Ms Paula Hutchinson

: Operating department practitioner

: ODP32166

: Final Hearing

Date and Time of hearing:10:00 14/09/2017 End: 17:00 15/09/2017

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

: Conduct and Competence Committee
: Conditions of Practice

Allegation

(As amended at the final hearing)
During the course of your employment as an Operating Department Practitioner at Nuffield Health Leeds, you:

1. On or around 10 June 2016:
a. did not check that Patient A was wearing the correct wristband prior to Patient A's operation:
i. on the ward; and
ii. in the anaesthetic room.
b. initialled the Pre-Procedure Checklist confirming that Patient A's identity had been confirmed and corresponded with Patient A's wristband and patient records when you had not checked.
c. did not record on the Pre-Procedure Checklist that you had obtained signature evidence to confirm your discussion of the Consent Form with Patient A.
d. allowed Patient A to be transferred to an operating theatre with an incorrect wristband.

2. On or around 21 April 2016:
a. during surgery on Patient B, prepared and supplied to the Anaesthetist an Insulin ampoule of 1000 units in 50 mls diluent instead of the requested 50 units of Insulin in 50 mls diluent.

3. The matters referred to at Particular 1(b) are dishonest.

4. The matters set out in paragraphs 1 - 2 constitute misconduct and/or a lack of competence.

5. The matter set out in paragraph 3 constitutes misconduct.

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

Finding

Preliminary matters
Application to amend the Particulars
1. At the beginning of the hearing, Ms Jones, counsel appearing for the HCPC, applied to amend a number of the Particulars. Ms Sharma, counsel on behalf of the Registrant did not oppose the application.

2. Having heard and accepted the advice of the Legal Assessor, the Panel decided to allow the proposed amendments in full. It was of the view that the amendments were minor in nature, essentially clarifying the position of the HCPC, and did not materially change the nature of the Allegation against the Registrant. The Panel was satisfied that there would be no prejudice to the Registrant in allowing the proposed amendments.

Proceeding in private
3. The Panel, with the agreement of the parties, determined to hear any parts of the evidence which related to the Registrant’s health or personal circumstances, in private, so as to protect her private life.

Background
4. The Registrant is a registered Operating Department Practitioner (ODP), who qualified in 2009. She was employed at Nuffield Health Leeds, a private hospital (the Hospital), from 27 July 2015 to 10 August 2016.

5. On 21 April 2016, the Registrant was working in the cardiac surgery theatre. Patient B was due for surgery and had been anaesthetised in preparation for the operation. Patient B had type 2 diabetes and when placed on coronary artery bypass, an emergency situation developed. During this emergency, the anaesthetist, SW, asked the Registrant to prepare ’50 in 50’, which means 50 units of insulin in 50ml of saline diluent. Insulin was stored in 10ml vials at the Hospital, and 10ml of insulin equated to 1000 units of insulin.

6. It is alleged that in response to the anaesthetist’s request for insulin of ’50 in 50’, the Registrant used the whole vial of insulin, thus  she incorrectly prepared and supplied 1000 units of insulin in 50ml of saline diluent to the anaesthetist.

7. The anaesthetist injected an initial 4ml of the prepared insulin intravenously to Patient B through a central venous line. He then loaded the prepared syringe into a syringe driver and commenced a continuous infusion at a rate of 4ml per hour. Shortly after starting the infusion, SW noticed that the vial was empty. On checking, the Registrant, confirmed that she had used the whole vial of insulin. The infusion was stopped and Patient B’s blood glucose levels were monitored.

8. An investigation into the incident was conducted by CK, Senior Sister at the Hospital, and the Registrant was suspended pending that investigation. On 25 April 2016, CW conducted an investigatory interview with the Registrant. The Registrant admitted her error in supplying the wrong quantity of insulin to the anaesthetist. Following the investigation, the matter proceeded to disciplinary proceedings, the outcome of which was that the Registrant received a final written warning.

9. On 1 June 2016, the Registrant returned to work, subject to conditions, one of which was that she was to be under the supervision of another ODP.

