Mr Gareth E Williams

: Speech and language therapist

: SL31094

: Final Hearing

Date and Time of hearing:10:00 20/02/2017 End: 17:00 23/02/2017

: Health and Care Professions Council, 405 Kennington Road, London, SE11 4PT

: Conduct and Competence Committee
: Conditions of Practice

Allegation

Between 11 March 2013 and 18 November 2014, during the course of your employment as a Speech and Language Therapist by The Dudley Group NHS Foundation Trust:

 

1. You demonstrated unsafe practice, in that:

 

a). On the 02 October 2014, during and/or following a visit to Patient B:

(i) you did not contact the GP service to update them of the outcome of a second food trial;

(ii) you did not complete clinical notes in relation to the visit, within the required timescales;

(iii) you contacted the GP service and discussed 'feed at risk' and/or 'enteral feeding' without getting advice from a senior speech and language therapist.

(iv) you did not document a telephone call with a senior speech and language therapist and/or the clinical advice which was given

(v) you did not set goals within your follow up notes

(vi) you did not record use of the East Kent Outcome System (EKOS) on the outcome measure sheet in the patient records

 

2. You did not keep accurate and/or contemporaneous records, in that:

 

a) . In November 2013, in relation to Patient C, you recorded the patient had declined an assessment, even though the assessment was not carried out because you were late.

 

b) . In December 2013, an audit of 20 of your case files was carried out and it was found:

(i) you did not record complete notes and/or document visits for 7 sets of case notes;

(ii) you did not record the correct information for 1 set of case notes

(iii) you retrospectively added entries for 2 sets of case notes

(iv) you inappropriately duplicated notes

(v) you did not record and/or complete discharge and/or follow-up appointments within the required timescales

(vi) you did not document when letters and/or faxes were sent, in a least one set of case notes

(viii) you did not accurately record the number of NCRS contacts and/or diarised appointments, in at least 1 set of case notes

 

c) . Following a visit to a patient on 9 April 2014, you did not complete the patient follow up document within 24 hours.

 

3. Following a visit in October 2014, you inappropriately took home 3 sets of patient notes belonging to Patients D, E and F, making the said notes unavailable for clinical intervention by another therapist.

 

4. The matters described in paragraphs 1 - 3 constitute misconduct and/or lack of competence.

 

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

 

Finding

Preliminary matters:

Application to amend the Allegation


1. At the outset of proceedings, Ms Sheridan made an unopposed application to amend the Allegation. Due notice had been provided to the Registrant in a letter from the HCPC on 23 December 2016.  The stated purpose was to reflect the evidence better and involved the removal of some of the wording of the particulars. 


2. The Panel determined that it was in the interests of justice to grant the application.

Application to proceed in private

3. Ms Sheridan made another unopposed application for a small part of these proceedings that made reference to the health of the Registrant to be held in private. Again, the Panel found it appropriate to grant this application.

Background:

4. The Registrant’s first, post qualification, employment was with the Dudley Group NHS Foundation Trust (the Trust) as a Speech and Language Therapist (SLT) which started on 11 March 2013.

5. The Registrant’s post as a Band 5 SLT included 6 monthly rotation through various clinical specialties.  The rotation commenced in May 2013.  Mr Williams’ first rotation was working across ‘acute in-patient stroke wards’ for 1 day per week and 3 days in community services where his clinical caseload included working with patients in a clinic setting and in their homes.  During this rotation the community SLT services transferred to a new multi-disciplinary service, Dudley Rehabilitation Service, which remains part of the Dudley Group, and, as his rotation was in part with community service, the Registrant moved with the rest of the SLT team.


6. The Registrant was responsible for assessing, treating and managing adult patients with communication disorders and, once he had completed his post graduate dysphagia training, this also included patients with swallowing difficulties.

7. Concerns were first raised about the Registrant’s note keeping and time management in October 2013 and therefore Stage 1 Capability Proceedings commenced in accordance with the Trust Capability Policy. To support the Registrant’s development it was decided to reduce patient contact and supervision was increased to weekly structured supervision.

 
8. On 8 November 2013, concerns were raised that the Registrant’s record keeping was not up to SLT standards.  In his notes for Patient C he recorded that the patient had declined an assessment and that the visit had ended early. On investigation, however, it transpired that the Registrant in fact was late in arriving for the visit and did not undertake the assessment (this is the subject of particular 2(a)). On 13 November 2013, the Registrant admitted that this record was not a true reflection of events. 


