Bridget M Boyce

Preliminary Matters

Hearsay application

1.Mr Foxsmith made an application that the report of an expert witness, Ms Chantell Hodgson, be admitted as hearsay evidence at the Hearing. The application was opposed by Mr Hamill.
2. Mr Foxsmith told the Panel that Ms Hodgson had been instructed by the HCPC on 7 April 2020 to prepare an independent report in respect of certain elements of the Allegation. Ms Hodgson’s report was received by the HCPC on 26 June 2020. On 4 October 2022, the HCPC sent a Notice of Hearing to Ms Hodgson advising her that she would be required to attend the Final Hearing to give evidence on 9 March 2023. On 6 January 2023, Ms Hodgson wrote to the HCPC to advise that, owing to a health issue, she would be unable to attend the Final Hearing to give evidence. On 28 February 2023, the HCPC requested that Ms Hodgson provide medical evidence to confirm her inability to attend the Final Hearing to give evidence. On 1 March 2023, Ms Hodgson provided the HCPC with the requested medical evidence.
3. Mr Foxsmith submitted that Ms Hodgson’s evidence was important, but not essential, in explaining certain elements of the Allegation and, in particular, that aspect of the evidence which touched upon histopathology and immunohistochemistry (‘IHC’).
4. Mr Foxsmith told the Panel that, if the application was refused, he intended to proceed with presenting the HCPC’s case at this Hearing, in the absence of Ms Hodgson, and would rely on those other witnesses who had attended to give evidence.
5. Mr Hamill submitted that the admission of Ms Hodgson’s report as hearsay evidence would be unfair. He drew the Panel’s attention to the timeline as set out by Mr Foxsmith. Mr Hamill stated that the HCPC, from early January 2023, was on notice of Ms Hodgson’s inability to give evidence at the Final Hearing. The HCPC had not advised the Registrant or her legal representatives of the difficulty in securing Ms Hodgson’s attendance at the Final Hearing until 2 March 2023, when the hearsay application was served.
6. In addition, Mr Hamill submitted that Ms Hodgson’s evidence, as an expert witness, was crucial to complex and technical elements of the evidence. It would be wrong in law and unfair to admit the evidence of Ms Hodgson as hearsay. The proper approach, in Mr Hamill’s submission the alternative approach if the Panel was minded to admit Ms Hodgson’s report was for the hearing to be adjourned for a short period. That period would permit Ms Hodgson’s health issue to be attended to, so that she would be able to attend any re-scheduled Final Hearing to give evidence.
7. The Panel heard and accepted the Legal Assessor’s advice. The Panel was not persuaded by Mr Foxsmith’s submission that it was fair and appropriate to admit Ms Hodgson’s report as hearsay evidence. To the Panel’s mind, to adopt such a course, would unfairly deprive the Registrant from having an opportunity to challenge aspects of Ms Hodgson’s evidence. The Panel further bore in mind that in its view the HCPC had an ample opportunity to put Registrant’s Representative on notice of the difficulty in respect of the attendance of the witness.
8. Accordingly, the Panel refused Mr Foxsmith’s application to admit Ms Hodgson’s report as hearsay evidence.

Application to amend the Allegation

9. Mr Foxsmith applied to amend the Allegation. Mr Foxsmith submitted that the application was made to better reflect the evidence which would be presented at the Hearing. The Registrant had been on notice of the application since 26 March 2021 when the HCPC wrote to her and put her on notice of the intention to amend the Allegation.
10. Mr Hamill adopted a neutral position and left the matter to the Panel’s judgement.
11. Having heard and accepted the Legal Assessor’s advice, the Panel granted the application to amend the Allegation.
12. Thereafter, the Registrant made admissions to the following Particulars of the Allegation as amended: 1(a); 1(f); 2; 4(b); 4(c); 5(f) and 6(a) in respect of 4(b). These admissions were noted by the Panel.

Background

13. The Registrant is a registered Biomedical Scientist (‘BMS’).
14. The Registrant commenced her employment with the Western Health and Social Care Trust (‘the Trust’) in 1996. At all material times, during the period covered by the Allegation, the Registrant was employed by the Trust as a Band 8A Lead BMS for the Histopathology Department (‘the Department’) at Altnagelvin Hospital (‘Altnagelvin’). The Registrant also operated as the Service Manager for the Department. She also held additional responsibilities as the Manager of the Mortuary at Altnagelvin and the South West Acute Hospital (‘SWAH’), Enniskillen.
15. On 3 March 2015, the Department’s Laboratory (‘the Lab’) was inspected by the United Kingdom Accreditation Service (‘UKAS’) as part of a UKAS accreditation process. The Lab failed to achieve accreditation, after which an investigation into the Registrant’s conduct in the run up to the inspection was commenced by the Trust. The investigation addressed practices and procedures in the Lab in general, and the IHC section of the Lab in particular.
16. At the hearing, the Panel heard evidence from the following witnesses:
a. Mr GMcN: Pathology General Manager
b. Dr MMcK: Consultant Pathologist, Cellular Pathology
c. Mr SMcL: Quality Officer at Cytology
d. Ms JD: Section Lead at the Lab
e. NMcD: Senior BMS at the Lab

GMcN:

17. At the material time, GMcN was the Pathology General Manager at the Trust. He was responsible for the laboratory service in the Trust, which included the laboratories at both Altnagelvin and the SWAH. GMcN did not work clinically. Each departmental head reported to him and thus GMcN oversaw general management in key result areas such as service delivery, quality, change management, finance management, leadership and reviewing performance.
18. GMcN stated that he knew the Registrant from approximately May 2013. At that time, the Registrant was the Histopathology Manager at Altnagelvin and he was in the equivalent position in another Trust. He knew the Registrant professionally. He described his relationship with the Registrant, through various interactions as ‘professional and friendly.’
19. In his position at the Trust, GMcN had five Lead BMSs reporting to him, one of whom was the Registrant. While the Registrant reported to GMcN in relation to general management issues, she reported to MMcK in relation to clinical and scientific issues. Thus, the Registrant had two line managers.
20. GMcN had monthly meetings with the lead BMSs, together with ten pathology governance meetings a year where work related issues would be discussed. These issues were reported by GMcN through the Trust hierarchy. The Registrant oversaw a BMS team and support workers in the Lab, together with staff at the mortuaries connected to Altnagelvin and the SWAH.
21. On 29 August 2014, GMcN met MMcK in relation to concerns which MMcK stated he had with the Registrant’s management of the Lab. The Lab, together with the Cytology Department at Altnagelvin were, at that stage, progressing towards a UKAS inspection which was scheduled to take place in March 2015. In September 2014, GMcN had several meetings with the Registrant to discuss the concerns which had been raised about her by MMcK. On 8 October 2014, GMcN met the Registrant and agreed a program on IHC, in advance of the UKAS inspection.
22. GMcN stated that, in the course of their meetings, the Registrant told him that things were progressing well within the Department. Support was offered by GMcN in relation to the Registrant’s work, but his evidence was that the Registrant stated that she did not need any assistance.
23. On 2 March 2015, the day before the UKAS inspection, MMcK contacted GMcN to express concern as to what MMcK had seen in the IHC section of the Lab. When GMcN went to the Lab to inspect the fridges within the IHC section, he was ‘shocked’ at what he saw therein. GMcN found badly labelled vials of reagents, for example, some were missing dates of expiry and/or dates of preparation. Everything was generally of a very poor standard. It was at that stage that GMcN realised that, contrary to what he had been told by the Registrant, the IHC section was not ready for a UKAS inspection. GMcN informed MMcK of his decision, with immediate effect, to suspend the IHC service and to bring in another BMS to take over the running of the IHC section.
24. GMcN gave evidence of an investigation which he conducted into concerns about the Registrant’s management of the Lab, which commenced in April 2015 and culminated in a disciplinary hearing which took place over 23 days between December 2016 and December 2017. GMcN’s investigation addressed the procedures in place in the IHC section of the Lab which dealt with the following:
a. antibodies, and specifically, fit for purpose testing, topping up antibodies, prep kits;
b. the use of non-conformity forms;
c. staff training generally; and
d. the Registrant’s management of the mortuaries, attached to Altnagelvin and the SWAH.

25. In so far as the use of antibodies within the IHC section was concerned, GMcN’s investigation established that, following inspection, only approximately 10% of the antibodies in the IHC section had the appropriate validation paperwork. Further, the Registrant did not keep an accurate track of stock which resulted in stock running out and the Registrant, as a consequence, having to take shortcuts. One such shortcut, in GMcN’s evidence, was the topping up of antibodies. A risk with topping up antibodies was that they could get mixed up unintentionally, causing tissue to be stained incorrectly which could affect a patient’s diagnosis and treatment. The investigation also found that prep kit dispensers were being reused, contrary to good practice, which dictated that they must be disposed of after a single use. Prep kits were discovered which had multiple barcode labels on them.
26. GMcN stated that the investigation also found a significant number of non-conformity forms which had not been filled out correctly, actioned or closed by the Registrant. This had resulted in Department errors not being properly investigated or escalated to an appropriate level, thereby increasing the risk of faults recurring, and raising the possibility of an increased risk to patients.
27. The investigation found the Lab staff had only been trained to do basic level duties and that the Registrant's management style did not permit senior staff, such as Band 7 staff, attaining responsibility for their own sections within the Lab. In addition, contrary to what he had been told previously by the Registrant, GMcN discovered that 11 staff had not been appraised by the Registrant and there was no evidence that appraisals had been conducted by the Registrant on staff on an annual basis.
28. The Registrant managed the two mortuaries attached to Altnagelvin and the SWAH. GMcN stated that the investigation found a number of alleged serious failings in the Registrant's management of the mortuary at the SWAH which included: body parts being stored for longer than indicated in the Trust’s Standard Operating Procedures (‘SOPs’); inaccurate recording in the mortuary register; inadequate policies regarding the storage of bodies and body parts; inadequate staff training and a failure by the Registrant to attend the mortuary on a regular basis.