10. On 10 June 2016, the Registrant was working in a surgical theatre at the Hospital. Patient A was due to undergo an elective surgical operation under general anaesthetic. He had been issued with an incorrect wrist band, which had been generated from the Hospital’s Patient Information Management System (PIMS). When Patient A had been admitted to the ward, a Health Care Assistant had put the incorrect patient wristband on his wrist, because the wrong wristband had been printed and placed in the folder containing Patient A’s medical notes. On the ward, the nurse who had been allocated Patient A, had not checked that the wristband was correct. A consent form for the elective surgery had been completed in respect of Patient A, which he had signed.

11. Before a patient proceeds to surgery, a Pre-Procedure Checklist (PPC) is required to be completed in respect of the patient. The PPC is a chart listing all relevant matters which should be checked. Both the nurse and the ODP are required to check a certain number of points with the patient. Some of the points must be checked by the nurse on the ward, and then there are further checks to be completed by the nurse and the ODP together when the patient is transferred to the anaesthetic room. They then add their initials to the chart to indicate what has been checked.

12. The Registrant collected Patient A, together with his medical notes, from the ward, to take him to theatre. Whilst on the ward, the Registrant verbally confirmed Patient A’s medical notes with him, however, it is alleged that she did not check that the wristband that he was wearing was correct before she took him from the ward.

13. Patient A was then moved to the anaesthetic room in order to be anaesthetised in preparation for surgery. The Registrant went through the details again to confirm that Patient A was the correct patient in respect of the patient notes, and went through the consent form with him. During this process, it is alleged that:
• The Registrant did not record on the Pre-Procedure Checklist (PPC) that she had obtained signature evidence to confirm her discussion of the consent form with Patient A;
• The Registrant did not check Patient A’s identity details against the patient wristband;
• Initialled the PPC to confirm that Patient A’s identity had been confirmed and corresponded with Patient A’s wristband and patient records, when she had not checked the wristband; and
• Her actions in initialling the PPC to confirm that Patient A’s identity had been confirmed and corresponded with Patient A’s wristband and patient records, when she had not checked the wristband, were dishonest.

14. CK, the Senior Sister, was again appointed to conduct an investigation into this second matter. On 15 June 2016, she conducted an investigatory interview with the Registrant. The Registrant, in that interview accepted that she had not checked the patient’s wristband. CK also interviewed other members of staff as part of her investigation, including the nurse on the ward and the Health Care Assistant. Following the investigation, the matter proceeded to disciplinary proceedings. The Registrant left the Hospital on 10 August 2016.

Decision on facts
15. At the outset of the Hearing, the Registrant admitted all of the clinical facts in respect of the two incidents of 21 April 2016 (Particular 2) and 10 June 2106 (Particular 1). She denied the allegation of dishonesty.

16. On behalf of the HCPC, the Panel heard evidence from CK, Senior Sister at the Hospital, who had been instructed to undertake the two investigations. The Panel was also provided with a documentary exhibits bundle, which included summaries of the investigative interviews and statements from other members of staff.

17. The Registrant gave evidence, and provided two bundles of documents, the first of which was her statement and the second of which contained testimonials from, JB and GR, former colleagues and registered nurses, FG, a longstanding personal friend and AV, an ODP who had worked with the Registrant at the Hospital.

18. The Panel heard and accepted the advice of the Legal Assessor. Although the Registrant admitted each of the Particulars of fact relating to clinical matters, which is persuasive, the Panel recognised that it had to be satisfied that those Particulars of fact were capable of proof. In respect of both the admitted and disputed facts, the Panel recognised that the burden of proving each individual fact rests always on the HCPC and that the HCPC will only be able to prove a particular fact if it satisfies the required standard of proof: namely the civil standard, whereby it is more likely than not that the alleged incident occurred.

19. The Panel considered the evidence of CK. It found that she was credible in the evidence she gave to the Panel in respect of reporting the information she had gathered in her two investigations. However, the Panel found that she had been somewhat linear in those investigations, in that they reflected a disciplinary approach, rather than an investigative approach and there was a lack of depth to the investigations. In the Panel’s view, CK had not acknowledged the context in which the Registrant was working, namely the Registrant’s personal circumstances at the time of the two incidents; the common poor practices which existed in the Hospital, particularly around medicines management; and the emergency situation of the incident of 21 April 2016. Although CK had not known the Registrant before she was asked to undertake the first investigation, the Panel was concerned that the process of the second investigation may have been flawed, given CK’s earlier involvement. The Panel also found that the extent of her evidence was limited, given that it was third party evidence.