9. As a result of this matter coming to light, in December 2014 a review of the Registrant’s case load was undertaken. This revealed that a number of entries in patients’ records had not been made contemporaneously with appointments.


10. Standing Operating Procedure (SOP) stipulates that ‘records should be written as soon as possible after an event has occurred (but not later than 24 hours) to ensure information is current and accurate.’ The following omissions were discovered:


• Patient H (particular 2(b)(i)). The Registrant completed a partial note which recorded that he had conducted a visit to this patient on 6 November 2013. However, the note was not completed until 13 November 2013.  


• Patient I (particular 2(b)(ii). The Registrant had completed a partial note recording that a visit had been conducted by him to this patient on 21 October 2013. This note, though, was not completed until 13 November 2013. 

• Patient J (particular 2(b)(iii)). An appointment for this patient was scheduled for 6 November 2013.  However, the only reference to this was one of 13 November 2013 which stated ‘note following entry written from memory of 6/11/13 at 13.30’.

• Patient K (particular 2(b)(iv)). The Registrant made an entry in this patient’s notes which gave no details as to whether the contact had been made by him over the telephone or face-to-face. Neither was there a record of any handover. The entry was unfinished and unsigned. 


11. In relation to particular 2(c), the review found that the Registrant had made 2 separate entries for Patient L on 9 November 2013. Neither corresponded with the other and the final recommendation differed.  The entry in the second set of notes was unfinished and unsigned.


12. In relation to particular 2(d)(ii), the Registrant, on 24 October 2013 sent a fax to the General Practitioner (GP) of Patient I, advising him that the patient had undergone a dysphagia assessment and needed a modified texture for food and the fax requested a thickener.  

 
13. Similarly, the Registrant sent a letter to the same GP on 13 November 2013 which was also omitted from the hand written patient notes (particular 2(d)(i)). 


14. As far as particular 2(e) is concerned, Patient G was seen by the Registrant on 9 April 2014 at 11.45am.  His notes were not written up until 4.30pm the next day. This followed one hour after a supervision session the Registrant had had with a Specialist SLT, during which it had emerged that the Registrant had not at that point written up his notes and that he could not identify the patient referred to in his crib notes.


15. In relation to particular 1, the Registrant attended an urgent visit to Patient B on 2 October 2014.  Patient B was an 86 year old lady with Parkinson’s disease who was having increasing difficulty in swallowing and was coughing regularly when taking fluids and diet.


16. Concerned that Patient B was unsafe on all diet intake, the Registrant contacted a GP and discussed with him “feed at risk” and/or “enteral feeding”. This was done without the Registrant asking for the requisite advice from a senior SLT (particular 1(iii)).


17. The GP confirmed a visit would be arranged. A Highly Specialist SLT at Russell’s Hall Hospital advised the Registrant to try to thicken fluid to a puree consistency. This was done and the Registrant phoned back to tell the SLT of its success. He was then advised to contact the GP to provide an update of the outcome of a second food trial, namely that Patient B was able to safely swallow.  The SLT further advised the Registrant that the patient would still benefit from a medical assessment of her respiratory functioning.  

 
18. The Registrant failed to update the GP of the outcome of the second food trial (particular 1(ii)).  Apparently, “it had slipped his mind”, as he later acknowledged. 


19. Patient B was later admitted to hospital and considered for enteral feeding based on the Registrant’s failure to update the information he provided to the GP in relation to the patient’s swallow status.


20. Particulars 1(ii), (iv), (v) and (vi) concern failures in the Registrant’s record keeping in relation to Patient B. The case record for the Registrant’s visit on 2 October 2014 was not completed by the Registrant until 13 October 2014, some 10 days after the incident.


21. Another omission was the absence in the patient notes of any details of the Registrant’s telephone call to the Senior SLT, or the recommendations that she gave (particular 1(iv)).


22. Similarly, there was no goal setting or an East Kent Outcome measure sheet in the patient records (particulars 1(v) and (vi)). 


23. The Registrant was suspended from work on 3 October 2014. Five days later, he accepted that he had unintentionally removed and had taken home the Patient notes of Patient F, whom he had seen on 30 September, Patient D (1 October) and Patient F (3 October) . This is the subject matter of the Allegation concerned within particular 3. The effect of this was that other individuals in the Registrant’s team had no access to these notes when needed.  