MMcK:

29. MMcK, since 2009, has been employed by the Trust as a Consultant Pathologist within Cellular Pathology. MMcK’s duties include, but are not limited to, providing a clinical diagnostic interpretive service on biopsy and cytology material, together with laboratory management.
30. Upon taking up his position in 2009, MMcK was the Registrant's line manager in relation to clinical and scientific issues.
31. In 2012, the Registrant enrolled the Lab as a pilot site, moving from the Clinical Pathology Accreditation (‘CPA’) standards to those accreditation standards used by UKAS. MMcK stated that the gap in the two standards was significant and therefore a lot of work needed to be undertaken for the Lab to successfully attain UKAS accreditation.
32. At the same time as the Lab was undertaking the transition to the UKAS standards, another department at Altnagelvin, Cytology, which was on the same floor, was moving from the CPA to the UKAS standards. MMcK’s evidence was that there was a stark difference in the manner in which both departments transitioned to the new standards. Although both departments were in many respects identical, there was a marked lack of progress towards the UKAS accreditation by the Histopathology Department. MMcK was clear in his evidence that the reason for this was the resistance of the Registrant to engage in the change needed to successfully attain UKAS accreditation.
33. The UKAS inspection for the Lab was scheduled for March 2015. In late 2014, MMcK escalated his concerns to GMcN as to how the Registrant was managing the Lab. MMcK felt, at the time, that the Lab would not be capable of acquiring UKAS accreditation at the March 2015 inspection. It was agreed, in conjunction with Human Resources, that GMcN would informally manage the Registrant over a three-month period and that she would focus, although not exclusively so, on the IHC section of the Lab.
34. On 2 March 2015, the day before the UKAS inspection, MMcK showed GMcN evidence of the poor practice being undertaken at the IHC section of the Lab for which the Registrant had responsibility. After this, GMcN informed MMcK that he had decided to suspend the IHC section and removed the Registrant from her role with immediate effect.
35. MMcK gave evidence to the Panel of the Registrant’s alleged poor clinical practice. He stated that the Registrant had not followed the correct procedures for ensuring that antibodies were fit for purpose. The Registrant was just using them and there was no written documentation to prove either verification or validation ever occurred. Validation and verification were important because there was a need to ensure that the antibodies were working correctly before being used in patient tests.
36. Another issue of concern was traceability. There was no documentation, which meant that there was no ability to trace what antibody from the fridge had been used, when they had been used or on which patients. It was also not possible to identify the stock vial which each dispenser of antibody had been made up from, when it had been validated or the expiry date of that stock.
37. MMcK gave evidence to the Panel about the Registrant's alleged failure to label prep kits and her reusing of prep kits. Prep kits are single use only and, once empty, must be discarded. MMcK stated that the Registrant was reusing the plastic dispenser of prep kits and that, as a result, there were prep kits that had multiple handwritten labels with the names of antibodies written on. There were no details of the batch of antibody which had been decanted into them, nor any other identifying details. The Registrant’s practice in this regard introduced a significant risk of inaccurate results being obtained.
38. Another concern which MMcK expressed in evidence was the allegation that the Registrant was regularly topping up antibodies. MMcK stated there was no written evidence or protocol as to how topping up was validated within the Lab.
39. MMcK also gave evidence about the Registrant’s alleged failure to complete and/or escalate non-conformity forms. These forms were designed to record an untoward incident, assess the risk associated with it, identify any changes that needed to be made to address the risk and detail when the changes were to be made. At Quality Meetings, where the non-conformity forms were discussed, MMcK stated that the Registrant indicated that none of the forms within her Department were for discussion, that they were low risk and no trend had been identified.
40. MMcK also addressed the concerns that had arisen as a result of the Registrant’s management of the mortuary at the SWAH, Enniskillen.

SMcL:

41. At the material time, SMcL was employed by the Trust as a Quality Officer in the Cytology Lab. In that role, SMcL was responsible for the writing and drafting of policies and procedures for submission to Service Managers for their review and approval. From June 2015, until September 2015, SMcL was acting BMS Histopathology Service Manager.
42. SMcL worked in a separate department to the Registrant. He worked in the Cytology Lab, the Registrant worked in the Histopathology Lab. The two departments were in the same building and both departments came under the same Quality Management System (‘QMS’). This was part of the requirements for transition to UKAS accreditation. In the early phases of their professional contact, SMcL’s relationship with the Registrant was friendly. She was someone to whom SMcL would turn for advice, and he trusted her.
43. Around 2013, it was agreed that both departments would transition from CPA to UKAS accreditation. SMcL spoke of a trip to Birmingham. Accompanying him on that trip was the Registrant, MMcK and NMcD. The purpose of the trip was to attend a UKAS meeting to address the process of transitioning and to engage in a gap analysis. A gap analysis looked at those areas in the practices and procedures of both departments which needed to be addressed to make them compliant with UKAS standards.
44. While the challenge of attaining UKAS accreditation was taken up by the Cytology Lab, SMcL stated that the Registrant from an early stage demonstrated that she was resistant to change. An example of that resistance, given by SMcL, was the Registrant’s approach to the introduction of new non-conformity forms, which were UKAS compliant. The Registrant reluctantly used the form but only after an extended period when she used both the old query form and the non-conformity form. This double working was unnecessary and took up time. SMcL also attended monthly Quality Meetings. It was SMcL’s recollection that the Registrant never brought up any issues with non-conformities within the Lab. As Service Manager in the Lab, it was the Registrant’s responsibility to ensure that non-conformity forms were being used in accordance with the applicable policy.
45. SMcL’s role was to write new draft policies and procedures in anticipation of the transition to UKAS. This was to ensure that Service Managers in both departments felt supported and could focus on other duties. However, in the Registrant’s case, as Service Manager at the Lab, it was SMcL’s evidence that she sought to frustrate and delay the process as much as possible.

JD:

46. At the material time, JD was the Section Lead at the Lab. Her duties included ensuring that the flow of work out of the Lab was timely, staining carried out was of sufficient quality and, for some time in 2016, acting as the key person on validation of new machinery that came into the Lab. Towards the end of her time in the role, JD took part in Quality Meetings and was part of a team involved in getting information ready in preparation for the Lab’s transfer to the UKAS standards.
47. JD gave evidence about the various working practices of the Lab. An aspect of those practices was fit for purpose testing. Before using antibodies, they must be tested to ensure they were fit for purpose. Two ways this was achieved was by means of the validation and verification of antibodies. If an antibody was in concentrate form, it needed to be diluted. To change an antibody by dilution meant that it needed to be validated. This was to ensure that it was made up in the appropriate manner. If an antibody came ready to use (‘RTU’), there was no need for it to be diluted as it came pre-diluted from the manufacturer. There was no need to validate the antibody in those circumstances but there was a requirement to verify the antibody to ensure there was no inter-batch variation.
48. JD’s evidence was that from when JD started employment with the Trust, the Registrant was diluting antibodies. JD stated that she was unaware as to whether the Registrant failed to ensure the validation or verification of antibodies that were used in the Lab. Further, she was unaware whether the Registrant ensured that antibodies were optimised before use. In her position, it was JD’s evidence that the Registrant was responsible for ensuring the validation, verification and optimisation of antibodies being used in the IHC section of the Lab.
49. JD also gave evidence about the topping up of antibodies. JD stated that topping up was conducted by the Registrant and that there would be frustration in the Lab at the Registrant due to the low volumes of antibodies being made up during the topping up process.
50. The Panel was also told by JD that out-of-date antibodies were sometimes used for testing patient tissue. When this was brought to her attention by JD, the Registrant told JD to go ahead and use the out-of-date antibody. The Registrant also told JD to enter a date a month in advance into the relevant database as a means by which to circumvent the requirement to enter the expiry date on the database before the antibody was used. In her evidence, JD stated that out of date antibodies were used in this fashion quite frequently.
51. Staff training in the Lab was unstructured. There was no one specific person assigned to individual lab sections. JD stated that, in the absence of proper training, staff ‘just muddled through.’ There was no structured line management or supervision process and there was a minimal appraisal process. During the period when the Registrant was Lead BMS, JD estimated that she had had two or three appraisals, the last being a group appraisal with the other senior BMSs just before the UKAS inspection. JD also stated that, in January 2015, she was told by the Registrant to backdate staff training documents to a date in November 2014.

NMcD:

52. During the relevant period, NMcD was employed by the Trust as a Senior BMS at the Lab. NMcD gave evidence in relation to various aspects of the Lab’s work, including antibodies, fit for purpose testing, the use of expired antibodies, topping up antibodies and prep kits. NMcD also gave evidence concerning the use of non-conformity forms, mortuary management and the issue of staff training.