20. In respect of the Registrant, the Panel found her to be a credible witness, and her evidence to be open and honest. She had admitted her clinical errors at the outset in the investigatory interviews and again before the Panel at this Substantive Hearing. The Panel found that, she had been consistent in her account throughout the Hospital’s investigations and in her evidence before the Panel. The Panel was satisfied that overall her evidence was credible and could be relied upon.

Particular 1(a)(i) and 1(a)(ii) – found proved
1. On or around 10 June 2016:
a. did not check that Patient A was wearing the correct wristband prior to Patient A’s operation:
i. on the ward;
ii. in the anaesthetic room.

21. The Panel finds Particulars 1(a)(i) and 1(a)(ii) proved on the basis of the documentation and the Registrant’s admissions.

22. The Panel was satisfied from all the evidence that the wristband Patient A was wearing when the Registrant went to the ward to collect him was incorrect, and she had not checked the wristband either in the ward or in the anaesthetic room to confirm the patient’s identity, although she had verbally checked his identity against his patient notes.

Particular 1(b) – found proved
1. On or around 10 June 2016:
b. initialled the Pre-Procedure Checklist confirming that Patient A’s identity had been confirmed and corresponded with Patient A’s wristband and patient records when you had not checked.

23. The Panel finds Particular 1(b) proved on the basis of the Registrant’s admission and the documentation.

24. The Panel had sight of a copy of the PPC and was satisfied that the initials ‘PH’ appeared on the form, in the box to confirm identity by wristband. The Registrant admitted that she had not checked Patient A’s wristband and that she had initialled the PPC to the effect that she had checked the wristband, in error. She said that she had placed her initials in the wrong box.

Particular 1(c) – found proved
1. On or around 10 June 2016:
c. did not record on the Pre-Procedure Checklist that you had obtained signature evidence to confirm your discussion of the Consent Form with Patient A.

25. The Panel finds Particular 1(c) proved on the basis of the Registrant’s admission and the documentation.

26. The Panel had regard to a copy of Patient A’s consent form, and was satisfied that it had been signed by both Patient A and the consultant. The Registrant’s evidence was that she had gone through the consent form with the patient, and had effectively meant to record that she had signed to confirm evidence of consent, but had placed her initials in the wrong box.

Particular 1 (d) – found proved
1. On or around 10 June 2016:
d. allowed Patient A to be transferred to an operating theatre with an incorrect wristband.

27. The Panel finds Particular 1(d) proved on the basis of the Registrant’s admission and the documentation.

28. The Panel took account of the Registrant’s acceptance that she had not checked Patient A’s wristband before he was taken into theatre. The evidence was that the error of the incorrect wristband was identified once Patient A was in theatre, and under anaesthetic. Therefore the Panel was satisfied that the Registrant had allowed Patient A to be transferred to theatre with an incorrect wristband.

Particular 2(a) – found proved
2. On or around 21 April 2016:
a. during surgery on Patient B, prepared and supplied to the Anaesthetist and insulin ampoule of 1000 units in 50mls diluent instead of the requested 50 units of Insulin in 50mls diluent.

29. The Panel finds Particular 2(a) proved on the basis of the Registrant’s admission and the documentation.

30. The Panel had regard to the email sent by SW, the anaesthetist, to CK setting out his account of the events of 21 April 2016, which was not challenged by the Registrant. He described the emergency nature of the deteriorating condition of Patient A. He said:

A number of problems developed on transfer into theatre. The patients blood pressure continued to fall, he was tachycardic and there was some ischaemia showing on the ECG. When plugged into the theatre monitoring system the patient’s blood pressure failed to display properly and I had to palpate the patient’s temporal artery to establish that there was some blood pressure.

At this point I made a number of requests of [the Registrant] in fairly quick succession. I asked for the blood pressure monitoring to be displayed properly. I requested Noradrenaline infusion 4mg in 50mls diluent. There was a surgical request for a trans-oesophageal echo probe to be inserted and I asked [the Registrant] to prepare the probe. I also asked for an insulin infusion ’50 in 50’ meaning 50 units insulin in 50 mls of diluent and some tranexamic acid as an infusion.”

