Ms Margaret Dean

: Dietitian

: DT04278

Interim Order: Imposed on 11 Mar 2016

: Final Hearing

Date and Time of hearing:10:00 21/08/2017 End: 17:00 23/08/2017

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

: Conduct and Competence Committee
: Suspended

Allegation

Allegation (as amended at the final hearing)
Whilst employed as a Dietitian by Alder Hey Children’s NHS Trust:
1. In relation to Patient A:
a) On or around 20 May 2015, you miscalculated the 'weight to scoop' conversion for Patient A's feed recipe;
b) On or around 20 May 2015, you did not document the calculations for Patient A's feed recipe in his dietetic notes;
c) On or around 20 May 2015, you did not provide Patient A's family with weighing scales;
d) Between approximately 2 February 2015 and 17 June 2015, you did not plot Patient A's weight on his growth chart;
e) On or around 21 May 2015, when Patient A's mother explained that the feed looked thin, you did not discuss with Patient A's mother the instructions she was using to make the feed;
f) On or around 8 June 2015, when Patient A's mother explained about Patient A's weight loss, you did not discuss this with a member of the clinical team;

2. In relation to Patient B:
a) On or around 25 June 2015, you changed Patient B's feed plan;
b) Your actions described at particular 2(a) were carried out without you having consulted Patient B's dietetic notes;
c) Your actions described at particular 2(a) were carried out without you having consulted with a senior dietetic colleague and/or consultant;

3. Between 31 March 2015 and 1 July 2015, you did not document adequately or at all on Patient C's Dietetic record card:
a) the referral
b) any follow up actions; and/or
c) proposed dietetic interventions;

4. Between 26 March 2015 and 1 July 2015, you did not document adequately or at all on Patient D's dietetic record card:
a) the referral
b) a follow-up plan from that referral; and/or
c) proposed dietetic reviews;

5. Between 25 March 2015 and 1 July 2015, you did not document adequately or at all on Patient E's dietetic record card:
a) the referral
b) any follow up actions; and/or
c) a follow-up appointment;

6. Between 23 March 2015 and 1 July 2015 you did not document adequately or at all on Patient F's dietetic record card:
a) the referral
b) follow up actions; and/or
c) dietetic Interventions; and/or
d) a follow-up plan;

7. In relation to Patient G, between 1 April 2015 and 1 July 2015, you did not create a dietetic record card for the patient.

8. In relation to Patient H, between 24 October 2014 and 1 July 2015, you did not create a dietetic record card for the patient

9. In relation to Patient I, between 17 December 2014 and 1 July 2015, you did not create a dietetic record card for the patient.

10. Your actions described at particulars 1 to 9 constitute misconduct and/or lack of competence;

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

Finding

Preliminary matters
1. Mrs Margaret Dean (“the Registrant”) is registered with the HCPC as a Dietitian and at the relevant times she was employed as a Band 6, Specialist Paediatric Dietitian by Alder Hey Children’s NHS Foundation Trust (“the Trust”).

Service
2. Notice of the hearing was sent on 25 April 2017, by post to the address given by the Registrant to the HCPC for registration purposes. The Panel took into account that the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 permit the service of hearing notices by post and was satisfied there had been good service of the hearing notice.

Proceeding in the absence of the Registrant
3. There was no attendance by the Registrant. Solicitors acting for the Registrant wrote to the HCPC on 23 January 2017 to say that the Registrant would not be attending “the substantive hearing as she is finding this process extremely distressing. She has not practised as a Dietitian for a considerable period of time and has no intention of working as a Dietitian in the future”. In addition, in paragraph 34 of her statement dated 19 October 2016, the Registrant stated that she did not wish to attend any future hearings.

4. The Panel considered whether it was fair to proceed in the absence of the Registrant and took into account the HCPTS Practice Note “Proceeding in the absence of the Registrant”. There is a public interest in proceeding with matters such as these in an expeditious manner. The Registrant was clearly aware of the proceedings and had chosen not to attend. She had, through her solicitors, provided a witness statement in which she set out her position with regard to each of the Particulars in the Allegation. It was unlikely that the Registrant would attend on a future occasion if the hearing were to be adjourned. The Panel was satisfied that it was fair to proceed in the absence of the Registrant.

