Mr John Barron

: Operating department practitioner

: ODP18793

: Final Hearing

Date and Time of hearing:10:00 08/05/2017 End: 17:00 10/05/2017

: Health and Care Professions Tribunal Service (HCPTS), 405 Kennington Road, London, SE11 4PT

: Conduct and Competence Committee
: Struck off

Allegation

Allegation:

(As put forward by the Investigating Committee Panel on 20 April 2016)


Between January and February 2015, during the course of your employment as an Operating Department Practitioner by Maidstone and Tunbridge Wells NHS Foundation Trust:

1. On 18 January 2015 you:

a. Did not check Patient A's care plan and/or prescription chart to determine the correct dosage of morphine to administer.

b. Administered an incorrect dosage of morphine to Patient A, in that you administered 10mg instead of 6mg.

2. On 05 February 2015, in relation to Patient B, you;


a. Recorded vital sign observations within Patient
B's records that had not been taken by you.

b. Inappropriately administered morphine.

c. Having administered morphine to Patient B, did not carry out and/or record:

i. Pain score;
ii. Respiratory rate;
iii. Pulse;
iv. Oxygen Saturation;
v. Supplementary oxygen; and
vi. Blood pressure.


3. On 5 February 2015, in relation to Patient C,
you:

a. Prior to the administration of morphine, did not carry out and/or record a full set of vital sign recordings including the pain score.

b. Having administered morphine to Patient C and did not carry out and/or record:

i. Pain score;
ii. Respiratory rate;
iii. Pulse;
iv. Oxygen Saturation;
v. Supplementary oxygen; and
vi. Blood pressure.

c. Did not record the administration of opioid morphine on Patient C's prescription chart.

4. Your actions described in paragraph 2a were dishonest.

5. The matters described in paragraphs 1, 2 and 3 amount to misconduct and/or lack of competence.

6. The matters described in paragraph 4 amount to misconduct.

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

Allegation:
(As Amended at the substantive hearing on 08 May 2017)


Between January and February 2015, during the course of your employment as an Operating Department Practitioner by Maidstone and Tunbridge Wells NHS Trust:

1) On 18 January 2015 you:

a) Did not check Patient A's prescription chart to determine the correct dosage of morphine to administer.

b) Administered an incorrect dosage of morphine to Patient A, in that you administered 10mg instead of a maximum dose of 6mg, as prescribed.

2) On 05 February 2015, in relation to Patient B, you;

a) Recorded vital sign observations within Patient B's records that had not been taken by you.

b) Inappropriately administered morphine.

c) Having administered morphine to Patient B, did not carry out and/or record at regular intervals:

i. Pain score;
ii. Respiratory rate;
iii. Pulse;
iv. Oxygen Saturation;
v. Supplementary oxygen; and
vi. Blood pressure.
vii. Temperature
viii. Airway

3) On 5 February 2015, in relation to Patient C, you:

a) Prior to the administration of morphine, did not carry out and/or record a full set of vital sign recordings including the pain score.

b) Having administered morphine to Patient C and did not carry out and/or record:

i. Pain score;
ii. Respiratory rate;
iii. Pulse;
iv. Oxygen Saturation;
v. Supplementary oxygen; and
vi. Blood pressure.
vii. Temperature
viii. Airway

c) Did not record the administration of morphine on Patient C's prescription chart in a timely manner.

d) Did not record the date and time of administration of morphine on Patient C’s prescription chart.

4) Your actions described in paragraph 2a were dishonest.

5) The matters described in paragraphs 1, 2 and 3 amount to misconduct and/or lack of competence.

6) The matters described in paragraph 4 amount to misconduct.

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

Finding

Preliminary matters:


1. The Panel was satisfied that good service had been effected.

2. On behalf of the HCPC, Ms Daly made an application to proceed in the absence of the Registrant. She told the Panel that the only communication which the HCPTS has had with the Registrant was at the beginning of March 2017 when he was served with the hearing bundle. Ms Daly submitted that the Registrant was aware of this hearing and its purpose and had deliberately chosen not to be present

3. Before reaching its decision on the application the Panel accepted the advice of the Legal Assessor. The Panel determined to proceed in the absence of the Registrant. It was satisfied that the Registrant was aware of the date, location and purpose of this hearing and had waived his right to be present or represented. He had not requested an adjournment and the Panel did not consider that an adjournment would secure his attendance at a later date. The Panel reminded itself that no adverse inferences should be drawn from the Registrant’s failure to attend the hearing.