31. The Panel was satisfied on the evidence that the anaesthetist had requested ’50 in 50’ and that the Registrant had incorrectly prepared and supplied to him a syringe with the whole of the insulin vial/ampoule of 10ml, meaning that she had prepared and supplied him 1000 units in 50ml, albeit she had correctly labelled the syringe.

Particular 3 – found not proved
3. The matters referred to at Particular 1(b) are dishonest.

32. The Panel finds Particular 3 not proved.

33. The Panel had regard to and accepted the Registrant’s evidence in respect of her working environment. She described the Hospital as having longer lists with greater time constraints than she had experienced in similar circumstances in the NHS. She said that she had raised concerns about certain practices with the Deputy Manager, including the absence of a second checker of drugs, and that she was uncomfortable drawing up drugs on her own, as most of the anaesthetists did not check them.

34. On the 10 June 2016, the Registrant explained that Patient A was the last patient of a busy morning list, and she and the other ODP on duty, AV, had been taking it in turns to collect the patients from the ward, rather than a nurse bring them to theatre, so as to ensure the smooth and swift running of the list. She said that Patient A had been waiting since 7:30am and was anxious, with growing concerns for the intervention of anaesthesia and post operative pain.

35. In her oral evidence, the Registrant said that she went through verbal identification checks as well as the consent form with the patient which had already been signed by him. She accepted that she had not checked the wristband herself. In respect of her initialling the PPC, she said she put her initials in the wrong box. She had meant to initial the box below, in answer to the question: ‘Consent form signed by patient and consultant’. She said that it had been an error on her part, but she had not been deceitful or dishonest. She said that she had been diverted from her usual plan of checks with the patient, and although she had not checked the wristband, she had undertaken all other checks.

36. The Panel, having already determined that the Registrant is a credible witness, accepted the Registrant’s explanation that she had made a mistake in placing her initials in the box confirming the checking of the wristband. The Panel was not satisfied to the required standard that she had intended to do anything to mislead others, nor that she had sought to cover up any matters. In all the circumstances, the Panel was not satisfied that the Registrant’s actions were dishonest.

37. The fact that only one of the two boxes requiring signature was signed by the Registrant was one factor that persuaded the Panel that this was an error rather than an act of deception.

Decision on grounds
38. The Panel next considered whether the matters found proved as set out above, amounted to misconduct and/or lack of competence, and if so, whether by reason thereof, the Registrant's fitness to practise is currently impaired.

39. The Panel considered the submissions made by Ms Jones on behalf of the HCPC. The Panel also considered the submissions from Ms Sharma on behalf of the Registrant.

40. The Panel heard and accepted the advice of the Legal Assessor. The Panel was aware that any findings of lack of competence and/or misconduct and impairment were matters for the independent judgement of the Panel.

41. The Panel first considered whether the clinical incidents admitted by the Registrant either individually or cumulatively, amounted to misconduct. In the Panel’s judgement the Registrant’s clinical errors in respect of Patients A and B do not amount to misconduct. Whilst they amount to instances of poor practice, the Panel was not of the view that they were of a level of seriousness which could be said to cross the threshold from poor practice into misconduct. In reaching this judgement, the Panel had regard to the circumstances in which the two incidents had arisen. At the time, the Registrant was experiencing very challenging personal circumstances, as well as health issues, and she found the  environment in which she was working, unsupportive and very pressurised.

42. The April 2016 incident involving the incorrect dose of insulin arose in the context of an emergency situation in which the patient was rapidly deteriorating. The Registrant, whilst she had seven years of experience, was new to cardiac surgery and had not worked with that anaesthetist before. Given the emergency, the anaesthetist was making a number of urgent requests of the Registrant in quick succession, of which the request for insulin was one. On being asked by the anaesthetist about the amount of insulin prepared, the Registrant had immediately said it was the whole vial, at which the infusion was immediately stopped, and the patient’s blood glucose levels were monitored.