Further amendment to the Allegation

53. Prior to closing the case on behalf of the HCPC, Mr Foxsmith applied to further amend the Allegation. This had arisen as a result of the evidence given by the witnesses called in the course of the Hearing. The application was made on the basis that the further proposed amendments better particularised the Allegation following the presentation of the evidence.
54. The amendments sought were as follows:

‘4. Did not ensure that record keeping within the Department was being carried out to the required standard, in that you:
a) In or around October 2015 January 2015 backdated staff training documents and/or instructed staff members to backdate staff training documents to make it appear the documentation had been completed in around November 2014, when it had not;

5. In respect of Enniskillen Mortuary, you failed to:
f. attend the mortuary and/or send a Senior BMS on your behalf on a regular basis’ .

55. Mr Hamill did not object to the application.
56. Having heard and accepted the Legal Assessor’s advice, the Panel granted Mr Foxsmith’s application to further amend the Allegation for the reasons which he advanced.

Allegation (as further amended at the close of the HCPC Case on 9 March 2023)

In your role as a Biomedical Scientist at Western Health and Social Care Trust (“WHSCT”), between around January 2012 and March 2015 you:
1. Did not ensure that clinical processes within the Histopathology Department (“the Department”) were being carried out to the required standard in that you:
a. allowed out of date antibodies to be used;
b. did not ensure antibodies were tested to ensure they were fit for purpose;
c. did not ensure verification and/or optimisation on/ of antibodies was carried out and/or recorded adequately;
d. did not ensure validation was carried out and/or recorded correctly;
e. did not ensure ‘prep kits’ were labelled correctly;
f. caused or allowed antibodies to be ‘topped up’ and/or did not ensure an adequate planned time and/or process was followed for making them up;
g. Did not ensure there was an adequate policy in place for the use of antibodies.
h. Did not ensure effective stock control was carried out;

2. Did not ensure that staff appraisals were being conducted regularly in the Department.
3. Did not ensure staff in the Department received adequate training.
4. Did not ensure that record keeping within the Department was being carried out to the required standard, in that you:
a. In or around January 2015 instructed staff members to backdate staff training documents to make it appear the documentation had been completed in around November 2014 when it had not;
b. Recorded and/or informed colleagues that you had carried out staff appraisals, when you had not done so;
c. did not complete and/or escalate non-conformity forms;
d. did not ensure accurate records of stock usage and/or product expiry dates were kept.

5. In respect of Enniskillen Mortuary, you did not:
a. Identify and/or address the fact that bodies and/or body parts were not being stored for longer than indicated in the Trust’s Standard Operating Procedures;
b. Ensure that there was an assurance process for the release of bodies;
c. Ensure that the Mortuary Register was completed accurately;
d. ensure adequate policies were in place regarding the storage of bodies and/or body parts;
e. ensure staff received adequate training;
f. attend the mortuary and/or send a Senior BMS on your behalf on a regular basis.

6. Your conduct at paragraphs 4(a) and/or 4(b) was:
a. Misleading
b. Dishonest

7. The matters set out at paragraphs 1 to 3 and/or 5 constitute misconduct and/or lack of competence.
8. The matters set out at paragraph 4 and/or 6 constitute misconduct.
9. Your fitness to practise as a Biomedical Scientist is impaired by reason of your misconduct and/or lack of competence.

57. Following the further amendment, the Registrant admitted Particular 4(b). She also admitted, in respect of that Particular, that her conduct was misleading but not dishonest.

The Registrant’s evidence:

58. The Registrant gave evidence at the fact-finding stage of the proceedings.
59. The Registrant set out her education and employment history. Her employment with the Trust started as a Grade 1 BMS in 1996. Her career progressed and she attained the position of Lead BMS in April 2000.
60. The Registrant was the subject of disciplinary proceedings commenced against her by the Trust following the failure of the Lab to attain UKAS accreditation in March 2015. The outcome of the disciplinary process was that the Registrant was downgraded to a Band 6, from the Band 8 position she had held as Lead BMS, and she no longer held a supervisory role. The Registrant was also moved from the Lab to Microbiology. The Registrant had no experience in Microbiology. She had not been in work, owing to sickness absence and suspension since April 2015. The Registrant retired from the Trust on 3 June 2019.
61. Following a period of reflection, the Registrant applied to work as a swabber at the COVID testing centres in County Donegal. She was employed in that position from October 2020 by the Health Service Executive (‘HSE’), the broad equivalent to the NHS, in the Republic of Ireland. From November 2021, the Registrant was employed by the HSE as a business manager in the public health arena. In that role, the Registrant had oversight of six counties in the Republic of Ireland. She had no clinical responsibilities. However, drawing upon her experience as Lead BMS at the Trust, the Registrant was responsible for ensuring that swabbing processes were safe and effective.
62. The Registrant set out the backdrop to the Lab being put forward as a pilot site for UKAS accreditation. The Registrant told the Panel about the months running up to the UKAS inspection in March 2015. In September 2014, when she came back from annual leave, the Registrant was advised by NMcD and PMcK that MMcK had taken over the lead role for the UKAS accreditation project and that the Registrant was required to get the IHC section of the Lab up to speed for the UKAS inspection. The Registrant was told not to interfere in the work of the other section leads in the Lab, who were also responsible for getting their respective sections ready for the inspection.
63. During the period 2012 to 2015, the Registrant stated that there were staffing issues at the Lab. These arose as a result of increased workload and a level of staff sickness that was higher than the Trust average. Staffing issues and a feeling of exhaustion had resulted in the Registrant writing an email, in September 2014, to state that she wanted to ‘step back.’ The Registrant denied that she was incapable of delegation. The Registrant stated that Band 6 and Band 7 staff at the Lab were unable to work to their grade owing to the volume of work, and not as a result of any act on her part not to delegate.
64. The Registrant said that she was ‘shocked’ by the evidence given by former work colleagues, who gave evidence at the Hearing, that she acted in a bullying manner in the workplace, that she was resistant to change or that she was inapproachable. She stated that all staff at the Lab, including her, were under considerable pressure in 2014 and 2015 but she always tried to be open and approachable in her role. The extended working day, the forthcoming UKAS inspection and a procurement process for new equipment – on top of her day-to-day responsibilities – added to the pressure which the Registrant was under.

Particular 1:

65. The Registrant accepted that she had allowed out of date antibodies to be used but that this happened on one occasion when the Lab’s purchasing level had been exceeded. The Registrant denied that she did not ensure that antibodies were tested to ensure they were fit for purpose. She stated that internal processes within the Lab were designed to ensure antibodies were fit for purpose. Similarly, internal processes were such that antibodies were properly verified and optimised and that a record of these processes were contained on internal Lab processes, such as the database, slides, track and trace and run reports. The Registrant stated that prep kits were labelled correctly. The name of the antibody and the date of the preparation was logged on the Lab database and there was a SOP which covered the labelling of prep kits. The Registrant admitted topping up antibodies but denied cleaning out vials to top up antibodies. There was nothing wrong with topping up certain types of antibodies per se. The practice continued in the Lab for a time after the Registrant left in March 2015. The Registrant stated that there was an adequate policy in place for the use of antibodies and that most of the consumables were managed using the Electronic Materials Management (‘EMM’) system.

Particular 2:

66. The Registrant accepted that staff appraisals were not conducted regularly. This was put down by the Registrant to the high volume of work and a high level of staff sickness. Appraisals were not prioritised over the needs of patients. The staff were canvassed in October 2014, and they opted for a group appraisal rather than individual appraisals. The Registrant was clear with staff that the next appraisals, scheduled for April 2015, would be on an individual basis. These were slotted onto Q Pulse so that the Registrant could be reminded to do the appraisals between April and June 2015.

Particular 3:

67. It was denied by the Registrant that staff were not adequately trained. All staff, who had worked at the Lab for a considerable period, were trained to CPA standards. There was an appreciable gap between CPA standards and what was required to secure UKAS accreditation. The Registrant stated, to address this, she developed staff training manuals which were compliant with UKAS standards. From April 2015, it was the Registrant’s intention to have weekly and monthly CPD and information sessions for staff.

Particular 4:

68. The Registrant accepted in her evidence that she had requested Lab staff to backdate training records. She denied that she had acted misleadingly or dishonestly in that regard. She also admitted that she had informed GMcN that she had carried out staff appraisals when she had not. She accepted that this was a misleading, but not dishonest, act. She denied that she had not ensured accurate records of stock usage and/or product expiry dates were kept.

Particular 5:

69. The Registrant admitted that, from September 2014 onwards, she had not attended the mortuary at Enniskillen on a regular basis, nor had she sent a senior BMS on her behalf to the mortuary regularly. On the day of the UKAS inspection, on 2 March 2015, she accompanied the UKAS inspector. The Registrant stated that she was ‘shocked’ at what she observed at the mortuary. With the exception of her admission to sub-particular 5(f) in relation to the failure to attend the mortuary on a regular basis, the Registrant denied the rest of the sub-particulars of Particular 5. Training of mortuary staff was arranged by the Registrant but undertaken by member of Trust staff who went off sick in September 2014 and never came back to work. That member of staff held the key to training records to which the Registrant did not have access.