Amendment to the Allegation
5. Ms Parry applied for permission to amend the Particulars of the Allegation in a number of instances. The Registrant and her solicitors had been notified of the detail of the application by letter dated 6 January 2017. The Panel took into account that there had been no objection to the application raised by the Registrant or her solicitors. The Registrant had been given 7 months’ notice of the application. The Panel was satisfied that the proposed amendments did not amount to changes of substance in the nature of the Allegation. The proposed amendments better reflected the evidence and did not significantly change the nature of the case. The Panel was satisfied that it was fair to approve the amendments. The Allegation, as amended, is shown above.

Background
6. The Registrant’s employment with the Trust started in February 2010 and she had previous experience working as a Dietitian since 1987. Since around 2011 she had been working in the Dietetic department at the Trust and had been given specialist areas of cardiology and food allergy, as well as general paediatrics. In June 2015 the Trust became aware of concerns regarding the Registrant’s treatment of two young patients (“Patient A” and “Patient B”). The Registrant was suspended from her employment and an investigation commenced. During the course of that investigation further concerns arose regarding the standard of record keeping on the part of the Registrant. A disciplinary procedure commenced and during the course of that process the Registrant resigned from her employment.

Decision on facts
7. The Panel took account of all of the documentary evidence put before it by the Council and the Registrant, and the oral evidence of four witnesses called by the Council. It also received and accepted advice from the Legal Assessor. In making findings of fact the Panel has taken into account that the HCPC has the burden of proving the case on the balance of probabilities. The fact that the Registrant has not attended this hearing is not to be treated as, in any way, assisting the HCPC case.

8. The Registrant has provided a witness statement dated 19 October 2016. She admitted each of the Particulars 1 to 9 of the Allegation. She said that she understood “the importance of accurate record keeping and that this is a standard set by the HCPC for good reason”. She accepted that the responsibility of plotting the weight of a patient was an “essential task” and “a vital part of the assessment of a child’s nutritional status, and should be carried out regularly”. She accepted her record-keeping “was not up [to] the required standard and I understand that this is a very important standard. I understand that it could lead to the patient not receiving the correct treatment which is very serious. I also understand that if a patient is to be made aware of poor record keeping then it can undermine their faith in the NHS and the Dietetic Service”.

9. She continued in her statement by saying that her work leading up to her resignation “was not of the standard that it had been in the past and I accept that there were serious failings. I was very busy and my standards slipped. I accept that these actions demonstrate a lack of competence. I have been out of practice now for 16 months and I have not worked in the field at all. I have not kept up to date with my continued professional development I therefore do not feel that I would be able to take up a role as a Dietitian again without further training. My fitness to practice is currently impaired as I have been unable to remediate my failings”. The Registrant went on to say that she felt her confidence had been undermined and she had no intention of returning to practice.

10. The admissions from the Registrant have been taken into account by the Panel but it has to make its own judgment as to whether the Allegation is made out, taking into account all of the evidence submitted.

11. During the hearing, the Panel asked for information relating to any annual leave taken by the Registrant during March and April 2015. That information was provided to the Panel during the second day of the hearing. The Panel also asked the HCPC to produce what appeared to be a missing portion of the Dietetic Notes relating to Patient C. That missing note was provided during the course of the hearing and added this as page 133a to the Council’s exhibit bundle. The Panel was not provided with any of the patients’ medical notes which may have shown dietetic interventions.

12. The Panel heard evidence from four witnesses in support of the HCPC case and the names of the witnesses and their job titles at the relevant times are shown below:
(i) RW -  Head of Dietetics at the Trust.
(ii) MK - Advanced Paediatric Dietitian at the Trust – who
gave evidence by video link and both those in the
hearing and the witness could clearly
communicate
(iii) MC     - Advanced Paediatric Dietitian at the Trust.
(iv) CL      -           Service Manager at the Trust.

13. The Panel found each of the above witnesses to be honest and credible and accepted that they had each given fair and balanced evidence.

14. The Panel has considered each of the Particulars of the Allegation and has made the findings as shown below.

Particular 1(a) – found proved
In relation to Patient A:
a) On or around 20 May 2015, you miscalculated the 'weight to scoop' conversion for Patient A's feed recipe;

15. This Particular was admitted by the Registrant. The Panel accepted the evidence of RW and MC in this respect. At the relevant time Patient A was just under one year of age. He was a complex cardiac patient who had experienced a number of palliative surgeries and who was receiving most of his nutritional requirements via a tube. On 19 May 2015 the Registrant gave advice to the mother of Patient A regarding a powdered feed plan that the mother should prepare for Patient A once he had returned home following discharge.