43. The June 2016 incident involving the incorrect wristband arose in the context of the Registrant’s recent return to work after suspension, when she was to be supervised by another ODP. It was also during a time in her personal life where she was experiencing extreme distress. The incorrect wristband had initially been generated  by the ward clerk and had been placed on Patient A in error by a Health Care Assistant. The ward nurse had also not identified the incorrect wristband when she had signed the PPC to confirm that she had checked that the wristband corresponded to the patient’s identity. The Registrant had gone to collect the patient from the ward, rather than wait for the nurse to bring him to theatre, so that the list continued to run smoothly. The Registrant did not check the wristband against the patient’s identity, although she had conducted verbal checks with the patient to check his identity against the patient records.

44. The Panel next considered whether the clinical incidents admitted by the Registrant either individually or cumulatively, amounted to a lack of competence on her part. In relation to the 10 June 2016 incident, the Panel did not find that this amounted to a lack of competence. In the Panel’s judgement, this was not an incident in which the Registrant lacked the appropriate standard of skill. Her normal practice was to check all of a patient’s identity details, which would include the wristband. However, on this occasion she had a lapse caused by the rush to get the last patient on the list into theatre and by the patient’s high level of anxiety. These events diverted her from checking all the relevant identity information and she omitted to check the wristband.

45. In relation to the 21 April 2016 incident, in respect of the insulin, the Panel did find that this amounted to a lack of competence on the Registrant’s part. The Panel acknowledged that it was a single occasion. However, in the Panel’s judgement, this was one of those exceptional cases in which the Registrant’s error on that occasion denotes a standard of professional performance which is unacceptably low.

46. The Registrant had admitted in her oral evidence, that she had not known to use a 1ml insulin syringe when preparing an insulin infusion. The evidence in CK’s statement was that a dose of insulin is usually prepared with an insulin syringe and the standard dose is 50 units, usually 0.5ml, of insulin in 50ml of diluent. CK said that anyone engaged in preparing insulin for infusion should be aware of this as it is not unique to cardiac theatres. The Registrant had readily accepted her error, but she was unable to identify why she had put 1000 units of insulin in 50ml diluent. The Panel was of the view that it was a basic requirement that the Registrant, as an ODP, should have the knowledge and skills to draw up a standard insulin infusion, and the Registrant’s error in this regard, amounted to a lack of competence in that specific area of her clinical practise.

Decision on impairment
47. The Panel had regard to the HCPC Practice Note on Impairment and in particular the two elements of impairment, namely the ‘personal component’ and the ‘public component’.

48. The Panel first considered the ‘personal component’.

49. The Panel had regard to the testimonials of former work colleagues of the Registrant, which attested to a high level of commitment and dedication to the role of an ODP on the part of the Registrant. It was clear to the Panel that the Registrant was conscientious and passionate about her work. However, the Registrant’s lack of knowledge in respect of insulin and medicines administration, was an area in which she lacked competence, but it was also an area which, in the Panel’s view, was easily remediable.

50. The Panel was satisfied that the Registrant had been open and honest about her clinical failures, and had demonstrated a considerable level of insight and remorse regarding her actions. It accepted that she had reflected at length on the two incidents. The Panel was satisfied that she clearly understood the potential impact that such errors could have on patient safety.

51. However, the position today is that the Registrant has not been able to secure work as an ODP in the time since the second clinical incident in June 2016. This means that she has not practised as an ODP for some 15 months. Although the Registrant gave evidence that she had continued to read relevant journals, she had not provided tangible evidence before the Panel as to the extent of her learning and understanding in respect of insulin and medicines management, such as to reassure the Panel that there was no longer a risk of recurrence. The Panel acknowledged that financial pressures had affected the Registrant’s ability to undertake ongoing continuing professional development (CPD) learning. However, the reality is that the Registrant has not been able to demonstrate sufficient remediation.

52. In light of this the Panel could not be confident that there was no longer a likelihood of recurrence. It therefore concluded that in respect of the personal component, the Registrant’s fitness to practise is currently impaired.

53. The Panel went on to consider the ‘public component’.

54. In light of the ongoing risk of recurrence identified by the Panel, which, in turn may place patients at risk of harm, the Panel was of the view that the public would be concerned if a finding of impairment were not made and the Registrant were permitted to return to practice unrestricted. Furthermore confidence in the regulatory process, and the HCPC as a regulatory body, would be undermined.