Decision on Facts

70. Prior to retiring to consider its decision on the facts, the Panel received advice from the Legal Assessor. Amongst other matters, the Legal Assessor referred the Panel to the burden and standard of proof to be applied; the proper approach to considering the Allegation; the issue of dishonesty and the Registrant’s good character. The Panel was also referred by the Legal Assessor to the Practice Note entitled ‘Opinion Evidence, Experts and Assessors’ (February 2022), published by the HCPTS.
71. The Panel was mindful that the Allegation covered alleged incidents during a period between 2012 and 2015. In addressing those matters, which were alleged to have occurred a relatively significant period of time previously, the Panel paid particular attention to the documentary evidence which was as contemporaneous as possible to the incidents alleged in the Allegation.
72. The Panel also treated the Registrant as a person of good character and was mindful of the Legal Assessor’s advice in that regard.
73. The Panel was also aware that, due to an unfortunate oversight, there was contained in some of the witness statements certain matters which were alleged to have occurred in the period subsequent to the dates specified in the Allegation. These matters were not relevant to the proceedings, and they played no part in the Panel’s reasoning.
74. The Panel then turned to consider the Allegation.

In your role as a Biomedical Scientist at Western Health and Social Care Trust (“WHSCT”), between around January 2012 and March 2015 you:
1. Did not ensure that clinical processes within the Histopathology Department (“the Department”) were being carried out to the required standard in that you:
a. allowed out of date antibodies to be used;

75. The Registrant made a limited admission to this Particular. She accepted that, on one occasion, she had allowed out of date antibodies to be used.
76. The relevant SOP, which had been prepared by JD, was entitled ‘Antibody Preparation’. At point 2, it stated:
‘Check the bottle inside the tub is the appropriate antibody and that the antibody has not expired…’
77. In her evidence, JD stated: ‘When Bridget Boyce was Head of the lab out of date antibodies were sometimes used for testing patient tissue…I would frequently go to get an antibody from the fridge and see from the label on the bottle that it was out of date but there would be no alternative i.e. no antibody in date. When I would tell Bridget Boyce this she would tell me to go ahead and use it anyway.’
78. When JD was challenged about this issue during cross-examination, her evidence was that the use of out-of-date antibodies had occurred on more than one occasion.
79. The evidence of other witnesses and, in particular, GMcN, MMcK, NMcD and SMcL were supportive of JD’s account.
80. The Panel preferred the evidence of JD and the other witnesses called by the HCPC in respect of this Particular. The Panel was satisfied that out-of-date antibodies were used by the Lab, when the Registrant was the Head of the Lab, on more than one occasion.
81. Accordingly, the Panel found Particular 1(a) proved.

b. did not ensure antibodies were tested to ensure they were fit for purpose;

82. The Registrant denied that she did not ensure that antibodies were tested to ensure they were fit for purpose. She stated that internal processes within the Lab were designed to ensure antibodies were fit for purpose.
83. MMcK’s evidence was that ‘Bridget Boyce was not following the correct process for ensuring antibodies were fit for purpose; she was just using them, as no written documentation exists to prove either verification or validation ever occurred.’ Further, MMcK stated that he was ‘unable to find any documentary evidence of verification or validation for the antibodies in the fridge.’
84. The Panel preferred the evidence of MMcK in respect of this Particular. MMcK’s oral evidence was consistent with the account given by him in his witness statement. The Panel was satisfied that the Registrant did not ensure antibodies were tested to ensure they were fit for purpose.
85. Accordingly, the Panel found Particular 1(b) proved.

c. did not ensure verification and/or optimisation on/ of antibodies was carried out and/or recorded adequately; AND
d. did not ensure validation was carried out and/or recorded correctly;

86. The Registrant’s evidence was that internal processes in the Lab were such that antibodies were properly verified and optimised and that a record of these processes was contained on internal Lab processes, such as the database, slides, track and trace and run reports.
87. As part of the Trust’s investigation, NMcD prepared a document entitled, ‘Discovery of issues by [NMcD]’. The document recorded that NMcD ‘Had to throw out number of antibodies which were in use due to poor records.’ She further recorded:

‘3. Poor clones of antibodies in stock
Ak1 2 antibodies clone not good
As a result of findings the immune section had to discard all antibodies and validate new ones.’

88. The Panel had regard to notes of a meeting, which took place on 30 April 2015, with NMcD in GMcN’s office. The notes record as follows:
‘Antibodies are made up.
When opened it has to be logged onto system. I found that the batch no. was not logged on the system.
…
I had to scrap them all – some were dated 2013 and 2012. As batches were not logged these all had to be discarded.
We had to get more antibodies following the UKAS inspection. The inspector was horrified. We only had about 10% accepted. We had to stop the service for a week or more.’

89. In her evidence, NMcD stated: ‘After the UKAS inspection … I found there were files in the room that were meant to have held documentation confirming fit for purpose testing but the files were empty.’
90. In his evidence, MMcK stated:
‘As Lead Biomedical Scientist and Quality Manager, it was Bridget Boyce’s responsibility to ensure the correct procedures were being followed. We know that she did not do so because of the lack of documentary evidence. In March 2015 we had to dispose of the majority of the repertoire of what was in the Immunocytochemistry section of the lab as we could not confirm evidence of verification or validation, even retrospectively, because there was no record of the batch numbers or expiry dates of the antibodies.’

91. The Panel preferred the evidence of NMcD and MMcK, which was consistent with the documentary evidence, in respect of this Particular. The Panel was satisfied that the Registrant did not ensure verification, optimisation and validation of antibodies was carried out or that these processes were recorded correctly.
92. Accordingly, the Panel found Particulars 1(c) and 1 (d) proved.

e. did not ensure ‘prep kits’ were labelled correctly;

93. The Registrant stated that prep kits were labelled correctly. The name of the antibody and the date of the preparation was logged on the lab database and there was a SOP which covered the labelling of prep kits.
94. In her evidence, NMcD stated: ‘Whoever makes up a prep kit is responsible for ensuring that it is labelled correctly. For the majority of the time Bridget Boyce worked in the IHC room she would make up the antibodies and therefore would have been responsible for the prep kit labelling.’
95. Further, NMcD stated: ‘When I went into the IHC room I found a number of antibodies and prep kits that had no identifying details on them. Some of the prep kits looked old so we could not tell how long the antibodies had been in them…’

96. In her evidence, JD stated: ‘Bridget Boyce … after a stage in 2014 [was] the only person making up antibodies. She was therefore the person who would label the prep kits … during her time in the laboratory I personally saw prep kits that had multiple different labels for the same antibody placed on top of one another on prep kit dispensers, meaning that the dispensers were being reused.’

97. The Panel also had sight of photographs taken by GMcN as part of the Trust’s investigation. The photographs depicted prep kits which had no dates and others which were wrongly labelled, doubly labelled or not labelled at all.
98. The Panel preferred the evidence of NMcD and JD, which was consistent with the documentary evidence, in respect of this Particular. The Panel was satisfied that the Registrant did not ensure prep kits were labelled correctly.
99. Accordingly, the Panel found Particular 1(e) proved.

f. caused or allowed antibodies to be ‘topped up’ and/or did not ensure an adequate planned time and/or process was followed for making them up;

100. The Registrant accepted that she had topped up antibodies but denied cleaning out vials to top up antibodies. There was nothing wrong with topping up certain types of antibodies per se. The practice continued in the lab for a time after the Registrant left in March 2015.
101. NMcD, in her evidence, explained that topping up antibodies is when one or two millilitres of antibody is put into a prep kit rather than making a new prep kit to the full 12 millilitres.
102. NMcD stated that the Registrant was the person staff went to if antibodies were needed. If the Registrant was on leave, staff at the Lab would leave the prep kits out for the Registrant. The Registrant would make up the prep kits before she left to go on leave or would come in to work over the weekend to make them up. NMcD’s evidence was that the Registrant had indicated to JD that JD was not to make up antibodies. NMcD stated that topping up antibodies was not best practice. The risk in topping up antibodies is that the wrong antibody could be placed into the prep kit.
103. GMcN, in his evidence, explained how the Registrant would top up antibodies. The Registrant would top up antibodies when they were running low rather than sitting down methodically to make up new amounts.
104. The Panel had regard to a non-conformity form raised by JD and a DATIX in relation to the same incident on 2 December 2014. The incident in question related to the unintentional mixing up of antibodies by the Registrant which had occurred during the topping up procedure.
105. The Panel noted the Registrant’s admission to this Particular and had regard to the documentary evidence and the evidence of NMcD and GMcN.
106. Accordingly, the Panel found Particular 1(f) proved.

g. Did not ensure there was an adequate policy in place for the use of antibodies.