16. The Registrant made a serious error in calculating the appropriate proportion of powdered feed to be used. It appears that she erroneously converted “45 scoops” of powder to “45 grams” during her calculations. The effect of that was that Patient A was receiving 160 Kcal and 4.4 grams of protein daily instead of 748Kcal and 22.2 grams of protein (i.e. approximately 21% of what he should have been receiving). That can alternatively be expressed by saying that Patient A should have received 208 grams of powder in 1300 millilitres of fluid but he was incorrectly provided with 45 grams in 1300 millilitres of fluid.

Particular 1(b) – found proved
b) On or around 20 May 2015, you did not document the calculations for Patient A's feed recipe in his dietetic notes;

17. The Panel is satisfied that the Registrant did not properly record her calculations in respect of Patient A’s feed recipe in the dietetic notes for Patient A. The dietetic note created by the Registrant failed to record the weight of powder she was advising should be used or her calculations for this based on Patient A’s nutritional requirements. Her note refers simply to a number of scoops of powder to be used. The Panel is satisfied that established practice was to record the nutritional requirement and weight of powder within the dietetic record card. That would have been the safe standard of practice to be expected from a Dietitian. It meant that another member of staff looking at the record could see exactly what weight of powder was being used. In addition, if an adequate note recording the weight of powder had been made by the Registrant there would have been a real prospect of the Registrant realising she had made a serious error in her calculation. Instead she simply made the calculation on a “scrap of paper” and did not transpose this onto the dietetic record card.

Particular 1(c) – found proved
c) On or around 20 May 2015, you did not provide Patient A's family with weighing scales;

18.  The Panel saw an email from RW dated 15 January 2015 which stipulated that when a Dietitian was recommending a feed which required, amongst other factors, two or more ingredients or two or more different size scoops, then such patients should be provided with weighing scales. MC was clear in her evidence that weighing scales should have been provided, and in fact she did supply them to the mother when she realised the error. RW said that personally she would have only provided one scoop to the mother, but accepted that if multiple scoops were provided then weighing scales should also have been supplied.

19. The failure by the Registrant to follow the guidance set out in this email created a risk that a patient or carer would not accurately prepare a feed.

Particular 1(d) – found proved
d) Between approximately 2 February 2015 and 17 June 2015, you did not plot Patient A's weight on his growth chart;

20.  Patient A was a child with complex medical needs who was born in about July 2014. He was shown to be failing to thrive. In February 2015, the Registrant plotted his weight on a growth chart held with the dietetic records. The weight of Patient A was not subsequently plotted on that growth chart until this was done by MC on 15 June 2015 when she made retrospective entries. The Panel is satisfied that in the circumstances of Patient A it was proper practice, and essential, for a growth chart to be created and maintained. At the relevant times the Registrant was responsible for the dietetic care of Patient A. A growth chart would provide a clear picture of weight fluctuations over time and would allow for ready assessments of matters such as oedema (fluid retention) and failure to thrive. The Registrant failed to plot Patient A’s weight and record that information on a growth chart kept with the dietetic notes during the period 2 February 2015 to 17 June 2015.

21. The account from the Registrant in her statement was that she may have plotted Patient A’s weight on the growth chart held in the medical records but accepts that she should have also done this on the growth chart which was held in the dietetic record card. On the basis of the evidence provided (and no copy of the growth chart referred to by the Registrant has been located or produced) the Panel has concluded that the Registrant did not plot on the growth chart held within the dietetic records as was required.

Particular 1(e) – found proved
e) On or around 21 May 2015, when Patient A's mother explained that the feed looked thin, you did not discuss with Patient A's mother the instructions she was using to make the feed;

22.  On 21 May 2015 the mother of Patient A telephoned the Registrant to report that she thought the feed advised by the Registrant looked very thin. The Registrant assured Patient A’s mother that the feed was correct. The Registrant did not, as she should have done, consider the information from Patient A’s mother may be a signal that something may be wrong with either the make up of the feed or the way the mother was making up the feed as previously instructed by the Registrant. Both RW and MC stated that this should have “rung alarm bells” with the Registrant. An obvious and reasonable step that should have been taken by the Registrant was to review and discuss with Patient A’s mother whether she was properly following the instructions the Registrant had given. The Registrant failed to do so. In addition, it would have been advisable to refer back to the feed calculations to make sure these were correct.