55. Accordingly, in respect of the ‘public component’ the Panel concluded that the Registrant’s fitness to practise is currently impaired.

Decision on sanction
56. Having concluded that the Registrant’s current fitness to practise is currently impaired, the Panel went on to consider what would be the appropriate, proportionate and sufficient sanction or other outcome in this case.

57. The Panel accepted the advice of the Legal Assessor. It had regard to the latest copy of the Indicative Sanctions Policy (ISP), dated 22 March 2017, and considered the sanctions in ascending order of severity. The Panel was aware that the purpose of a sanction is not to be punitive, but to protect the public and to safeguard the wider public interest, which includes upholding standards within the profession, together with maintaining public confidence in the profession and its regulatory process.

58. The Panel considered that the following were mitigating factors:
a. The Registrant made immediate admissions to her errors;
b. The Registrant had a previously unblemished record or professional practice within the NHS;
c. The Registrant had been sought after by her previous NHS Manager;
d. The very positive testimonials from previous colleagues and her manager;
e. There was a chain of errors involving other practitioners in both instances;
f. There was a culture of poor practice within the Hospital, which existed at the time of the Registrant’s error on 21 April 2016, despite her attempts to challenge the poor administration of medicines;
g. The poor practice of other practitioners was not followed by the Registrant, in her refusal to connect drugs in advance and her attempt to have drugs checked;
h. The poor support from the organisation during the Registrant’s time of extreme personal difficulties.

59. The Panel considered that the following were aggravating factors:
a. The insulin error was a basic, but serious error, not expected of a practitioner of her experience;
b. The insulin error was a ‘never event’, namely an event which should never happen, due to the potential risk of a very high level of harm to the patient;
c. The Registrant did not seek appropriate support from HR or her GP, during her extreme levels of personal stress at the time, despite her recognition in hindsight that this level of stress may have compromised the standards of her practice.

60. The Panel considered that the options of taking no further action or mediation were neither appropriate or proportionate, given the findings in this case. Neither would address the identified risk of recurrence, nor address the wider public interest.

61. The Panel considered that a Caution Order was not sufficient to protect the public in the particular circumstances of this case, and therefore would not maintain public confidence in the profession.

62. The Panel next considered a Conditions of Practice Order. The Panel took account of paragraph 34 of the ISP, which indicates that ‘…a panel will need to consider carefully whether the Registrant can be trusted to comply with [conditions].’ In light of the Registrant’s evidence, the Panel was reassured that the Registrant would be both willing and able to adhere to conditions, and further would be committed to resolving her practice. The Panel was of the view that the lack of competence was in respect of a specific area of her practice and was capable of remediation. The Panel was therefore of the view that conditions could be formulated which would achieve the objectives of protecting the public and maintaining public confidence in the profession, while at the same time being workable, practicable, and proportionate. The Panel also considered, that there was a public interest in this case in formulating conditions which would allow the Registrant to return to safe and effective practice.

63. The Panel determined to make a Conditions of Practice Order for a period of 9 months. The Panel was of the view that this was an appropriate length of time to allow the Registrant to achieve remediation.

 

Order

Order: The Registrar is directed to annotate the Register to show that, 9 months from the date that this Order comes into effect (“the Operative Date”), you, Ms Paula Hutchinson, must comply with the following conditions of practice:
1) You must promptly inform the HCPC if you take up any employment, and provide details of that employment;

2) You must undertake and successfully complete an administration of medicines course, with a particular focus on the administration of insulin, and forward a copy of your results to the HCPC;

3) You must undertake monthly supervision meetings with your line manager in order to support your return to practice; 

4) You must provide a report to the HCPC from your line manager, commenting on your progress and the standards of your practice, before the review hearing;

5) You must inform the following parties that your registration is subject to these conditions:
A. Any organisation or person employing or contracting with you to undertake professional work;
B. Any agency you are registered with or apply to be registered with (at the time of application); and
C. Any prospective employer (at the time of application).

Notes

The order imposed today will apply from 13 October 2017 (the operative date).

This order will be reviewed again before its expiry on 13 July 2018.

Hearing history

History of Hearings for Ms Paula Hutchinson

Date Panel Hearing type Outcomes / Status
14/09/2017 Conduct and Competence Committee Final Hearing Conditions of Practice