107. The Registrant’s evidence was that there was an adequate policy in place for the use of antibodies.
108. The Panel had regard to the Trust’s SOP entitled ‘SOP for Antibody Preparation’. The SOP had been prepared by JD and its effective date of implementation was 10 December 2012. The SOP contained nine numbered instructions in relation to the retrieval and preparation of antibodies.
109. MMcK, in his evidence, stated that while there was a system in place for the use of antibodies, the Registrant had failed to adhere to it.
110. There was no evidence before the Panel to suggest that the applicable SOP was inadequate or insufficient to safeguard the safe use of antibodies.
111. Accordingly, the Panel found Particular 1(g) not proved.

h. Did not ensure effective stock control was carried out;

112. The Registrant denied that she failed to ensure that effective stock control was carried out. She stated that most of the consumables were managed using the Electronic Materials Management (‘EMM’) system.
113. The Panel had regard to the applicable Trust policy entitled, ‘Cellular Pathology Stock Management Policy’. One key purpose of the policy was to ensure that there was an effective inventory control system for reagents and consumables.
114. The Panel noted the contents of the UKAS Assessment Report dated 12 March 2015. In particular, the Panel noted the following findings contained within the Report:
‘Immunocytochemistry – … there are approx. 100 antibodies in the lab of which 10% have been acceptance tested prior to use…
Special stain (Cresyl Violet) - … there is no record of validation of methods…’

115. GMcN stated that, as part of the Trust’s investigation, the Registrant’s use of registration buttons for prep kits demonstrated poor stock control. GMcN gave evidence in relation to an inventory of prep kits and his finding that prep kit numbers had been allocated to different antibodies. These changes, in GMcN’s evidence, demonstrated poor stock control as the frequent reallocation of an antibody to a prep kit number was a sign that the Registrant had run out of the registration buttons.
116. MMcK stated that the Registrant ought to have been using a traffic light system in respect of antibodies. Green indicated that the antibodies had been tested and were ready for use; amber that they had been received but were not ready for use because the antibodies had not been tested and red to indicate that the antibody had been tested but was not suitable for use. On 5 March 2015, MMcK stated that he and GMcN had found out of date antibodies in the Lab’s clinical use fridge when they should have been in the red zone.
117. The Panel preferred the evidence of GMcN and MMcK, which was consistent with the documentary evidence, in respect of this Particular. The Panel was satisfied that the Registrant did not ensure effective stock control was carried out.
118. Accordingly, the Panel found Particular 1(h) proved.

2. Did not ensure that staff appraisals were being conducted regularly in the Department.

119. The Registrant admitted this Particular.
120. JD stated that her understanding was that staff appraisals ought to have been carried out by the Registrant on an annual basis. JD’s evidence was that ‘there was no structured line management supervision process and extremely minimal appraisal process… When I did have appraisals it was very much a matter of me coming into work and Bridget Boyce telling me that I was going to have an appraisal in a few days. I cannot remember how these appraisals were documented. I did not have an email account until 2013 and do not think I had a folder in which copies of appraisal documents or training certificates were kept. This was pretty much the case for everyone.’
121. The Panel noted the Registrant’s admission to this Particular and had regard to the evidence of JD.
122. Accordingly, the Panel found Particular 2 proved.

3. Did not ensure staff in the Department received adequate training.

123. The Registrant denied that staff did not receive adequate training. It was the Registrant’s case that all staff, who had worked at the lab for a considerable period, were trained to CPA standards. There was an appreciable gap between CPA standards and what was required to secure UKAS accreditation. The Registrant stated, to address this, she developed staff training manuals which were compliant with UKAS standards. From April 2015, it was the Registrant’s intention to have weekly and monthly CPD and information sessions for staff.
124. SMcL made a statement as part of the Trust investigation. The purpose of the statement was to provide an overview of the Lab in SMcL’s capacity as acting BMS Histopathology Service Manager between June 2015 and December 2015. SMcL observed that:
‘Staff training in almost every aspect of service provision was “patchy” and in my opinion was not adequately implement (sic) and therefore did not comply with QMS requirements.’

125. SMcL’s evidence was as follows:
‘When I went into the Histopathology department I found that staff training had not been undertaken as robustly as it should have been … I found that training portfolios for staff were not up to date, and when asked for evidence of their training staff could not provide it as they did not have any. There was no evidence that any of the staff had received yearly appraisals. The usual process would have been for Bridget Boyce to have held a central copy of portfolios with evidence of training undertaken and appraisals and staff would also hold their own copies for their records … there were significant gaps in the evidence of staff training having been undertaken.’

126. The Panel preferred the evidence of SMcL in respect of this Particular. The Panel was satisfied that the Registrant did not ensure that staff received adequate training.
127. Accordingly, the Panel found Particular 3 proved.

4. Did not ensure that record keeping within the Department was being carried out to the required standard, in that you:
a. In or around January 2015 instructed staff members to backdate staff training documents to make it appear the documentation had been completed in around November 2014 when it had not;

128. The Registrant accepted the facts of this Particular in her evidence but did not, in the course of the Hearing, make a formal admission to Particular 4(a).
129. NMcD stated that, in January 2015, in the run up to the UKAS inspection of the Lab, the Registrant instructed staff to backdate training documents to 24 November 2014. The date selected was the date the extended working day had come through. NMcD stated that, by that date, it was assumed that all staff had been trained in all relevant areas. The Panel had regard to an email, dated 20 January 2015, sent to JD by the Registrant in response to JD’s email to her on the same date. JD had emailed the Registrant to enquire as to what date should be specified for training on the competence certificate. In her email, the Registrant stated:
‘… put in the date 24/11/14 because on that date it was accepted that all staff could complete the tasks prior to the implementation of the extended working day.’

130. The Panel noted the Registrant’s evidence and the evidence given by NMcD. The Panel was satisfied, on the evidence, that the Registrant instructed staff members to backdate staff training documents to make it appear that the documentation had been completed in or around November 2014 when it had not.
131. Accordingly, the Panel found Particular 4(a) proved.

b. Recorded and/or informed colleagues that you had carried out staff appraisals, when you had not done so;

132. The Registrant admitted this Particular.
133. GMcN, in his evidence, stated that, as part of his role, he was responsible for informing senior management as to the number of appraisals that had been carried out during the year. GMcN told the Panel that he had received an email from the Registrant, dated 5 December 2013, in which she advised GMcN that she had appraised 11 Lab staff. The email, to which GMcN referred, was before the Panel.
134. The Panel noted the Registrant’s admission to this Particular and had regard to the evidence of GMcN and the documentary evidence.
135. Accordingly, the Panel found Particular 4(b) proved.

c. did not complete and/or escalate non-conformity forms;

136. The Registrant admitted this Particular.
137. MMcK gave evidence as to the importance of non-conformity forms as the basis by which to identify any issue of concern occurring in the Lab and, at Quality Meetings, agreeing effective action to address those issues. It was MMcK’s evidence that, at Quality Meetings, the Registrant would indicate that none of the non-conformity forms completed within her department were for discussion. That is to say, the non-conformities were low risk and no trend had been identified. MMcK stated that, subsequent to the UKAS inspection in March 2015, he and GMcN discovered non-conformity forms in the Registrant’s office which should have been brought to the Quality Meetings for discussion. None of the non-conformity forms had been closed off and no corrective actions had been put in place.
138. GMcN’s evidence was as follows:
‘The investigation team found a significant number of non-conformity forms in Bridget Boyce (sic) office that had not been filled out correctly or actioned or closed.’

139. GMcN carried out an audit of the non-conformity forms raised. He concluded that the Registrant, on a consistent basis, was closing off only a small number of them.
140. JD’s evidence was that, as the UKAS inspection was approaching, she started to attend some Quality Meetings. She stated:
‘I did not have any experience of these meetings and therefore it took me some time to understand what was going on and the language used at the meetings. I do remember that I knew from people's frustration that something was going on with Bridget Boyce and the non-conformity forms. I think there was talk of non-conformities being reported as completed when nothing had been … there were times at these meetings where Bridget Boyce would say that non-conformities had been dealt with appropriately when this was not true …’

141. The Panel noted the Registrant’s admission to this Particular and had regard to the evidence of MMcK, GMcN and JD, together with documentary evidence.
142. Accordingly, the Panel found Particular 4(c) proved.

d. did not ensure accurate records of stock usage and/or product expiry dates were kept.

143. The Panel considered that the evidential basis underpinning this Particular was very similar, if not identical, to the evidence which was relevant to its consideration of Particular 1(h).
144. Accordingly, for the same reasons as those set out in respect of Particular 1(h), the Panel found Particular 4(d) proved.

5. In respect of Enniskillen Mortuary, you did not:
a. Identify and/or address the fact that bodies and/or body parts were being stored for longer than indicated in the Trust’s Standard Operating Procedures;

145. In so far as the storage of body parts was concerned, the Registrant’s evidence was ‘I don’t recall the timeframe but I know in the procedure it says [body parts] to be kept for at least 14 days.’ Further, the Registrant stated that, as far as she could recollect, there was no reference in the applicable SOP which governed the storage of bodies.
146. In order for the Particular to be proved, the Panel needed to be satisfied that there was, in evidence, a SOP which specified the maximum period for which bodies and/or body parts could be stored.
147. The Panel carefully considered the following SOPs:
a. Fixation of Organs & Specimen Storage;
b. Release of Bodies Policy;
c. Identification and Registration of Bodies Policy; and
d. Mortuary Admission Policy.

148. The Panel noted that the Mortuary Admission Policy, under the heading ‘Collection and Disposal of Amputated Limbs’ provided as follows:
‘If limb requires hospital disposal it is to be held in mortuary freezer for at least 14 days before disposal.’

149. The Panel further noted that the Mortuary Admission Policy, although prepared by MMcK on 25 February 2015, did not have an implementation date until 23 May 2015, which was a period falling outside the scope of the Allegation.
150. From its careful consideration of the SOPs, it was plain to the Panel that none of them specified a maximum period for which bodies and/or body parts could be stored.
151. The Panel had regard to the UKAS Assessment Report, dated 12 March 2015, which stated as follows:
‘The procedures state that bodies are not retained in the body store for longer than seven days…’

152. In relation to this passage, GMcN’s evidence was as follows:
‘The [UKAS] assessor also found a body stored in the fridge at Enniskillen for longer than indicated in the SOP, i.e. for over a week, when the procedure stated that the bodies were not to be retained for longer than seven days. I am unaware of the SOP that the assessor was referring to; it is possible that he was looking at an old document.’