Particular 1(f) – found proved
f) On or around 8 June 2015, when Patient A's mother explained about Patient A's weight loss, you did not discuss this with a member of the clinical team;

23. On 8 June 2015 the mother of Patient A telephoned the Registrant again, this time to report that Patient A had lost a kilo of weight. That represented an 11% loss of body weight over four weeks in a child who only weighed eight kilograms. The Registrant told the mother that the weight loss may be a result of the medication being taken by Patient A. The Registrant made no adequate assessment as to the possible causes of weight loss or reviewed Patient A’s nutritional intake. Again, this should have alerted the Registrant to the fact that something may be wrong. It would have been expected for the Registrant to ask about Patient A’s bowel movements, tolerance to feeds and whether he was vomiting. The Registrant made no notes of any such assessment. The extent of the weight loss was notable and because of the child’s clinical condition this should have been discussed with colleagues within the clinical team.

Particulars 2(a), 2(b), 2(c) – found proved
In relation to Patient B:
a) On or around 25 June 2015, you changed Patient B's feed plan;
b) Your actions described at particular 2(a) were carried out without you having consulted Patient B's dietetic notes;
c) Your actions described at particular 2(a) were carried out without you having consulted with a senior dietetic colleague and/or consultant;

24. Patient B was about a year old and he had been a long term patient of the Registrant. He was failing to thrive for an unknown cause. He had chronic reflux, constant vomiting and food aversion. He was awaiting surgical intervention, for a fundoplication, on Thursday 25 June 2015.

25. The mother of Patient B was a doctor. She expressed clear objections to a number of staff members about the treatment plan of Patient B and his proposed feed regime.

26. The Registrant was away from work on annual leave for the week commencing Monday 15 June 2015. During that period of absence a feed regime was introduced for Patient B by MK with an aim to feed over a longer period to try and reduce the reflux and vomiting described by the mother. On the Thursday of that week the planned surgery was cancelled. Patient B’s mother subsequently decided in the circumstances that she would discharge Patient B.

27. Upon returning to work the following week the Registrant spoke with Patient B’s mother who was resistant to the hours of the feeds proposed by MK. Patient B had a twin whom the mother was caring for at home, and she stated that she did not want to have to feed Patient B over-night. She was concerned that Patient B was not sleeping in her bedroom and if he vomited after feeds, as was his tendency, she would not be there. The Registrant decided to change the feed plan. The Panel is satisfied that the Registrant did so without consulting Patient B’s dietetic notes. She could not have done so because, at the time, the notes were held by MK although the Registrant would have had access to the medical notes held on the ward and the “bed end chart” which would have shown the feeding regime. She also did so without consulting her senior dietetic colleague, MK, or a consultant. In her witness statement the Registrant maintained that she had spoken to MK but the Panel is satisfied that any such conversation took place after the decision to change the feed plan had been made.

Particulars 3(a), 3(b), 3(c) – found not proved
In relation to Patient C:
Between 31 March 2015 and 1 July 2015, you did not document adequately or at all on Patient C's Dietetic record card:
a) the referral
b) any follow up actions; and/or
c) proposed dietetic interventions;

28. The Panel has taken into account the additional dietetic record note produced during the hearing in response to the Panel’s request. The referral in respect of Patient C was received on 31 March 2015. The dietetic record note produced during the hearing confirms that the Registrant made a record of the fact of the referral on 2 April 2015. On the basis of the note prepared by the Registrant the Panel is satisfied that the Registrant gave advice to the mother of Patient C and, further, confirmed with the mother that the Registrant would phone the mother on 7 April 2015 after the Easter bank holiday weekend to check current circumstances. The Registrant duly phoned Patient C’s mother on that day and suggested that the mother try stopping the Gaviscon. The dietetic record note shows that the Registrant was considering proposed dietetic interventions including changing the patient’s milk type, using an alternative anti-reflux medication and providing high energy feed.

29. In summary, the Panel is satisfied that the Registrant did properly record the fact of the referral. She undertook appropriate follow up actions and considered, and documented, proposed dietetic interventions.