Decision on Facts


24. The Panel has considered all of the documentary evidence placed before it and has had regard to the testimony of the witnesses called by the HCPC. They were SL, the Registrant’s Line Manager from March 2013 and JG, who gave evidence, with the leave of the Panel, over the telephone, the Registrant’s Overall Service Manager from March 2013.


25. The Registrant himself gave evidence and provided a reference and Continuous Professional Development (CPD) documentation.

26. In the view of the Panel, all 3 witnesses gave credible and reliable evidence. 

27. The Panel accepted the advice of the Legal Assessor and paid due regard to the closing submissions from each side. 


28. In the knowledge that the requisite standard of proof is the civil standard, the Panel, in coming to its determination on the facts, paid particular regard to the fact that, from the outset of these proceedings, the Registrant had admitted all of the facts. 


29. With regard to the particulars of the Allegation, the Panel made the following findings:-
Particulars 1(i), (ii), (iii), (iv), (v), 2(a), (b)(i), (b)(ii), (b)(iii), (c), (d), (e), and 3 were found proved and admitted by the Registrant and confirmed by the documentary and oral evidence.  

 
Decision on Grounds:


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


31. Throughout its deliberations on these subjects, the Panel reminded itself that lack of competence is regarded as less serious than misconduct and that the proved facts, in appropriate cases, can amount both to misconduct and lack of competence.


32. As far as misconduct is concerned, the Panel was aware that this could not be found unless it judged that the conduct concerned was serious and brought the profession into disrepute.


33. As far as lack of competence is concerned, the Panel recognised that this is conceptually separate from misconduct and connotes a standard of professional competence which is unacceptable, in relation to a fair sample of the Registrant’s work.

34. Ms Sheridan submitted that the facts found proved in this case amounted, in the main, to lack of competence. She added that it could be said, in her contention, that particulars 2(e) and 3, might more appropriately fall within the category of misconduct. 


35. Mr Geering, for his part, invited the Panel to judge that none of the accepted factual failures of his client amounted to misconduct. He conceded, however, that many of them could be properly described as examples of lack of competence. Having said that, he added that the record keeping failures of the Registrant in October 2014, that are described within particular 1, could be seen as not forming part of a fair sample of the Registrant’s work at that time.  Furthermore, he sought to argue that the unintentional taking home of the three sets of patient notes (particular 3) should be seen in the context of a young man who, at the time, was suffering from the stress and pressure caused by the fact that he had just been suspended by the Trust.

36. With these submissions in mind and with consideration of all of the evidence in this case, the Panel’s judgment is as follows:

• The Registrant’s record keeping was well below the standard expected of a Band 5 SLT, even one newly qualified.  The October 2014 examples of failure in this regard formed part of a pattern of such shortcomings that had started a year earlier.

• The Registrant’s management of the assessment of Patient B and his concomitant failure to contact the GP service, despite being advised to do so by the Senior SLT, resulted in Patient B being admitted to hospital for an unnecessary assessment.

• In the immediate aftermath of his suspension from work he unintentionally took patients notes home in his bag. This act of carelessness put the patients concerned at risk.

37. The Panel found that the Registrant fell below the following ‘Standards of conduct, performance and ethics’:

• 1 – You must act in the best interests of service users;

• 5 – You must keep your professional knowledge and skills up to date;

• 7 – You must communicate properly and effectively with service users and other practitioners;

• 10 – You must keep accurate records.

38. The Panel found that the Registrant also fell below the following ‘Standards of proficiency for Speech and language therapists’:

• 1.2 – recognise the need to manage their own workload and resources effectively and be able to practise accordingly;

• 4.1 – be able to assess a professional situation, determine the nature and severity of the problem and call upon the required knowledge and experience to deal with the problem;

• 4.2 – be able to make reasoned decisions to initiate, continue, modify or cease treatment or the use of techniques or procedures, and record the decisions and reasoning appropriately;

• 10.1 – be able to keep accurate, comprehensive and comprehensible records in accordance with applicable legislation, protocols and guidelines.

39. In relation to all the proved facts, the Panel’s judgement is that the Allegation of lack of competence is well founded. 