153. In the Panel’s view, the available evidence did not establish that there was, at the material time, a SOP which specified the maximum period for which bodies and/or body parts could be stored.
154. Accordingly, the Panel found Particular 5(a) not proved.

b. Ensure that there was an assurance process for the release of bodies;

155. The Registrant’s evidence was that processes were in place, which had been written in conjunction with mortuary staff, for the release of bodies.
156. The Panel also had sight of those policies, referred to in its decision in respect of Particular 5(a), in which, amongst other matters, the release of bodies was addressed.
157. There was no evidence presented at the Hearing, by the HCPC, which demonstrated that the Registrant had failed to ensure that there was an assurance process for the release of bodies.
158. Accordingly, the Panel found Particular 5(b) not proved.

c. Ensure that the Mortuary Register was completed accurately;

159. The Registrant, in her evidence, accepted that, on the day of the UKAS inspection in March 2015 and in respect of one body, the mortuary register had been not completed accurately. The Registrant put this omission down to nervousness on the part of the mortuary technician on the day of the inspection. With the exception of that occurrence, the Registrant made no admission, in general terms, to the Particular.
160. GMcN’s also gave evidence in relation to the incident on the date of the UKAS inspection in March 2015. Further, GMcN stated:
‘As the Service Manager responsible for the mortuary, Bridget Boyce should have had the procedure for checking in and checking out bodies written up clearly for staff to refer to. She also should have been carrying out regular competency audits of the staff to ensure that they were competent to carry out this task. There were no training records available for these mortuary staff.’

161. The Panel was persuaded by GMcN’s evidence and was satisfied that, in her capacity as Service Manager, the Registrant had not ensured that the mortuary register was completed accurately.
162. Accordingly, the Panel found Particular 5(c) proved.

d. ensure adequate policies were in place regarding the storage of bodies and/or body parts;

163. The Panel considered that the evidential basis underpinning this Particular was very similar, if not identical, to the evidence which was relevant to its consideration of Particular 5(a).
164. The Panel considered that the applicable policies, amongst other things, addressed the procedure for the storage of bodies and/or body parts. There was no evidence before the Panel to call into question the adequacy of the policies.
165. Accordingly, the Panel found Particular 5(d) not proved.

e. ensure staff received adequate training;

166. The Registrant’s evidence was that training was arranged by her but was undertaken by member of Trust staff who went off sick in September 2014 and never came back to work. That member of staff held the key to training records to which the Registrant did not have access.
167. In the notes of a meeting between GMcN and PMcK, then Lead BMS, on 20 April 2016, PMcK is recorded as stating:
‘Mortuary staff have no knowledge of training records, training manuals, appraisals. Bridget never attended the mortuary on a regular basis.’

168. In the notes of a meeting between GMcN and PM, Section Lead for Mortuary, on 25 April 2016, PM is recorded as stating that the training of mortuary staff was ‘very irregular’ and ‘not documented.’
169. The Panel preferred the evidence of PMcK and PM as recorded in the notes in respect of this Particular. The Panel was satisfied that the Registrant did not ensure that mortuary staff received adequate training.
170. Accordingly, the Panel found Particular 5(e) proved.

f. attend the mortuary and/or send a Senior BMS on your behalf on a regular basis.

171. The Registrant admitted this Particular.
172. In his evidence, GMcN stated as follows:
‘Bridget Boyce was manager of department, which included the mortuary services, therefore should have been either physically attending the … mortuary or sending a Senior BMS on her behalf on a regular basis, to ensure that everything was being done properly.’

173. In the notes of a meeting between GMcN and PMcK, then Lead BMS, on 20 April 2016, PMcK is recorded as stating:
‘Mortuary staff have no knowledge of training records, training manuals, appraisals. Bridget never attended the mortuary on a regular basis.’

174. The Panel noted the Registrant’s admission to this Particular and had regard to the evidence of GMcN and PMcK as recorded in the notes.
175. Accordingly, the Panel found Particular 5(f) proved.

6. Your conduct at paragraphs 4(a) and/or 4(b) was:
a. Misleading

176. When considering Particular 6, the Panel considered Particular 4(a) and Particular 4(b) separately and decided, first, whether the Registrant’s actions in respect of each Particular were misleading and, second, whether they were dishonest.
177. When approaching the question as to whether the Registrant's actions were misleading, the Panel looked at the natural and ordinary meaning of that word; namely, to cause a person to believe that something was correct when in fact it was not. The concept is devoid of intention.
178. In respect of Particular 4(a), the Panel was satisfied, by instructing staff members to backdate staff training documents, that the Registrant’s actions were misleading. The Registrant’s instruction would give a false picture that the training undertaken had been completed in or around November 2014 when, in fact, it had not.
179. Accordingly, the Panel found Particular 6(a) in respect of 4(a) proved.
180. The Registrant had admitted, in respect of Particular 4(b), that her actions were misleading. The Panel was in no doubt that the Registrant’s admission in that regard had been properly made. The contents of the Registrant’s email to GMcN, dated 5 December 2013, that 11 staff had been appraised was false.
181. Accordingly, the Panel found Particular 6(a) in respect of 4(b) proved.

b. Dishonest

182. The Panel considered whether the Registrant’s actions, at Particular 4(a), were dishonest. The Panel first addressed the Registrant’s ascertainable state of mind at the time during which the alleged dishonesty arose.
183. The Panel had regard to the fact that the instruction to backdate staff training records occurred in the time preceding the UKAS inspection which was scheduled to take place in March 2015. The evidence from witnesses, including the Registrant herself, was that the lead up to the UKAS inspection was a challenging and stressful time for all the staff concerned. The evidence suggested that the relevant training, as required as part of the UKAS accreditation process, had been completed by staff. The evidence further suggested that the Registrant’s instruction to backdate the training records was to take account of the extended working day. The Panel was satisfied that the Registrant’s actions in selecting November 2014 was not due to dishonesty. She had specified November 2014 as the date as it aligned with processes being undertaken within the Lab as part of the preparation for the UKAS inspection.
184. Accordingly, the Panel found Particular 6(b) in respect of 4(a) not proved.
185. The Panel considered whether the Registrant’s actions, at Particular 4(b), were dishonest. The Panel first addressed the Registrant’s ascertainable state of mind at the time during which the alleged dishonesty arose.
186. GMcN was responsible for informing senior management at Altnagelvin as to the number of staff appraisals which had been carried out by managers. In the discharge of that responsibility, GMcN requested that the Registrant provide him with the number of staff in respect of whom appraisals had been conducted.
187. In her email to GMcN, dated 5 December 2013, the Registrant replied:
‘Laboratory staff 11 staff complete…’

188. In these proceedings, the Registrant had admitted that she had not conducted staff appraisals on a regular basis. There was compelling evidence from NMcD, JD and SMcL that, at best, staff appraisals were sporadic and unstructured. There was no evidence to support what the Registrant had written in the email. It was, on the evidence, plainly false.
189. In taking account of the Registrant's understanding of the circumstances, the Panel concluded that an ordinary decent person would find the Registrant’s actions, as found proved in Particular 4(b), to be dishonest.
190. Accordingly, the Panel found Particular 6(b) in respect of 4(b) proved.

Decision on Grounds

191. At the grounds and impairment stage of the proceedings, in answer to questions from the Panel, the Registrant explained how she would do things differently if similar circumstances arose in the future. The Registrant stated that she would complete a gap analysis and conduct a traffic light system.
192. In her current role, the Registrant told the Panel that she has weekly meetings with her General Manager and goals are achieved as a result of regular communication with her team. She told the Panel she has management responsibility for a team of 9 people.
193. Further, the Registrant told the Panel that she was not currently working in a regulated role and that her managers in her current position had been aware, at all stages, of the HCPC investigation to which she was subject. They have provided testimonials on her behalf.

Parties’ submissions

194. Mr Foxsmith, at the outset of his submissions, told the Panel that the HCPC acknowledged that the Registrant was a competent and experienced practitioner. This was demonstrated on the evidence, both prior to the period covered by the Allegation and at the present time, as illustrated by the professional testimonials submitted on the Registrant’s behalf. Mr Foxsmith stated that he had no instructions to withdraw that part of the Allegation which alleged current impairment by reason of lack of competence. Although a matter for the independent judgement of the Panel, Mr Foxsmith submitted that this was a case in which the Registrant was alleged to be currently impaired by reason of misconduct and not as a result of any lack of competence on her part.
195. Mr Foxsmith submitted that the Registrant’s actions, as found proved, amounted to misconduct. He invited the Panel, in consequence, to make a finding that the Registrant’s fitness to practise was currently impaired in order to protect the public and uphold the public interest.
196. On the facts found proved, Mr Hamill acknowledged the possibility that the Panel might conclude that the Registrant’s conduct amounted to misconduct. He submitted that such a finding, in the absence of a separate finding of current impairment, was sufficient to protect the public and uphold the public interest. In the alternative, he submitted that, if the Panel went on to consider current impairment of the Registrant’s fitness to practise, such a finding should only be made in respect of the public interest.
197. Before retiring to consider its decision on statutory grounds and impairment, the Panel received advice from the Legal Assessor which it accepted. The Panel was reminded that at this stage of the proceedings it was required to exercise its independent judgement in relation to the oral and documentary evidence presented at the Hearing.
198. In relation to the statutory ground of lack of competence, the Panel was referred to the following authorities: Holton v GMC [2006] EWHC 2960 (Admin), R(Calhaem) v GMC [2007] EWHC 2606 (Admin) and Vali v GOC [2011] EWHC 310 (Admin). In relation to the statutory ground of misconduct, the Panel was referred to Roylance v GMC (No2) [2000] 1 AC 311. The Panel was also referred to the HCPTS Practice Note, ‘Fitness to Practise Impairment’ (February 2022) and CHRE v NMC and Grant [2011] EWHC 97 (‘Grant’).
199. The Panel carefully considered the oral and documentary evidence, together with the parties’ submissions.