Particulars 4(a), 4(b), 4(c) – found proved
In relation to Patient D:
Between 26 March 2015 and 1 July 2015, you did not document adequately or at all on Patient D's Dietetic record card:
a) the referral
b) a follow-up plan from that referral; and/or
c) proposed dietetic reviews;

30. The Panel is satisfied that the referral in respect of Patient D was received by the Dietetic department on 26 March 2015. Patient D was a child aged approximately 4 years who had a congenital heart defect. It was the responsibility of the Registrant to take appropriate action following the referral. There was no record of the referral made by the Registrant. Upon receiving the referral on or about 26 March 2015, the Registrant should have initiated a dietetic record for Patient D. She did not do so. It is unclear whether the Registrant saw the patient, but in any event she did not create any plan of treatment and did not propose any dietetic reviews.

Particulars 5(a), 5(b), 5(c) – found proved
In relation to Patient E:
Between 25 March 2015 and 1 July 2015, you did not document adequately or at all on Patient E's Dietetic record card:
a) the referral
b) any follow up actions; and/or
c) a follow-up appointment;

31. The referral was received by the Dietetic department on 25 March 2015 and it was the Registrant’s responsibility to take appropriate action. Patient E had multiple medical issues including irregular blood sugar levels and global developmental delay which affected eating ability. There is no record at all that the Registrant took any action upon receiving the referral.

Particulars 6(a), 6(b), 6(c), 6(d) – found proved
In relation to Patient F:
Between 23 March 2015 and 1 July 2015 you did not document adequately or at all on Patient F's Dietetic record card:
a) the referral
b) follow up actions; and/or
c) dietetic Interventions; and/or
d) a follow-up plan;

32. Patient F, approximately 3 years old, had a congenital heart defect and had undergone heart surgery on 11 March 2015. The referral was received by the Dietetic department on 23 March 2015 and it was the Registrant’s responsibility to take appropriate action in view of the fact that since the surgery the weight of Patient F had decreased from 18.2 kilograms to 16.4 kilograms.

33. The Panel is satisfied that the Registrant started to create a dietetic record but the record shows only the name of the relevant consultant and the diagnosis. It does not record the date of the referral, the nature of the medical condition, any actions taken by the Registrant, details of any dietetic interventions or any follow-up plan.

Particular 7 – found proved
In relation to Patient G:
In relation to Patient G, between 1 April 2015 and 1 July 2015, you did not create a dietetic record card for the patient.

34. This case was referred to the Registrant directly by a doctor within the Trust by email dated 1 April 2015. Patient G, who was a child, was experiencing multiple allergies. The doctor asked the Registrant to identify foods that would be suitable for Patient G. As the child was starting to wean this placed him at risk of nutritional deficiencies.

35. There is no evidence that the Registrant created any dietetic record in respect of Patient G or saw the patient. It appears she simply made a brief handwritten note on the email from the doctor in which she made reference to a clinic appointment. The Registrant has admitted the Particular. The Panel is satisfied that the Registrant made no proper dietetic record to show why the patient had been referred, when the out-patient appointment was and what the dietetic action plan was if any action had been taken.

Particular 8 – found proved
In relation to Patient H:
In relation to Patient H, between 24 October 2014 and 1 July 2015, you did not create a dietetic record card for the patient

36. This referral was received on 24 October 2014 and the Registrant had responsibility for this case. Patient H was a 3 month old in-patient who had a dilated cardiomyopathy and who had a proportion of her nutrition provided via a nasal-gastric feeding tube. Her weight had declined from birth and she required a nutritional assessment. The referral contained a request that Patient H be seen on the day of the referral if possible because she was transferring to another area.

37. The Registrant made a handwritten note on the referral document noting there had been a weight loss between 23 October 2014 and 27 October 2014 and that Patient H needed immunisations before her transfer. It is unclear whether the Registrant saw the patient and what the source of the recorded weights was. There is no evidence to show that the Registrant created any dietetic record in respect of Patient H showing why the patient had been referred and what the dietetic action plan was.

Particular 9 – found proved
In relation to Patient I:
In relation to Patient I, between 17 December 2014 and 1 July 2015, you did not create a dietetic record card for the patient.

38. This referral was made by a Consultant Paediatrician by a letter typed on 7 January 2015 addressed to the Registrant who had responsibility for this case. Patient I was a 12 months old boy who was weaning with multiple food intolerances and allergy. There is no evidence to show that the Registrant created any dietetic record in respect of Patient I showing why the patient had been referred and what the dietetic action plan was. The Registrant has admitted this Particular. The notes following the Registrant’s suspension from work showed that Patient I had been seen in clinic, possibly by the Registrant, on 8 May 2015 but there was no letter back to the consultant following this appointment.