Decision on Impairment 


40. Whether or not a Registrant’s fitness to practise is currently impaired is a question for the Panel alone. 


41. The Panel paid due regard to the submissions of both sides and reminded itself of the contents of the HCPC’s Practice Note entitled ‘Finding that Fitness to Practise is Impaired’. It also accepted the advice of the Legal Assessor.  

42. Ms Sheridan, in contending that the fitness to practise of the Registrant is currently impaired, emphasised the seriousness of the Registrant’s failings and stressed that these occurred even though, as he himself acknowledged, he had been given as much support as was possible by the Trust.

43. Ms Sheridan pointed out to the Panel that the work the Registrant had undertaken since October 2014 (a Youth Worker for six months and a manager within the retail sector since then), had no direct bearing on his ability to re-enter the profession successfully. The pressures were bound to be different. 

44. Mr Geering contended that the Registrant, at that time, had found it extremely difficult to cope with the pressures of work. He was a young man fresh from qualification, who was doing his best to rise above the personal difficulties that he was suffering from and, above all, now had had a long time to consider where things went wrong. Mr Geering further submitted that the Registrant has shown obvious remorse and a considerable degree of insight into his shortcomings.  He urged the Panel to take the view that the Registrant would never repeat such failures, particularly if, on returning to the profession, he was able to concentrate exclusively on work within a specific chosen clinical setting. It was the community aspect of the Registrant’s work that had caused these upheavals and he reminded the Panel that the Registrant had said he had no intention of returning to such work.

45. In reaching its determination, the Panel has had regard to the public interest in the wider sense – that is, the maintenance of public confidence in the profession and the upholding of proper standards of conduct and behaviour – and whether or not the conduct is likely to be repeated.  

46. As has been noted above, the Registrant has not been working in any capacity within the profession since October 2014.  He does, however, produce a testimonial dated 16 February 2017 from a SLT colleague, the content of which was disputed by the oral and documentary evidence adduced by the HCPC. He provided evidence of some recent reading that pertains, in particular, to the topic of record keeping.  The Panel noted the contents of the documents provided by the Registrant on this subject. 

47. He has shown much remorse and has demonstrated some insight into his failings.

48. Nevertheless, the Panel’s view is that if the Registrant were permitted to practise unrestricted in the future the risk of repetition of these shortcomings would be high. 

49. Consistent with this assessment, the Panel takes the view that there could be a risk of patient harm were the Registrant be able to practise without restrictions and, also, that public interest considerations demand that the appropriate judgment to reach in this case is that the Registrant’s practice is currently impaired.

Decision on Sanction:

50. In coming to its own independent decision on sanction, the Panel paid careful regard to the submissions of both parties and the HCPC’s Indicative Sanctions Policy (ISP).  It also noted the advice of the Legal Assessor that it should apply the principle of proportionality, weighing the interests of the public with those of the practitioner.  The public interest includes not only the protection of patients but also the maintenance of public confidence in the profession, and the declaring and upholding of proper standards of conduct and behaviour.

51. Given the serious nature of the Registrant’s lack of competence and its potential to put patients at risk and to undermine the reputation of the profession, the Panel is of the view that it would not be sufficient to conclude this case by taking no action or by referring it for mediation. Neither course would serve to protect patients or maintain the standing of, and the public confidence in, the profession.

52. The Panel then moved on to consider whether to conclude this case by the imposition of a Caution Order. The Panel does not consider this sanction would adequately reflect the seriousness of the lack of competence, or provide adequate protection to patients, nor uphold proper standards of conduct or behaviour for the profession at large. In addition the Panel considered that there is a risk of repetition and a Caution Order would not protect the public.

53. Next, the Panel considered whether the case could be concluded with a Conditions of Practice Order. In so doing, it had regard to the advice of the Legal Assessor that the conditions must be appropriate, measurable, workable and verifiable.

54. The Registrant was at the beginning of his career and the failures arose during his first year of employment. The last example of the Registrant’s lack of competence was in October 2014, since when he has not worked in his chosen profession in any capacity. 

55. Ms Sheridan, in her submissions, drew the Panel’s attention to its finding that there was a high risk of repetition if the Registrant were permitted to remain in unrestricted practise and this should be taken into account when deciding on sanction.

56. Mr Geering, in seeking to persuade the Panel that the appropriate sanction in this case would be the imposition of a Conditions of Practice Order for 18 months, emphasised his client’s early admissions to the Allegation, his obvious remorse and his clear desire to learn from the experience of these incidents. 