Standards

200. The Panel considered that, during the material time covered by the Allegation, the Registrant had breached the following professional standards:
HCPC Standards of Conduct, Performance and Ethics (July 2008)
Standards 1, 5, 6, 7, 8, 10 and 13

HCPC Standards of Conduct, Performance and Ethics (January 2016),

Work with colleagues
2.5 You must work in partnership with colleagues, sharing your skills, knowledge and experience where appropriate, for the benefit of service users and carers.
2.6 You must share relevant information, where appropriate, with colleagues involved in the care, treatment or other services provided to a service user.
4 Delegate appropriately.
6 Manage risk.
Identify and minimise risk
6.1 You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.
6.2 You must not do anything, or allow someone else to do anything, which could put the health or safety of a service user, carer or colleague at unacceptable risk.
9. Be honest and trustworthy.
Personal and professional behaviour
9.1 You must make sure that your conduct justifies the public’s trust and confidence in you and your profession.
10 Keep records of your work.
Keep accurate records
10.1 You must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to.
10.2 You must complete all records promptly and as soon as possible after providing care, treatment or other services.

Decision on lack of competence

201. The Panel noted that lack of competence involved the consideration of an unacceptably low standard of professional performance, judged on a fair sample of work, which could put patients at risk. When addressing the question of lack of competence, the Panel was aware that it would need to measure the standard of the Registrant’s performance against that expected of a competent practitioner in the circumstances.
202. The Panel agreed with Mr Foxsmith’s submissions and, for the reasons he advanced, concluded that the facts found proved at Particulars 1(a) to 1(f), Particular 1(h), Particular 2, Particular 3, Particular 5(c) and Particulars 5(e) and 5(f) did not amount to a lack of competence on the Registrant’s part.

Decision on misconduct

203. The Panel considered, in respect of those Particulars found proved, whether they amounted to misconduct on the Registrant’s part.
204. The Panel noted that it had made findings in respect of a number of aspects of the Registrant’s practice which related to failings in her clinical practise, staff training and appraisals, record keeping together with failings in the Registrant’s management of the mortuary at the SWAH, Enniskillen.
205. The Panel considered each of these elements in turn.
206. Over a significant period, in her capacity as Lead BMS at the Lab, the Registrant had engaged in a series of clinical failings in relation to the use of antibodies. As the evidence demonstrated, the proper utilisation of antibodies was fundamental to the effective functioning of the Lab. Although there was no evidence that patients had come to harm as a result of the Registrant’s actions, the risk of harm could not be discounted. The Panel recalled the evidence of GMcN who stated that the failure to ensure that antibodies had been properly tested and/or verified prior to use presented the risk that the Lab might provide clinically inaccurate information and, in consequence, inaccurate diagnoses to patients.
207. As a result, the Panel was satisfied that the Registrant’s clinical failings, in her capacity as Lead BMS at the Lab at the material time, represented a serious departure from the applicable standards and amounted to misconduct.
208. The Panel had found that the Registrant had failed to conduct adequate training and regular appraisals of staff at the Lab. The impact of these failings was set out starkly by NMcD who stated as follows:
’Looking back now, I see that under Bridget Boyce I was not functioning to the level I should have been and thought I was. Even a few months after Bridget Boyce left the Trust I could see what Band 7s did at ward level and their other responsibilities and recognised that we were not on the same level…
With the implemented changes since Bridget Boyce has left each staff member has regular line management meetings and appraisals so they can express whether they feel they are meeting the requirements of their role and are given the opportunity to flag if they have areas where they feel they require assistance.’

209. The evidence was that adequate staff training and regular appraisals had an essential part to play in ensuring that the Department in general, and the Lab in particular, was performing effectively. Over a considerable period, by failing to advance training and conduct appraisals, the Registrant had had a detrimental impact on the performance of the Lab and the staff employed by the Trust to work there.
210. The Panel was satisfied, in failing to ensure adequate training and by not conducting staff appraisals on a regular basis, that the Registrant’s actions fell far below the standards to be expected of a registered BMS and amounted to misconduct.
211. The Panel was satisfied that the Registrant’s dishonest assertion to GMcN that staff appraisals had been carried out when, in fact, they had not, taken together with her failure to properly utilise non-conformity forms and failure to document stock usage and expiry dates was a serious departure from accepted standards by the Registrant and amounted to misconduct. The Panel considered that its finding, at Particular 4(a), that the Registrant had instructed staff to backdate training records to November 2014, while crossing the threshold of misconduct was not, taken on its own, sufficient to amount to serious misconduct. This conclusion was reached by the Panel on the same basis which had resulted in the Panel’s conclusion that the Registrant’s actions, while misleading, were not dishonest.
212. With regard to its findings in respect of the mortuary at Enniskillen, the Panel was satisfied that the Registrant’s failure to ensure that mortuary staff were adequately trained and her failure to maintain effective oversight of the mortuary, in her capacity as manager, was a serious departure from the applicable standards and amounted to misconduct. The Panel had made a finding that, on the occasion of the UKAS inspection, a member of the mortuary staff had made an incorrect entry in the mortuary register. Although the Registrant, in her capacity as manager, had the ultimate responsibility for ensuring the mortuary register was accurately completed, the evidence suggested that the error on the date in question had arisen as a result of human error rather than any deliberate act or omission on the Registrant’s part. Accordingly, in relation to Particular 5(c), the Panel was not satisfied that its finding in relation to that Particular, taken on its own, was sufficient to amount to misconduct.

Decision on Impairment

213. To the Panel’s mind, the misconduct which underpinned the Allegation comprised attitudinal issues and clinical failings on the Registrant’s part. In principle, with appropriate evidence of insight and remediation, the Panel accepted that the Registrant’s misconduct was capable of remedy.
214. The Panel next considered whether, in fact, the Registrant’s misconduct had been remedied. The Panel acknowledged that, following her departure from the Trust, the Registrant had not worked in a clinical setting as a BMS. In the interim period, however, while not working in a regulated role, the Registrant had worked in a managerial role in the public health arena in the Republic of Ireland. She is responsible for managing 9 staff in her current capacity as a Business Manager in Public Health Medicine with the HSE. Prior to that, the Registrant had worked for the HSE as a swabber in a COVID testing centre.
215. The Registrant expressed regret and remorse for her failings. In particular, the Registrant apologised for the email sent by her to GMcN, the contents of which the Panel had found to be false and dishonest. The Registrant set out matters related to her health and family life with which she was dealing at the material time. The Registrant pointed to what she described as ‘the failure of the communication systems within the department’, combined with a failure to bring her personal and professional difficulties to senior managers, as significant contributing factors which had ultimately resulted in her referral to the HCPC.
216. In her reflective piece, which had been submitted to the Panel on the day of the Hearing on which grounds and impairment were considered, the Registrant accepted the negative impact which her actions, as Lead BMS at the material time, would have had on her professional colleagues, her regulatory body and the public in general. The Registrant identified how clear and unambiguous communication with the team; an appreciation as to how personal difficulties could negatively impact one’s working life and how effective team training were key factors in preventing a repetition of the conduct which had resulted in her regulatory referral.
217. The Panel also had regard to the professional testimonials which had been submitted to the Panel on the Registrant’s behalf. The testimonials spoke highly of the Registrant, both personally and professionally.
218. In particular, the Panel had regard to the testimonial of Ms MO’D dated 20 February 2023. Ms MO’D, who is a Clinical Nurse Manager employed by the HSE, stated that she had left her employment to work in the community as a result of alleged bullying in the workplace. Ms MO’D stated that this had happened prior to the Registrant being employed in her former place of work and she was persuaded to return there by the Registrant after the Registrant had taken up her role.
219. Ms MO’D stated:
‘I started back in the department on September 5th and although the department was undergoing reform and amalgamation … it was obvious that Bridget had everything under control. She had undertaken risk assessments and audits and had policies and procedures in place that were not there when I left - she very much works to guidelines and maintains a well-structured and disciplined department, where party of all staff is obviously paramount to her.
…
I can unreservedly say that Bridget is conscientious in her work and does everything she can to ensure the safety of all around her, be that through policy and guidelines and/or ensuring respect and dignity is shown to all staff, regardless of role or title.’