Decision on grounds
39. In making these assessments the Panel takes into account that misconduct may be defined as an act or omission that amounts to a serious breach of professional standards. Lack of competence may be defined as a serious or persistent failure to demonstrate the skill and knowledge to be expected of a registered Dietitian and which has been demonstrated by a fair sample of the registrant’s work.

40. The Panel is satisfied on the evidence that the Registrant was a Dietitian with approximately 28 years’ service. The witnesses gave evidence, which was accepted by the Panel, that, at times, the Registrant was capable of competent work. MC confirmed that the Registrant had the skills and knowledge required to undertake the role and clearly knew what was expected of her. The Panel has concluded that the Registrant had substantial professional experience. When she was spoken to about her standard of work there would be an improvement for the period thereafter. The Panel has concluded that the failings on the part of the Registrant as recorded above did not result from a lack of competence.

41. The Panel is satisfied that in respect of each of the Particulars or sub- Particulars found proved above, apart from Particular 2, the Registrant knew what should have been done but failed to take appropriate actions and this amounted to serious misconduct. The Panel sets out below its reasons for these findings of misconduct by reference to each patient.

Patient A
42. The Panel accepts that there can be mistakes in making feed calculations. However, the failure by the Registrant in miscalculating the food recipe was likely to have been apparent if she had clearly recorded the weight and nutrition used in the feed calculation in the dietetic notes. Her action in this respect created a risk of harm to the child. The two occasions when Patient A’s mother reported to the Registrant that the feed looked thin and that Patient A had experienced a kilogram loss of weight should have created alarm signals for the Registrant. She should have realised that further investigation and action were required. She failed to take appropriate action. Her failings in this respect caused potential risk of harm to a vulnerable child and were serious. A further risk was created by the failure on the part of the Registrant to plot Patient A’s weight on a growth chart. Her failure meant that it was unlikely that she (or another member of staff) could make an adequate contemporaneous assessment of Patient A’s weight growth or loss. The Registrant admits that these were serious failings which fell below the standard required of a dietitian and she expressed her remorse in her witness statement.

Patient B
43. The Panel has concluded that the actions of the Registrant in this respect did not cross the seriousness threshold so as to amount to misconduct. The Registrant had had long experience of Patient B and a good understanding of his nutritional and medical needs. Upon the surgery being cancelled, Patient B’s mother said that she would be taking Patient B home. Patient B’s mother was a doctor and it is clear to the Panel that she would put pressure on medical staff regarding appropriate treatment for Patient B. Patient B’s mother indicated to the Registrant that she was not satisfied with the length of feeds that had been proposed by MK. The Panel has concluded that the Registrant decided, in the knowledge that Patient B would be returning home to be cared for by his mother, that it was in the interests of Patient B to introduce a feed plan that was more likely to be followed by the mother. The Panel has noted that in changing the feed plan the Registrant did not have access to the dietetic notes and nor did she consult with dietetic colleagues or a consultant. However, the Gastro team had indicated they were content for Patient B to return home even though they were aware of the new proposed feed regime.

44. The Panel accepts it was likely to have been difficult for the Registrant to make contact with the relevant consultant in the time available. It was likely that medical notes (as opposed to dietetic notes) would have been available to the Registrant on the ward and the “bed end chart” would have recorded the feeding regime and tolerance. Patient B’s mother was in a position to make an informed choice. The Panel is satisfied that, whilst the actions of the Registrant did not amount to best practice, she took her action believing there would be a higher risk to the child if Patient B were returned home on the original feed plan, when there was a real prospect that that plan would not be complied with.

45. The Panel takes into account the history of regular past contact between Patient B’s mother and the Dietetic department and is sure that if Patient B’s mother thought that the replacement feed plan offered by the Registrant was not being tolerated by Patient B, then she would have made urgent contact with the Trust. The Panel therefore finds that the Registrant’s actions did not amount to misconduct.

