Mrs Jane M Little

: Radiographer

: RA27652

Interim Order: Imposed on 14 Dec 2017

: Review Hearing

Date and Time of hearing:10:00 17/07/2017 End: 12:30 17/07/2017

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

: Conduct and Competence Committee
: Suspended

Allegation

During  the  course  of  your  employment  as  a  Radiographer  for  Blackpool  Teaching Hospitals NHS Foundation Trust
1. On 8 October 2014, in respect of Patient 2
a. You did not ask a colleague to double-check the isotope vial and/or sign the administration sheet;
b. You injected Patient 2 with the wrong radiopharmaceutical

2. On 12 February 2015, you did not follow the correct procedure for a Glomerular Filtration Rate (GFR) test in relation to Patient 3 in that you:
a. Did  not  take  blood  from  the  patient  prior  to  the  administration  of  the radiopharmaceutical;
b. Did not complete an administration sheet in relation to the procedure

3. On 28 January 2015, in relation to Patent 4
a. You did not ensure that the adenosine  infusion  tubing had been correctly inserted into the infusion pump;
b. You administered an unmeasured volume of adenosine to Patient 4

4. On 2 July 2015, you did not check the calibration factor setting and/or calculate the radiopharmaceutical does accurately in the cases of:
a. Patient 6
b. Patient 7
c. Patient 8
d. Patient 9

5. Your actions as set out in paragraphs 1-4:
a. Exposed patients to unnecessary radiation, and/or
b. Demonstrated unsafe clinical practice,

6. The matters as described in paragraphs 1-5 constitute misconduct and/or lack of competence.

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

Finding

Preliminary Matters:

Service

1. The Panel had sight of a letter dated 14 June 2017, sent to the Registrant at her registered address, giving notice of today’s hearing, and determined that service had been properly complied with in accordance with the requirements of the Health Professions Council (Conduct and Competence Committee) Rules 2003 (“the Rules”).

Proceeding in absence

2. The Panel accepted the advice of the Legal Assessor, who took the Panel to the Practice Note on Proceeding in the Absence of the Registrant, to Rule 11 and to the guidance given in the cases of R –v- Jones [2003] 1 AC 1, Tait v The Royal College of Veterinary Surgeons [2003] UKPC 34 and GMC –v-  Adeogba [2016] EWCA Civ 162.

3. The Panel was informed that the Registrant had contacted the HCPC by telephone on 3 July 2017, stating: “she will not be attending the hearing as she is caring for" a member of her family.  This was followed up by the HCPC by means of a number of telephone calls and emails in which the HCPC expressed its concern and enquired whether the Registrant wanted to make written submissions or attend by telephone or request an adjournment. The Registrant did not respond until the morning of this hearing, 17 July 2017, when she telephoned to say that she would not be attending as she is caring for a family member. 

4. The Panel was satisfied that the Registrant had been served with Notice of today’s hearing. The Registrant had made contact in advance of today to say that she would not be attending the hearing. However, the Registrant had not applied to adjourn the proceedings until this morning, despite having had the opportunity to make that application at an earlier date. The Registrant had not made it clear that she was unable to attend by reason of caring for a family member, as opposed to choosing not to attend. The Panel concluded that an adjournment was very unlikely to result in the attendance of the Registrant at a later date because the current order was due to expire on 15 August 2017 and it appeared, from the information the Registrant had provided, unlikely that the Registrant would attend prior to that date. The Panel bore in mind that it was in the public interest to hear cases expeditiously. Accordingly, the Panel decided to reject the application made by the Registrant today to adjourn and decided to proceed in the absence of the Registrant.

Background:

5. At the time of the Allegation the Registrant was employed as a Band 7 Radiographer at Blackpool Teaching Hospitals NHS Foundation Trust (“the Trust”) as the Deputy Nuclear Medicine Manager.

6. Between 8 October 2014 and 2 July 2015 seven incidents occurred which gave rise to concerns about the Registrant’s ability to practice safely. The Registrant administered the wrong dosage of intravenous radio pharmaceutical drugs and/or failed to follow correct clinical procedures. It was found that the Registrant failed to carry out tasks appropriately which resulted in patients and others being exposed to unnecessary radiation. For example, in relation to Particular 1 the Registrant admitted, and it was found proved, that on 8 October 2014 she had injected Myoview instead of HDP into a patient who had been booked in for a bone scan. The Trust’s policy clearly required a second radiographer to check and sign the administration sheet, which was not done. As a result of the Registrant’s behaviour the patient had to be recalled to hospital for checks and a further scan which caused unnecessary delay in the patient’s care.

