assist the Registrant with the manual handling issues that had earlier been identified. When they saw Patient I, the patient was using a wheelchair. A rotunda was used. The use of a rotunda in the short term will improve a patient’s leg strength and improve their standing tolerance. However, as the use of the rotunda involves pulling himself or herself up onto the equipment, it will not serve to improve a long-term goal of standing from a seated position that is undertaken by pushing down with the arms and the use of leg muscles. Patient I was able to use the rotunda successfully, but when the Registrant switched to trying to achieve rising from a seated position by using hand blocks, the patient was unable to raise herself. At this point the Registrant asked the patient to revert to practising on the rotunda. Ms JR had to prompt the Registrant to consider other equipment that might be used to enable the patient to raise herself other than by using the rotunda, and she prompted the Registrant to consider using a height adjustable rehabilitation plinth with a firm platform. When it became desirable to raise the height of the plinth to enable the patient to raise herself using leg muscles and downward pushing with her hands, the Registrant stated that the height to which it would be necessary to raise it to was not the ideal transfer height for the patient. This reply indicated that the Registrant was not able to problem solve when faced with a difficulty.

46. Patient I was fitted with a catheter and she said that the catheter bag was quite full when they first arrived at the gym. The catheter bag was positioned above the patient’s knee. Although the Registrant stated that the bag could be emptied the patient did not respond, and the Registrant carried on preparing for the transfer. When the patient completed the transfer from the wheelchair to the plinth she again stated that the catheter bag was full, but the Registrant did not do anything about it. At this point Ms JR intervened and suggested to the Registrant that it should be emptied.

47. In relation to particulars 9(a) and (b), in the judgement of the Panel the actions and discussions concerning plinth height demonstrate that the Registrant was unable to carry out therapeutic interventions and assessments without prompting. These also demonstrate inadequate clinical reasoning. Particular 9(c) is predicated upon some aspect of the Registrant’s interventions with regard to Patient I being outside her knowledge area. The Panel does not accept that any of the actions involved interventions that should have been beyond the competence of a Band 5 Occupational Therapist. In relation to particular 9(d), the events concerning the catheter bag meant that there was not effective communication between the Registrant and Patient I. So far as particular 9(e) there is no evidence upon which the Panel could find that there were any shortcomings in relation to the records made relating to Patient I. Finally, so far as particular 9(f) is concerned, the Panel does not find that there is evidence that the Registrant demonstrated a lack of knowledge in the areas of posture and positioning during the use of the rotunda; indeed, she appreciated the limitations of the rotunda, and the essence of the criticisms made in relation to this patient concerning the Registrant’s inability to problem solve the use of the alternative to the rotunda, a criticism that is met by the finding of particulars 9(a) and (b).

48. It follows that particulars 9(a), (b) and (d) are proven. Particulars 9(c), (e) and (f) are not proven.

Particulars 10(a), (b) & (c) concerning Patient J.

49. Patient J had a fractured left wrist and was unable to weight bear on his left arm. He was using a piece of equipment named an “Arjo Stedy” (or “Sara Stedy”) in order to build up leg strength and standing tolerance. The aim was to develop sufficient leg strength to enable the patient to rise from a seated position to standing with the use of the right arm and leg strength alone. The criticism of the Registrant is that although she recorded the number of times the patient was able to stand, she did not record the duration of the standings. Without the information of both the number of occasions and the length of time of the raisings, it would not be possible to form an objective view of whether the patient was improving.

50. In the judgement of the Panel the absence of timings meant that the Registrant was unable to carry out therapeutic interventions and assessments without prompting and meant that adequate records were not maintained. However, in relation to particular 10(b), the Panel is of the same view it formed in relation to 9(c), namely that the shortcoming represented an area of knowledge that was or should have been known to a Band 5 Occupational Therapist.

51. It follows that particulars 10(a) and (c) are proven. Particular 10(b) is not proven.

Particulars 11(a) & (b) concerning Patient K.

52. Two criticisms are advanced in relation to Patient K arising from different occasions, but both involving occasions when Ms JR was working with the Registrant in an attempt to improve her skills with handling. On the first occasion the Registrant was working with the patient to assist the ability to transfer from an armchair to a standing position. The equipment being used was the same as that being used with Patient J, a “Sara Stedy”. Following the standing practice, the patient was positioned too far forward in the armchair; their back was not against the backrest. That meant that in order to obtain back support they had to lean backwards. It was a position that was undesirable for a number of reasons quite apart from discomfort and the sensation of slipping out of the chair that the patient might experience. The Registrant was unable to rectify the position and it fell to Ms JR to suggest the use of a slide sheet, something that she had suggested in relation to another patient on an earlier occasion.

53. The other occasion was when a different, and slightly more complicated, piece of equipment was being used, the “Arjo Encore”. On this occasion the patient was very fatigued, but the Registrant did not heed this fact or discuss with the patient whether it would be more beneficial to conduct the exercise on a different occasion when the patient was less tired.