220. Ms MMcG, a qualified nurse, who worked alongside the Registrant during the COVID pandemic, also provided a testimonial. She described how the Registrant, in her non-clinical role, was responsible for ensuring all patient samples were correctly labelled and that samples arrived at the laboratory and were properly accounted for. In that regard, Ms MMcG stated that ensuring samples were properly accounted for resulted, on one occasion, in the Registrant working unsocial hours in the performance of her duties.
221. Further, Ms MMcG stated:
‘Bridget Boyce began her role as Deputy/Covid Lead for the entire centre in February 2021 and this role included, amongst others, the collection, scanning, packing, and assorting into several categories and dispatching of samples on time and to the correct laboratories, including drawing up Off Duty and responsibility for 20+ staff members. All the while Bridget Boyce never failed to encourage those around her and was always approachable should staff need her time.
…
Bridget Boyce provided Standard Operating Procedures that were protocol driven, and carried out Audits to ensure the standards of the Centre were maintained or could be improved. Bridget Boyce’s dedication to her role and those of her colleagues provided the centre with achieving its first successful Audit. This included examination of the Site Safety Statement, Internal Emergency Plan, Risk Assessments, Chemical Risk Assessments, and Chemical Data Sheets amongst others.’

222. The Panel was mindful that the Registrant had not worked as a clinician since her departure from the Trust. While some elements of the Registrant’s evidence and written reflections tended to be self-focussed, nevertheless, the Panel considered that she had demonstrated developing insight into the seriousness of her misconduct and the negative impact which her actions could have had on patients and the public. The detailed testimonials presented by her current work colleagues, albeit in a different but not entirely dissimilar context, painted an encouraging picture of the Registrant. She had worked in a challenging environment and was well regarded, both personally and professionally. The Registrant was also considered by her colleagues as an approachable and effective leader and manager.
223. The Panel’s view was that while the Registrant did not have full insight into her misconduct, nevertheless, her insight into her misconduct was developing. She had placed before the Panel evidence of remediation, together with relevant professional testimonials. Accordingly, while repetition of the behaviour complained of could not be entirely discounted, having regard to the evidence of insight and remediation, in the Panel’s judgement, the risk of repetition was low.
224. The Panel considered the formulation provided by Dame Janet Smith in the Fifth Report to the Shipman Inquiry (cited with approval by Cox J in Grant) as follows:
‘Do our findings of fact in respect of [the Registrant’s] … misconduct…show that her fitness to practise is impaired in the sense that she:
1. has in the past acted and/or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and/or
2. has in the past brought and/or is liable in the future to bring the … profession into disrepute; and/or
3. has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the … profession; and/or
4. has in the past acted dishonestly and/or is liable to act dishonestly in the future.’

225. In light of its findings, looking backwards, the Panel considered that all four limbs of the formulation in Grant were engaged. However, having regard to its findings concerning the Registrant’s insight together with evidence of remediation, the Panel’s judgement was, looking forwards, that all four limbs of the formulation in Grant were not engaged.
226. Accordingly, the Panel is satisfied that a finding that the Registrant’s fitness to practise is currently impaired is not required to protect the public.
227. The Panel next considered whether a finding of current impairment was required in the public interest. The Panel reminded itself that the public interest comprised public protection, but also comprised broader concepts such as the need to maintain public trust and confidence in the profession and the need to declare and uphold proper professional standards.
228. The Panel had made findings in respect of the Registrant’s clinical practice which had had the potential to cause harm. She had failed to exercise proper oversight of the mortuary for which she had responsibility and had failed to ensure mortuary staff were adequately trained. The Registrant had also failed to maintain adequate training and conduct regular appraisals for Lab staff. The failings concerned a significant number of different elements of the Registrant’s practice over a significant period. The Panel concluded that the public’s trust and confidence in the profession would be seriously undermined if a finding of current impairment was not made. Further, the Panel concluded that not to make such a finding would fail to declare and uphold proper standards of conduct in the profession.
229. Accordingly, the Panel is satisfied that a finding that the Registrant’s fitness to practise is currently impaired is required in the public interest.
230. For these reasons, the Panel concludes that the Registrant’s fitness to practise is currently impaired, on public interest grounds, by reason of her misconduct.

Decision on Sanction

231. The Panel heard a submission from Mr Foxsmith on the question of what, if any, sanction should be imposed on the Registrant’s registration. He drew the Panel’s attention to the applicable Sanctions Policy (‘SP’) (March 2019) and set out what, in his estimation, were the aggravating and mitigating features in this case. Mr Foxsmith left the determination of sanction to the independent judgement of the Panel.
232. At the sanction stage, the Panel was provided with written submissions by Mr Hamill. He submitted, in light of the evidence and findings of the Panel, that the appropriate sanction to impose would be a Caution Order or, in the alternative, a short Suspension Order.
233. The Panel heard and accepted the Legal Assessor’s advice. The Panel, he advised, should exercise its independent judgement to arrive at a proportionate sanction that would adequately protect and uphold the public interest. The Panel was also advised to have proper regard to the SP.
234. The Panel carefully considered the available oral and documentary evidence which had been presented at the Hearing, together with the parties’ submissions.
235. At the outset, the Panel concluded, in accordance with its findings at the statutory grounds stage of the proceedings, that, should it be minded to impose a sanction, there were no concerns about the Registrant’s competence or clinical practice which would call for the imposition of conditions.
236. In accordance with paragraphs 25 to 41 of the SP, the Panel considered the mitigating factors. The Panel identified the following mitigating factors:
a. evidence of insight, albeit the Registrant’s insight was developing and was not, as yet, complete;
b. evidence of genuine regret and remorse, in both the Registrant’s oral evidence and in her reflective piece; and
c. evidence of appropriate remediation.

237. In accordance with paragraphs 42 to 55 of the SP, the Panel considered the aggravating factors. The Panel identified the following aggravating factors:
a. risk to the safety of patients;
b. adverse impact on the effective running, performance and progression of the Lab and mortuary;
c. adverse impact on colleagues; and
d. series of failures over a protracted period.

Mediation/ No Further Action

238. The Panel first considered the sanction of mediation and concluded that it was not appropriate - the matter was too serious to be resolved in this way. The Panel was of the same view in relation to the conclusion of the proceedings by taking no action.

Caution Order

239. The Panel next considered a Caution Order. Such a sanction, in accordance with paragraphs 101 and 102 of the SP, was deemed appropriate where:
‘101. […] the issue is isolated, limited, or relatively minor in nature; there is a low risk of repetition; the registrant has shown good insight; and the registrant has undertaken appropriate remediation.
102. A caution order should be considered in cases where the nature of the allegations mean that meaningful practice restrictions cannot be imposed but a suspension of practise order would be disproportionate.’

240. When considering the appropriateness or otherwise of a Caution Order, the Panel had careful regard to its findings and, in particular, that it had made a finding of dishonesty against the Registrant in relation to the email she had sent to GMcN in December 2014. The Panel had in mind paragraphs 56 to 58 of the SP which addressed how dishonesty findings should be considered in regulatory proceedings. The SP states:
‘56. The Standards of conduct, performance and ethics require registrants to be honest and trustworthy … Dishonesty undermines public confidence in the profession and can, in some cases, impact the public's safety.
57. Dishonesty, both in and outside the workplace, can have a significant impact on the trust placed in those who have been dishonest … It is likely to lead to more serious sanctions…
58. […] Panels should bear in mind that there are different forms, and different degrees, of dishonesty, that need to be considered in an appropriately nuanced way…’

241. In her reflective piece, the Registrant dealt with her dishonesty in this way:
‘I feel so stupid and upset that this email has potentially compromised my registration … I was literally trying to buy time for 3 weeks but I have learned the hard way - I should have reached out to the General Manager and requested some time and withdrawn the actual email. I can only explain this action as it relates to a very difficult time both personally and professionally.’

242. In assessing the seriousness of the dishonesty finding, the Panel noted that it related to a single act. The Panel was persuaded that the Registrant’s subsequent expressions of regret and remorse for sending the email were genuine. Accordingly, while recognising that any finding that a practitioner had acted dishonestly was serious, for the reasons outlined, the Panel considered that the Registrant’s dishonesty, in this single instance, was at the lower end of the spectrum of seriousness.
243. The Panel concluded that the majority of the features identified by the SP which would make the imposition of a Caution Order were present in this case. The Registrant had demonstrated developing insight and had provided appropriate evidence of remediation. Further, the Panel had identified that there was a low risk of repetition.
244. The findings made in this case, over the period covered by the Allegation, could not be said to be limited nor that they represented an isolated incident. However, after careful consideration, the Panel was persuaded that the findings made against the Registrant could properly be characterised as an isolated episode. The Registrant has been a registered BMS for the best part of thirty years. She had shown developing insight and had expressed genuine regret and remorse for her actions. She had taken appropriate steps to remediate her misconduct and, in the years following the period covered by the Allegation, the Registrant had not come to the adverse attention of her regulatory body.
245. On balance, taking these factors together, the Panel was persuaded that the imposition of a Caution Order, rather than imposing a Suspension Order, was the appropriate and proportionate sanction to apply which would uphold and protect the public interest.
246. Given the nature and extent of its findings, the Panel considered that the imposition of a Caution Order, for the maximum period of 5 years, rather than a short Suspension Order was required to mark the seriousness of the misconduct established in this case, to act as a deterrent and to bring home to the Registrant that her actions were unacceptable and must not happen again.
247. That brings these proceedings to an end.

Order: The Registrar is directed to annotate the Register entry of Mrs Bridget Boyce with a caution which is to remain on the Register for a period of 5 years from the date this Order comes into effect.

No notes available

History of Hearings for Bridget M Boyce