7. The substantive panel concluded that the Registrant, who had been qualified for 26 years, must have been aware of the required standards and that breaching them amounted to misconduct. The substantive panel was satisfied that the Registrant’s conduct had put her patients at unwarranted risk of harm by exposing them and others to unnecessary radiation and by demonstrating unsafe practice. The substantive panel was also satisfied that the Registrant had brought her profession into disrepute. The substantive panel accepted that the Registrant had belatedly demonstrated some insight, but concluded that she had not provided appropriate evidence of remediation. Additionally, the substantive panel found that the Registrant had failed to demonstrate sufficient insight into the substantial risks to service users, the public and the service as a whole as a result of her disregard for the Trust’s policies and procedures.

8. In considering sanction the substantive panel regarded the fact that the Registrant’s conduct had adversely affected seven different patients over a ten-month period of time as an aggravating factor. The substantive panel regarded the Registrant’s previous practice as a Radiographer over a period of 26 years without incident, and her engagement with the proceedings, to be mitigating factors. The substantive panel was not provided with any information regarding the Registrant’s professional circumstances.

9. The substantive panel concluded that a suspension order would afford an opportunity for the Registrant to demonstrate to a review panel that she had gained insight into the risk to patients and others, the damage caused to her profession by her misconduct and to produce a reflective piece dealing with the role and importance of policies and procedures used in radiography to safeguard the interests of patients and the wider public. The substantive panel decided that a suspension order for a 6-month period was the appropriate and proportionate sanction. It considered that a review panel would be assisted by evidence of how the Registrant has maintained her knowledge and skills as a Radiographer by providing her CPD portfolio as well as a reflective piece.

Decision

10. This Panel considered the issues carefully. It listened to and accepted the advice of the Legal Assessor. It paid attention to the HCPC’s Indicative Sanctions Policy.

11. The Panel concluded that nothing had changed since the substantive hearing. The Panel concluded that the Registrant’s misconduct was capable of remediation, but that the Registrant had not provided any evidence of remediation, despite having been given ample time in which to do so, and despite having been sent reminders by the HCPC. The substantive panel, who had sat some six months ago, had clearly set out what was required and yet the Registrant had not provided additional information as suggested.

12. The Panel could only conclude that there remained a likelihood of repetition of the Registrant’s misconduct if she were to be allowed to practise unrestricted. The public had been put at risk by her misconduct and it followed from her lack of remediation that there was risk that she would repeat her misconduct if permitted to practice unrestricted. The Panel also found that public confidence in the profession and the declaring of proper standards of conduct and performance demanded a finding of impairment given the lack of remediation and insight into the proven allegations.

13. The Panel considered whether to make no order or to impose a Caution Order but concluded that this would not be sufficient to protect the public or satisfy the public interest.

14. The Panel considered whether to impose a Conditions of Practice Order but concluded that this was inappropriate because it appeared to the Panel that the Registrant had limited insight. She had not provided any information of remediation since the findings of the substantive panel despite the request that was made.

15. The Panel concluded that an extension of the current Suspension Order was the appropriate and proportionate sanction in the circumstances.

16. The Panel gave careful consideration to the length of any extension and decided to suspend the Registrant for a further period of 9 months to enable the Registrant ample time, in light of her personal circumstances, to demonstrate remediation and insight into her failings. Having noted that the Registrant had not demonstrated remediation in 6 months, the Panel considered that the longer period of 9 months was necessary. The Panel concluded that the future reviewing panel would be assisted by:

• the Registrant’s attendance.

• a CPD portfolio evidencing, for example, journal articles read and courses undertaken (which may include online courses).

• a reflective piece detailing the role and importance of policies and procedures used in Radiography to safeguard the interests of patients and the wider public, as well as the impact the Registrant’s misconduct had or could have had on patients and others.

Order

Order: That the Registrar is directed to suspend the registration of Mrs Jane Little for a further period of 9 months on the expiry of the existing order.

Notes

The Order imposed today will take effect from the expiry of the current order on 15 August 2017.
The Order will be reviewed again before its expiry on 15 May 2018.

Hearing history

History of Hearings for Mrs Jane M Little

Date Panel Hearing type Outcomes / Status
17/07/2017 Conduct and Competence Committee Review Hearing Suspended
13/02/2017 Conduct and Competence Committee Interim Order Review Hearing has not yet been held
16/01/2017 Conduct and Competence Committee Final Hearing Suspended