4. Ms Daly applied to amend the particulars of the allegation. She noted that the Registrant had been given notice of the amendments in December 2016 and had not objected. Ms Daly submitted that the proposed amendments did not materially change the nature of the case against the Registrant and that he would not be disadvantaged if the application to amend were granted.

5. The Panel accepted that the purpose and effect of the proposed amendments was to clarify the particulars of the allegation. The proposed amendments do not materially affect the substance of the allegations which the Registrant faces. The Panel accordingly, exercised its discretion to grant the application to amend the particulars of the allegation.

Background:


6. The Registrant was employed by Maidstone and Tunbridge Wells NHS Trust (“The Trust”) as an Operating Department Practitioner. From 4 September 2006 the Registrant had worked as a Band 5 Theatre Practitioner. In that role he did not have line management responsibilities. He worked within a multi-disciplinary team based in the operating theatres providing care to adult and paediatric patients who required elective and emergency surgery.


7. On 5 February 2015 the Registrant was working as a recovery practitioner in the short stay surgical recovery area. Patient B was in his care having undergone a surgical procedure under general anaesthetic. When Patient B was moved out of the recovery area she complained to a clinical support worker that the Registrant had taken only one set of observations during her time in the recovery area. The Theatre Co-Ordinator checked Patient B’s notes and informed her that there were multiple other observations recorded in her notes. Patient B alleged that all the other observations were written into her notes at the same time and that the person attending her had only carried out one set of observations. Patient B made a written complaint on 8 February 2015.


8. Mr McCredie, Lead Practitioner for Anaesthetics and Recovery, was appointed to investigate Patient B’s complaint. During the course of his investigation concerns in relation to the Registrant’s care of two other patients emerged. The Registrant administered Morphine in excess of the dose prescribed to Patient A on 18 January 2015. Patient C was in the care of the Registrant on 5 February 2015 and he is alleged to have failed to carry out and/or record a full set of observations in relation to Patient C.


9. Following the conclusion of its internal processes the Trust referred this matter to the HCPC.

Decision on Facts


10. The Panel heard evidence from one witness, Mr McCredie, who was called on behalf of the HCPC. The Panel was assisted by the evidence given by Mr McCredie which it considered to be reliable and measured.


11. The Panel carefully considered all the documents provided in this case. These included witness statements and comments provided by the Registrant during the course of the Trust investigation.


12. In relation to each particular of the Allegation the Panel has carefully reviewed the relevant supporting documentation. It has assessed the written and oral evidence it has received.


13. The Panel has reminded itself that it is for the HCPC to prove the facts which it alleges and that the standard of proof is proof on a balance of probabilities.


Patient A


14. Patient A was fourteen years old. Patient A underwent surgery on 18 January 2015 and amongst other medication was prescribed 1-6 mg of Morphine if required in recovery. This was recorded on Patient A’s prescription chart. Patient A was in the Registrant’s care in the recovery area from 17:35 until 18:10. During that time the Registrant administered a total of 10mg of Morphine to Patient A and recorded this information on Patient A’s care plan. 


15. After the Registrant handed over the care of Patient A to JN, a recovery nurse, Patient A began to feel sick and told ward staff that she could not breathe. Mr McCredie told the Panel that Morphine can act as a respiratory depressant and therefore could have contributed to the respiratory problems experienced by Patient A.  An anaesthetic review of Patient A was undertaken and Naloxone was administered to Patient A to reverse the effect of the Morphine.

Particular 1a


16. The Panel finds this particular proved. During his investigatory interview on 26 May 2015 the Registrant accepted that he had not checked Patient A’s prescription chart to ascertain the dosage prescribed.

Particular 1b


17. The Panel finds this particular proved. During his investigatory interview on 26 May 2015 the Registrant accepted that he had administered ten mg of Morphine to Patient A and that the prescription chart indicated that six mg was the prescribed dosage.

Patient B


18. As noted above, Patient B was admitted for day surgery on 5 February 2015. She received a general anaesthetic and after surgery was moved to the recovery area at 15:05 where she came under the Registrant’s care. When Patient B was moved out of the recovery area she complained to a clinical support worker that the Registrant had taken only one set of observations during her time in the recovery area and had told her that he had forgotten to switch on the monitor. The Theatre Co-Ordinator checked Patient B’s notes and informed her that there were other observations recorded in her notes. Patient B alleged that all the other observations were written into her notes at the same time and that the person attending her had only carried out one set of observations.