Patient D
46. There was a failure on the part of the Registrant over a 3 month period to take proper dietetic action on this referral. The Patient was a 4 year old boy who had a congenital heart defect. He had a low weight for his age and required an assessment of his nutritional status. The Respondent’s failure to take dietetic action created a significant risk of harm for a vulnerable child and amounts to misconduct. As with all of the Particulars which relate to failure to complete a dietetic record adequately or at all, the risk was that if the Registrant was off work unexpectedly, or on annual leave, other members of staff could not quickly look at the card to establish the latest position, the action plan or whether immediate action was required for that patient. This put the patient at a potential risk of harm.

Patient E
47. This was a failure on the part of the Registrant that extended over a 3 month period. Patient E was an 8 year old girl with persistent hyperinsulinism, congenital chromosomal deletion and global developmental delay which affected her eating ability. She had a low weight for her age. The Registrant’s failure created a significant risk of harm for a vulnerable child and amounts to misconduct.

Patient F
48. This failure on the part of the Registrant extended over a 3 month period. Patient F was a 3 year old boy with a congenital heart defect who had undergone cardiac surgery 12 days before the date of the referral. He had lost 1.8 kilograms of body weight and although he had an acceptable weight for his age he required a nutritional assessment. The Registrant’s failure created a significant risk of harm for a vulnerable child and amounts to misconduct.

Patient G
49. The Registrant failed to take action on this referral over a 3 month period. Patient G was a one year old boy with multiple food allergies to milk, egg and peanut. The Respondent’s failure created a significant risk of harm for a vulnerable child and amounts to misconduct.

Patient H
50. The Registrant failed to take action on this referral over an 8 month period. Patient H was a 3 months old girl with dilated cardiomyopathy who had a proportion of her nutrition provided via a nasal-gastric tube. The Registrant’s failure created a significant risk of harm for a vulnerable child and amounts to misconduct.

Patient I
51. The Registrant failed to take action on this referral over a 7 month period. Patient I was a 12 months old boy with multiple food intolerances and allergy. The Registrant’s failure created a significant risk of harm for a vulnerable child and amounts to misconduct.

Decision on impairment
52. The Panel has taken into account the HCPTS Practice Note: “Finding that Fitness to Practise is Impaired”. An assessment has to be made of the Registrant’s current fitness to practise. Panels should take into account both the personal component and the public component. The personal component means the current competence and behaviour of the individual registrant and the public component means the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the Dietitian profession.

53. The Panel has to take into account the degree of harm or risk caused by a registrant and the registrant’s culpability for that harm or risk.

54. The Panel takes into account that the Registrant has admitted her failures and has shown remorse, particularly in the case of Patient A. However, the Registrant has not demonstrated full insight into her failings. She has said in her witness statement that she cannot explain why she acted, and failed to act, as she did. The failings found by the Panel are capable of remediation. The Panel notes the evidence that the Registrant has practised safely in the past. However, there is no evidence before the Panel of remediation on the part of the Registrant. She has not worked as a Dietitian since July 2015. She accepts that she has not kept her skills and continuing professional development up to date. In those circumstances the Panel has concluded there is a high risk of repetition of these types of failings if the Registrant were to return to unrestricted practice. Therefore, the Panel finds that the Registrant’s fitness to practice is currently impaired.

Decision on sanction
55. The Panel has considered the appropriate sanction and has taken into account the HCPTS “Indicative Sanctions Policy”. The purpose of sanctions is not to be punitive. The primary purpose is to protect members of the public. Relevant other objectives are to maintain the reputation of the Dietetic profession and confidence in this regulatory process.

56. In deciding what, if any, sanction to impose, Panels should ensure that any sanction is proportionate and strikes a proper balance between the protection of the public and the rights of the registrant.

57. The aggravating features in this case are:
(i) there were 7 vulnerable service users placed at risk of serious harm
(ii) the Registrant repeated the same type of failure on a number of occasions
(iii) Patient A was placed at particular risk of harm taking into account the degree of weight loss he experienced and the substantial error made by the Registrant in attempting to calculate his feed. The feed advised by the Registrant provided less than a quarter of the child’s nutritional requirements.
(iv) the Registrant has not shown full insight into her failings
(v) there is a risk of repetition of the failings if the Registrant were to return to unrestricted practice

58. The mitigating features are:
(i) the Registrant’s long career of 28 years
(ii) there have been no previous Fitness to Practise proceedings against the Registrant and no previous formal employment disciplinary proceedings with the Trust
(iii) the remorse expressed by the Registrant
(iv) the admissions made by the Registrant
(v) the lack of intention on the part of the Registrant to cause harm to patients.