54. In the judgement of the Panel the issues mentioned above mean that in relation to Patient K, the Registrant was unable to carry out therapeutic interventions and assessments without prompting and that she did not demonstrate adequate clinical reasoning.

55. It follows that particulars 11(a) and (b) are proven.

Summary of findings of fact.

56. In conclusion, particulars 2(a); 3(c); 4(c); 5(e); 9(c), (e) and (f); and10(b) are not proven. All other particulars are proven.

Decision on Grounds

57. The findings made by the Panel mean that there were not only wide-ranging multiple failings of core Occupational Therapy skills, but they also occurred in a context where very significant efforts were made by the Trust to support the Registrant in an attempt to enable her to practise competently. To attempt to understand how this situation arose, witnesses called by the HCPC were asked whether they had any insight into the reasons for the Registrant’s problems. In particular, the Panel considered it important to know whether the repeated problems arose because the Registrant could not be troubled to perform to an acceptable standard or whether they represented an inability to maintain consistent acceptable professional standards. None of the witnesses suggested that they believed that the problems represented indifference or lack of interest on the part of the Registrant, although they were at a loss to offer a positive reason as to why the shortcomings arose.

58. A related issue was whether there were relevant health issues. During the period of the Trust’s concerns over the Registrant’s performance, appropriate enquiries were made with regard to the Registrant’s health, but no information that was forthcoming provided any explanation for the shortcomings.

59. The evidence received by the Panel does not enable it to come to the conclusion that the Registrant was wilfully disregarding, or was indifferent to, the standards to which a Band 5 Occupational Therapist should have been practising. Rather, the evidence suggests that she was, quite simply unable to maintain a satisfactory level of performance or to achieve it when very closely supported. The findings involve eleven patients over a period of approximately eight months. As already stated, problems continued when the support measures were put in place. In the view of the Panel this is a case of lack of competence rather than one of misconduct.

60. The Panel has not overlooked the fact that it is customary to list the HCPC standards breached when reaching a decision on the statutory grounds. However, the Panel has come to the conclusion in this case that there would be no advantage in doing so because the failings are so wide-ranging and basic. The failings included inadequate record keeping, lack of clinical reasoning, impaired communication with patients and colleagues, ineffective interventions, an inability to undertake assessments and failing to transfer learning from one case to another.

Decision on Impairment

61. The issue in relation to impairment of fitness to practise is whether the lack of competence demonstrated by the Registrant’s professional performance in relation to the eleven patients over between June 2018 and March 2019 is still impairing her fitness to practice now, in February 2022.

62. In reaching its decision on this issue the Panel heeded the advice it received that it is necessary to consider both the personal component and the public component.

63. So far as the personal component is concerned, all of the failings identified by the Panel’s findings should be capable of being remedied; indeed, it should have been possible for them to have been remedied during the period when the Trust was providing the support to the Registrant that has been described. Yet they were not remedied during that period, and there is no evidence that they have been remedied since. It follows from this that the Panel has been driven to conclude that the Registrant’s fitness to practise is at least as impaired at the present time as it was during the period covered by the factual particulars, and that includes a very significant risk that professional failings would be repeated. Failings of the type identified have the potential to result in therapy being compromised and recovery impeded. In some instances they give rise to a risk of positive harm. These findings mean that a finding of personal component impairment of fitness to practice is required.

64. The Panel has also concluded that a finding of current impairment of fitness to practise should be made with regard to the public component. Fair-minded and fully informed members of the public would be justifiably concerned were an Occupational Therapist who would be liable to repeat failings of the type identified by the Panel’s findings to be allowed to practise without restriction. Furthermore, a finding of impairment of fitness to practise is required to declare and uphold proper professional standards and maintain public confidence in the profession.

65. The finding of current impairment of fitness to practise means that the lack of competence allegation is well founded. It follows that the Panel must go on to consider the issue of sanction.

Decision on Sanction

66. After the Panel handed down the determination on the allegation, the Panel allowed the Presenting Officer time to consider the document before she made her submissions on sanction.

67. When she addressed the Panel, the Presenting Officer identified a number of aggravating factors, which will be mentioned by the Panel below. She reminded the Panel of the proper approach to making a decision about sanction and urged the Panel to have regard to the Sanctions Policy in doing so. She did not make a positive submission as to the sanction that should be imposed, but she did submit that it would be unlikely that the Panel would conclude that either a caution order or a conditions of practice order would be appropriate, and thus the Panel might well arrive at the conclusion that a suspension order should be made.