Particular 2a


19. The Panel finds this particular proved. It accepts Mr McCredie’s evidence that practitioners are expected to record vital signs observations on patient records. The observations which were required were: pulse and oxygen saturation, blood pressure, respiratory rate, pain score, temperature and patient airway checks. In recovery the observations should be undertaken at five minute intervals for the first half an hour and then at ten minute intervals for up to an hour. The Panel notes that each of the required observations involves some interaction with the patient so that the patient is likely to have a level of awareness that observations are taking place. A full set of observations consists of a series of manual and automated checks. The Panel considers that the readings obtained from the blood pressure monitoring equipment are generally reliable. It accepts that the monitor was on ‘standby’ for a period of time and that the absence of blood pressure readings between 14:45 and 16:55 is explained by this. The Panel notes that the screenshot of the monitor’s readings clearly indicates that no blood pressure readings were taken in relation to Patient B until 16:55, this is consistent with Patient B’s account of events and in particular with her assertion that only one set of observations was carried out by the Registrant. The Registrant told the trust that he had taken blood pressure readings and entered them on to Patient B’s records retrospectively.


20. There is no evidence that the Registrant carried out any of the manual vital signs observations. It is the Panel’s view that it is highly unlikely that the Registrant could have taken any of the observations recorded without noticing that the monitor was on ‘standby’. Accordingly, the Panel believes that the recorded observations were fictitious.

Particular 2b


21. The Panel finds this particular proved. The Panel has found that the Registrant failed to undertake vital signs observations of Patient B. Morphine is a controlled drug and can have a depressant effect on the respiratory system. In these circumstances, carrying out vital signs observations was particularly important and the administration of Morphine without doing so was inappropriate.

Particular 2c


22. The Panel finds this particular proved. There is no credible evidence that the Registrant carried out and/or recorded vital sign observations at regular intervals having administered Morphine to Patient B.


Patient C


23. Patient C was a day surgery patient who was admitted on 5 February 2015. Patient C entered the recovery area at 13:37 and left at 14:45 having been transferred to a ward. Between 14:05 and 14:25 Patient C was under the care of JS, a Senior Theatre Practitioner, who relieved the Registrant whilst he took a break, for the remaining period he was responsible for Patient C’s care.


24. The Registrant recorded one set of observations in Patient C’s care plan at 13:37. The observations recorded are incomplete; the Registrant did not record entries in relation to Patient C’s pain score, temperature or airway. The Registrant administered two doses of Morphine to Patient C at 13:45 and 13:55. He recorded this information on Patient C’s care plan but did not record it on Patient C’s prescription chart.


Particulars 3a and 3b


25. The Panel finds these particulars proved. Patient C’s care plan contains a single, incomplete record of vital signs observations. There is no credible evidence that the Registrant conducted regular observations prior to and/or after the administration of Morphine but failed to record them.

Particular 3c

26. The Panel finds this particular proved. Patient C’s prescription chart contains an entry recording the administration of Morphine at 14:00 which was made by JS. In a statement provided to the Trust’s internal investigation JS stated that there was no entry in relation to the Registrant’s earlier administration of Morphine to Patient C when she made her entry at 14:00. The Registrant’s entry in Patient C’s prescription chart appears after JS’ entry and is not dated or timed. This suggests that the entry was made after 14:00. Given that the doses were administered at 13:45 and 13:55 the Panel is satisfied that the administration of Morphine to Patient C on these occasions was not recorded in a timely manner.

Particular 3d


27. As noted above the entries made by the Registrant to Patient C’s prescription chart were not dated or timed. The Panel therefore finds this particular proved.


Particular 4


28. The Panel has found particular 2a proved. The Panel is satisfied that a reasonable and honest person would consider the actions of the Registrant to have been dishonest. The Panel has been unable to identify any reason for making the entries other than to conceal the fact that required observations had not been made at the appropriate times. His actions in creating a false series of observations required a deliberate decision and created a potentially dangerous false impression of the patient’s clinical status. The Panel is also satisfied that the Registrant knew that his actions were dishonest and would be considered dishonest by the standards of reasonable and honest people. In these circumstances the Panel finds particular 4 proved.