59. In this case it is not appropriate to make no order because that would not provide adequate public protection. Mediation is not appropriate because of the lack of engagement on the part of the Registrant. A Caution Order is not appropriate because this was not an isolated lapse and was not of a minor nature. Such an order is not appropriate where there is a high risk of reoccurrence.

60. The Panel is satisfied that the failings of the part of the Registrant amount to breaches of the following:
Standards of conduct, performance and ethics:
Standard 1 –  You must act in the best interests of service users.
Standard 5 –  You must keep your professional knowledge and skills up to date.
Standard 7 – You must communicate properly and effectively with service users and other practitioners.
Standard 10 – You must keep accurate records.

Standards of proficiency for Dietitians:
Standard 1.1 – know the limits of their practice and when to seek advice or refer to another professional
Standard 1.2 – recognise the need to manage their own workload and resources effectively and be able to practise accordingly
Standard 4.1 – be able to asses a professional situation, determine the nature and severity of the problem and call upon the required knowledge and experience to deal with the problem
Standard 4.2 – able to make reasoned decisions to initiate, continue, modify or cease interventions or the use of techniques or procedures, and record and record the decisions and reasoning appropriately
Standard 4.4 – recognize that they are personally responsible for and must be able to justify their decisions
Standard 4.6 – be able to make appropriate referrals and requests for interventions from other services
Standard 10.1 – be able to keep accurate, comprehensive and comprehensible records in accordance with applicable legislation, protocols and guidelines
Standard 10.2 – recognise the need to manage records and all other information in accordance with applicable legislation, protocols and guidelines
Standard 14.10 – be able to critically evaluate the information gained in monitoring to review and revise the intervention

61. The Panel has considered a Conditions of Practice Order. Such an order will be appropriate where a Panel is confident that a registrant will adhere to the conditions, is genuinely committed to resolving the issues they seek to address and can be trusted to make a determined effort to do so. There has been limited engagement by the Registrant. The Panel recognises that the Registrant has admitted the Particulars of the Allegation but, nevertheless, is satisfied that there is a significant lack of insight on her part. She has not been able to give any reasonable explanation as to why she acted as she did. She has not practised as a Dietitian for over two years and she has indicated that she does not intend to return to practice. The Panel is satisfied that there are no conditions of practice that would provide sufficient public protection and which would be workable and enforceable. The Panel is satisfied that a Conditions of Practice Order is not appropriate.

62. The remaining options are a Suspension Order or a Striking Off order. The Panel is satisfied, taking into account the long service on the part of the Registrant and the lack of previous fitness to practise action, that a Striking-Off Order would not be proportionate, particularly when a Suspension Order would ensure adequate public protection and serve the public interest in maintaining confidence in the Dietetic profession and this regulatory process.

63. The Panel has concluded that a Suspension Order is the proportionate and appropriate order in this case. The failings of the Registrant are capable of remediation if she shows adequate insight. Despite what the Registrant has said about not returning to practice the Panel takes into account that after a period of reflection the Registrant may wish to follow such a course. There is no evidence that the Registrant has started a meaningful insight and remediation process. The Panel is satisfied that the Suspension Order should run for 12 months because it is likely that considerable time will be required for full insight and remediation to be gained.

64. The Suspension Order will be reviewed prior to its expiry. This Panel cannot bind the assessment that will be made by any future Reviewing Panel. However, it may assist any such Reviewing Panel, and the Registrant, if at any future review the Registrant were to produce:
(i) a written reflective piece dealing with why the failures identified in this Decision occurred and what steps she has taken to prevent such failings occurring again.

(ii) confirmation that she has undertaken continuing professional development which should include the importance of accurate record keeping

(iii) written confirmation, including testimonials if appropriate, of any work experience (unpaid or paid) carried out by her which demonstrate that the concerns of the Panel expressed in this Decision have been addressed.

Order

The Registrar is directed to suspend the registration of Mrs Margaret Dean for a period of 12 months from the date this order comes into effect.

Notes

The order imposed today will apply from 20 September 2017 (the operative date).

This order will be reviewed again before its expiry on 20 September 2018.

Hearing history

History of Hearings for Ms Margaret Dean

Date Panel Hearing type Outcomes / Status
21/08/2017 Conduct and Competence Committee Final Hearing Suspended