68. The Panel accepted the advice it received in relation to the decision it is required to make in relation to sanction. In particular, a sanction is not to be imposed to punish a registrant against whom findings have been made. Any sanction imposed must be the least restrictive outcome consistent with the Panel’s obligation to protect the public, to maintain public confidence and the registered profession and the regulation of it, and to declare and uphold proper professional standards. The finding that an allegation is well founded does not of itself require the imposition of a sanction, but if a Panel finds that in a particular case that a sanction is required, the consideration of the available sanctions must start with the least restrictive. More restrictive sanctions should only be considered if lesser sanctions are considered to be not appropriate. In the present case the fact that the finding is one of lack of competence means that the sanction range ends with the option of a suspension order. The Panel also accepted the advice relating to the importance of considering the HCPC’s Sanctions Policy in reaching its decision.

69. The Panel began its deliberations by identifying any aggravating and mitigating factors. The aggravating factors identified were the following:

• The failings were wide-ranging and repeated and occurred over a lengthy period of time. Furthermore, they occurred against a background of significant support to the Registrant by the Trust, yet there was a pattern of the Registrant not learning from earlier errors.

• There was a lack of insight, remorse or apology. There was no sustained improvement in performance, and there is a significant risk that shortcomings would be repeated.

• The Registrant’s failings had the potential to result in compromised patient recovery and even positive harm. Mention has already been made of the fact that the provision of the glide about commode was a factor in Patient A falling, something that set in train a series of events that had a very grave outcome. The risk of repetition necessarily means that there would be a future risk of harm to service users were the Registrant to return to practise as an Occupational Therapist without restriction.

70. There were no mitigating factors that the Panel could identify save that, as has already been stated in relation to the decision on the statutory grounds, the Panel did not conclude that the shortcomings arose from any wilful disregard of proper standards on the part of the Registrant.

71. When the Panel considered whether this is a case in which a sanction is required, the clear answer to that question is that it is. Not imposing a sanction would be to fail to protect the public from the risk of harm and it would also seriously undermine public confidence in the profession of Occupational Therapy.

72. The Panel therefore first considered whether a caution order would be appropriate and in that context considered paragraph 101 of the Sanctions Policy. The issues are not isolated, not limited and not minor in nature. There is a significant risk of repetition. The Registrant has not shown good insight and she has not undertaken appropriate remediation. Accordingly, the present case does not fit the factors suggested as being appropriate for a caution order, and the Panel rejected that option.

73. The Panel next considered a conditions of practice order. In that regard the Panel considered paragraph 106 of the Sanctions Policy. The Registrant does not have insight. Although the failings are conceptually capable of being remedied, the history of the Registrant’s performance while being supported by the Trust does not enable the Panel to find that they will be remedied by this Registrant. Furthermore, it is now very nearly three years since the Registrant’s employment at the Trust came to an end, and she stated as recently as 13 January 2022 that she is no longer working in the area of Occupational Therapy. In circumstances where someone is neither working in the profession nor demonstrating a desire to return to it, the Panel does not consider that a conditions of practice order is appropriate.

74. The rejection of the option of a conditions of practice order necessarily has the consequence that the Panel arrived at the sanction of a suspension order. In the judgement of the Panel, in a case where the failings are as wide ranging and serious as they are in the present case, that is the only sanction that will afford a proper degree of public protection. Furthermore, any lesser sanction would not be sufficient to ensure a proper degree of public confidence in the profession and regulation of it. Accordingly, the Panel’s decision is that the registration of the Registrant must be suspended.

75. As to the length of the suspension order, the Panel considers that it should be for the maximum period of 12 months as there are no reasons to conclude that the factors that require a suspension order will be removed in a shorter period.

76. The Panel acknowledges that it is customary when a suspension order is made for the Panel making it to offer guidance to the Registrant as to the steps that they might wish to consider taking in order to present evidence to a future reviewing Panel. Given the wide-ranging nature of the failings in this case, coupled with the fact they continued notwithstanding considerable support, the Panel does not consider that there are any realistic suggestions that can be made in this case.

77. Before closing the case the Panel would wish to make a suggestion that arises from its acknowledgment that the effect of making a suspension will be that, without positive steps being taken by the HCPC, the Registrant will be prevented from removing her name from the HCPC Register. Furthermore, she will be told that periodic reviews of the suspension order will be taking place. The Panel would wish to express the hope that the HCPC will consider the appropriateness of offering the voluntary removal process to the Registrant, so that (if the HCPC considers it appropriate) the Registrant can consider applying for voluntary removal from the HCPC Register if she has decided that she wishes to put Occupational Therapy behind her.

Order

The Registrar is directed to suspend the registration of Holly Tetlow for a period of 12 months from the date this Order comes into effect.

Notes

The Panel makes an Interim Suspension Order under Article 31(2) of the Health Professions Order 2001, the same being necessary to protect members of the public and being otherwise in the public interest.

Hearing History

History of Hearings for Holly Tetlow

Date Panel Hearing type Outcomes / Status
10/02/2022 Conduct and Competence Committee Final Hearing Suspended