Decision on Grounds


29. Ms Daly told the Panel that the HCPC relied on the statutory grounds of lack of competence and/or misconduct. Ms Daly directed the Panel the HCPC Standards of Conduct, Performance and Ethics and the HCPC Standards of Proficiency for Operating Department Practitioners. She submitted that there was clear and compelling evidence that the Registrant’s conduct and competence fell far below the required standards.


30. Before making its decision on grounds the Panel accepted the advice of the Legal assessor.


31. The Panel considered the organisational context in which the concerns about the Registrant’s practice arose. It noted evidence that the Department in which the Registrant was working was experiencing some challenges in terms of staffing levels and the availability of beds. The Panel also bore in mind evidence as to personal difficulties which the Registrant was experiencing at this time which concerned his health and family circumstances.


Lack of Competence


32. The Panel noted that the performance of a practitioner is to be measured against that expected of a reasonably competent practitioner of the same grade in the job the Registrant is actually doing. It also reminded itself that the Panel must be satisfied that the Registrant’s performance fell well below the standard expected and that this was demonstrated by reference to a fair sample of his work.


33. It is clear from the material before it that the Registrant is an experienced and knowledgeable practitioner. He had received training from the Trust and there was evidence of support and guidance being provided to him. The Panel is satisfied that in relation to Patients A, B and C the Registrant fell below the standards to be expected of a reasonably competent practitioner. However, the Panel is not satisfied that three incidents which occurred on two days is a fair or representative sample of the Registrant’s work.  In these circumstances the Panel does not find that the Registrant lacked competence.


Misconduct


34. The Panel noted that there is no statutory definition of misconduct. It is a word of general effect involving some act or omission which falls short of what would be proper in the circumstances.
35. The Panel has concluded that the Registrant’s conduct fell seriously below the conduct to be expected of a registered Operating Department Practitioner. In particular, the Panel considers that by his conduct the Registrant breached standards 1, (“You must act in the best interests of service users”), 10 (“You must keep accurate records”) and 13 (“You must behave with honesty and integrity”) of the HCPC Standards of Conduct, Performance and Ethics (2012).


Decision on Impairment 


36. Ms Daly submitted that the Registrant’s failure to engage with the hearing meant that the Panel had no information from him to inform its consideration of matters of insight, remediation and the risk of repetition. Ms Daly also submitted that the Panel ought not to lose sight of the importance of declaring and upholding proper standards in order to maintain public confidence in the profession.


37. The Panel accepted the advice of the Legal assessor.


38. The Panel reminded itself that whilst it had taken account of the Registrant’s past acts and omissions, its task was to determine whether the Registrant’s fitness to practise is currently impaired.

39. The Panel has had regard to the personal component of impairment. It has made findings that the Registrant’s conduct amounted to misconduct. By his actions the Registrant placed patients at risk of harm.


40. The Panel has only limited material before it to indicate what, if any, insight the Registrant now has in relation to his misconduct. There is no evidence that the Registrant has reflected more deeply on why he did what he did. There is no evidence of any steps taken by the Registrant to ensure that if he faced such difficult personal circumstances in the future he would be able to avoid a repetition of his misconduct. Whilst the Panel has some sympathy for the Registrant as regards the particular health and personal stresses that he faced at the time of these incidents, the Panel does not have any evidence that he has developed strategies to ensure that if comparable stresses arise in the future he is better placed to deal with them.


41. The Panel accepts the Registrant’s expressions of remorse as genuine. He knows that he fell short of the standards required of him as a health care professional.


42. The Panel has concluded that in the circumstances there is a risk that the Registrant’s misconduct might be repeated in the future. The Panel has concluded that there is current impairment of the Registrant’s fitness to practice having regard to the personal component.


43. The Panel has also taken into account the need to protect service users, declare and uphold proper standards of behaviour and to maintain public confidence in the profession in arriving at its decision on impairment. Members of the public would be dismayed if there were no finding of current impairment to mark disapproval of the Registrant’s misconduct. He failed to properly observe and record his findings of patients before and after the administration of Morphine, thereby placing patients at risk of harm and jeopardising their future care. The Panel is satisfied that a finding of current impairment would fail to declare and uphold proper standards and would undermine public confidence in the profession and in the regulatory process.