57. The Panel also noted the contents of the recently produced character references from the Registrant’s current employer. These stated that the Registrant is hard working, reliable and trustworthy. 

58. It is plain to the Panel that the Registrant now takes responsibility for his actions and is genuinely remorseful. Equally, his past failings are remediable, particularly in relation to record keeping. 

59. In considering the appropriate sanction to impose, the Panel paid particular attention to the contents of the ISP which detail the criteria for consideration before imposing a Conditions of Practice Order. In particular, the Panel considered that the Registrant could be expected to comply with conditions and that the failings are capable of correction.  While there was one incident which had an adverse impact on a patient, there was no evidence of general or persistent clinical failures. Therefore it is the Panel’s view that appropriate, realistic and verifiable conditions can be formulated.

60. Such an order will send out the appropriate signal to the profession and thereby serve to protect the public confidence in it and contribute towards seeking to ensure the safety of patients.

61. To impose a sanction of suspension would, in all of the circumstances, be out of proportion, not least because the Panel is very much aware that this Registrant’s failings took place at the outset of his career and are capable of remediation.   

62. Thus, the appropriate and proportionate sanction to impose, in the judgement of the Panel, is one of a Conditions of Practice Order for a period of 18 months. 

63. The conditions are as follows:

1. You must promptly inform the HCPC if you commence employment as a SLT.

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

• any organisation or person employing or contracting with you to undertake professional work; 

• any agency you are registered with or apply to be registered with (at the time of application);

• any prospective employer (at the time of your application).

3. You must complete a Royal College of Speech and Language Therapists (RCSLT) approved Return to Practice Course and provide evidence of your successful completion of the course in advance of a review of this Order.

4. You must not undertake domiciliary work in a community setting.

5. You must work with your manager to formulate a Personal Development Plan (PDP) designed to address the deficiencies in the following areas of your practice:

• record keeping and case note management;

• management of workload. 

6. You must meet regularly with your supervisor, at a frequency to be reviewed, but at least weekly in the first three months of your employment.

7. You must ensure that your supervisor regularly undertakes a comprehensive review of the case notes pertaining to your caseload.

8. You must allow your manager and supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your PDP in advance of a review of this Order. 

9. You must maintain the RCSLT CPD log and provide a copy of this in advance of a review of this Order. 

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

Order

Order: The Registrar is directed to annotate the Register to show that, for a period of 18 months from the date that this Order comes into effect (the Operative Date), you, Mr Gareth E Williams, must comply with the following conditions of practice:
1. You must promptly inform the HCPC if you commence employment as a SLT.

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

• any organisation or person employing or contracting with you to undertake professional work; 

• any agency you are registered with or apply to be registered with (at the time of application);

• any prospective employer (at the time of your application).

3. You must complete a Royal College of Speech and Language Therapists (RCSLT) approved Return to Practice Course and provide evidence of your successful completion of the course in advance of a review of this Order.

4. You must not undertake domiciliary work in a community setting.

5. You must work with your manager to formulate a Personal Development Plan (PDP) designed to address the deficiencies in the following areas of your practice:

• record keeping and case note management;

• management of workload. 

6. You must meet regularly with your supervisor, at a frequency to be reviewed, but at least weekly in the first three months of your employment.

7. You must ensure that your supervisor regularly undertakes a comprehensive review of the case notes pertaining to your caseload.

8. You must allow your manager and supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your PDP in advance of a review of this Order. 

9. You must maintain the RCSLT CPD log and provide a copy of this in advance of a review of this Order. 

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

The order imposed today will apply from 22 March 2017 (the operative date). This order will be reviewed again before its expiry on 18 September 2018.

Notes

The order imposed today will apply from 22 March 2017 (the operative date). This order will be reviewed again before its expiry on 18 September 2018.

Hearing history

History of Hearings for Mr Gareth E Williams

Date Panel Hearing type Outcomes / Status
09/11/2018 Conduct and Competence Committee Review Hearing Hearing has not yet been held
07/09/2018 Conduct and Competence Committee Final Hearing Suspended
22/08/2018 Conduct and Competence Committee Final Hearing Adjourned
20/02/2017 Conduct and Competence Committee Final Hearing Conditions of Practice