Decision on Sanction


44. Before reaching its decision on sanction the Panel heard evidence from the Registrant by telephone. The Registrant had been provided with the Panel’s decision on facts, grounds and impairment and with a copy of the HCPTS’s “Indicative Sanctions Policy” and given an opportunity to consider both documents before the hearing resumed. The Registrant repeatedly told the Panel that he did not accept its finding that he had acted dishonestly in relation to the recording of Patient B’s vital sign observations. He asserted that he had made a genuine mistake. The Registrant told the Panel “I am not dishonest. I do not care what you say at your end. Everything else I fully accept responsibility for.” 

45. The Registrant reiterated the very difficult personal circumstances he had faced at the time when these incidents occurred. The Registrant told the Panel that for four or five months after his employment ended he ran over the whole series of events in his head. He said that he had difficulty recognising himself as the person involved in the incidents as it was so far from his normal conduct and practice. The Registrant said that the only explanation he could offer was that he must have been suffering from the effects of a health condition at the time. In response to questions from the Panel about what he might do differently the Registrant said that he would see his doctor and get himself signed off as unfit for work.


46. The Registrant confirmed that he had practised for 27 years without being the subject of a formal complaint and had never come to the attention of his regulator. He told the Panel that he had not worked since his employment came to an end in July 2015 and that he intended to retire in November 2017.


47. The Panel gave careful consideration to the submissions of both parties on sanction and accepted the advice of the Legal Assessor. The Panel reminded itself that its task was to consider whether the Registrant may pose a risk to those who may need or use his services in the future. In addition, its decision must also give appropriate weight to the wider public interest. Where the Panel identifies a risk it must determine what degree of public protection is required to guard against it.


48. In the light of the evidence which the Panel has heard and read it has concluded that the Registrant may pose a risk to those who may need or use his services in the future. The Panel noted that the Registrant appeared not to understand the importance of undertaking regular clinical observations of patients rather than making them cups of tea or undertaking non-clinical work. The Registrant did not demonstrate any adequate understanding of the dangers of opiate analgesia. He was unable to appreciate that his actions had posed a real risk to the patients in his care. Whilst the Registrant had expressed remorse, that expression was qualified. It did not include his treatment of Patient A or his dishonest creation of observations in Patient B’s clinical records.


49. Further, the Panel had no evidence that the Registrant was willing or able to address his misconduct and the shortcomings in his practice.

50. In these circumstances, the Panel has determined that it is necessary to impose a sanction in this case. In identifying the appropriate sanction, the Panel has applied the principle of proportionality and has sought to strike a proper balance between the protection of the public and the rights of the Registrant.


51. The seriousness of the Registrant’s misconduct, the risk of recurrence and the lack of insight demonstrated by the Registrant lead the Panel to conclude that a Caution Order is not an appropriate sanction in this case.


52. The Panel noted that despite the passage of two years the Registrant has not engaged in meaningful, constructive reflection on his conduct. Notwithstanding the Panel’s finding of dishonesty, the Registrant continues to deny wrongdoing in this regard. In these circumstances the Panel does not consider that the Registrant is genuinely committed to resolving the issues or that he would make a determined effort to do so. The Panel has noted above the seriousness of the Registrant’s misconduct and the risk of repetition. The Panel does not consider that a Conditions of Practice Order would provide the necessary degree of public protection, even if appropriate, realistic and verifiable conditions could be formulated. Given that the Registrant has been out of practice for two years and is currently not employed, the Panel does not, in any event, believe that it could identify appropriate, realistic and verifiable conditions.

53. The Panel next gave very careful consideration to a Suspension Order. A Suspension Order would provide the required degree of public protection and maintain confidence in the reputation of the profession and the regulatory process. However, given the Registrant’s failure to understand and remedy his failings and the Panel’s view that he will be unable and unwilling to do so, the Panel has determined that a Suspension Order would be inappropriate.


54. The Panel has therefore come to the conclusion that a Striking Off Order is the appropriate and proportionate sanction in all the circumstances of this case.

Order

Order: The Registrar is directed to strike the name of Mr John Barron from the Register from the date this Order comes into effect.

Notes

The order imposed today will apply from 7 June 2017 (the operative date).

Hearing history

History of Hearings for Mr John Barron

Date Panel Hearing type Outcomes / Status
08/05/2017 Conduct and Competence Committee Final Hearing Struck off