Mrs Kelly Coburn
(as found proved at Substantive Hearing):
During the course of your employment as an Occupational Therapist with Rhondda Cynon Taf County Borough Council between June 2008 and July 2012 you:
1. Did not identify and/or undertake the appropriate assessment based on the service users' presenting condition;
2. Did not conduct assessments in an appropriate manner in that you:
a) Asked inappropriate and/or irrelevant questions;
b) Gave inappropriate and/or incorrect advice;
c) [Not Proved]
3. Recommended and implemented adaptations which were not necessary;
4. Did not demonstrate a basic level of competency in:
a) Problem solving;
b) [Not Proved]
c) Manual handling;
d) [Not Proved]
e) Report writing;
f) [Not Proved]
g) Decision making;
5. Did not communicate properly and effectively with service users and/or carers;
6. The matters set out in paragraphs 1 - 5 constitute a lack of competence.
7. By reason of your lack of competence your fitness to practise is impaired.
1. The Registrant qualified as an Occupational Therapist in 2005. She previously worked at Gwent NHS trust as a band 5 Occupational Therapist in a mental health setting.
2. On 30 June 2008 the Registrant was appointed as a community Occupational Therapist in the Adaptations and Community Equipment Team of Rhondda Cynon Taff County Borough Council (“the Council”).
3. In her role as a Community Occupational Therapist the Registrant assessed patients in the community to determine whether they needed any equipment or housing adaptations to assist them with their daily living. She also was expected to take the needs of carers into consideration. The patients the Registrant worked with had long term health conditions and/or substantial disabilities. The Registrant’s role also involved assessing and balancing the risks to service users and their carers in a way that promoted the independence of service users and assisted their carers. the Registrant played a part in managing the process by which decisions about the allocation of resources were made. The Registrant was required to account for her actions through effective and accurate recording of her assessments, decisions, plans and outcomes.
4. The Registrant was diagnosed with a health condition whilst she was at university. She did not disclose her diagnosis on her application form for employment with the Council.
5. At the start of her employment the Registrant was allocated MW, senior Occupational Therapist, as her supervisor. As her supervisor MW was responsible for authorising formal assessment documentation and clarifying the clinical reasoning it contained where appropriate. In the first three months of the Registrant’s employment MW became aware of issues concerning the Registrant’s report writing. These were primarily to do with the structure, spelling and grammar of the Registrant’s reports.
6. In a supervision session in October 2008 the Registrant disclosed her diagnosis of a health condition to MW. MW shared that information with the Team Manager, HT. The Registrant was referred to the Council’s Occupational Health department who confirmed a diagnosis of a health condition and referred her to the Workstep programme on 21 January 2009. The Workstep programme was designed to offer support to qualifying employees in the workplace. A number of recommendations were made to assist the Registrant at that time including the provision of a Dictaphone and read back software.
7. The Registrant undertook a range of training during the course of her employment with the Council. In November 2008 she completed modules C, D and F of the “All Wales Manual Handling Passport Training”. The passport training scheme was a national scheme designed to ensure consistency in manual handling training within the NHS in Wales. Module C of the course concerned ‘sitting, standing and walking’; module D ‘bed mobility’ and module F ‘hoisting’.
8. In January 2009 the Registrant also received manual handling training delivered by the Council’s own manual handling team.
9. Attempts had been made to introduce the Registrant to the manual handling elements of the Occupational Therapist role. She had undertaken a number of manual handling assessments. The Registrant made a number of high risk errors whilst on manual handling visits with her supervisor MW and with TM, a senior Occupational Therapist who oversaw manual handling practice within the team. As a result of these errors, from 26 July 2009 the Registrant was not permitted to undertake the manual handling elements of her role.
10. In April 2009 concerns were raised by the Council’s Private Sector Housing Unit about the accuracy of the Registrant’s recommendations for the installation of stair lifts. Further concerns were raised in June 2009 which included concerns that the Registrant often did not complete the necessary functional assessments on visits but nevertheless proceeded to make recommendations for service users.
11. As a result of these concerns it was agreed that MW would check the Registrant’s written work before it was uploaded to patient files. The Registrant was encouraged to use a camera to assist in her analysis of adaptation requests; provided with a typed summary of the Council’s processes which she could refer to during her assessment visits; and advised to contact the team’s advice line if issues arose while she was away from the office.
12. The Registrant commenced a period of maternity leave on 11 September 2009. During her absence her cases were allocated to other Occupational Therapists and further concerns came to light. The Council was required to resolve eight cases where ineffective adaptations had been made on the Registrant’s recommendation, many of which needed to be removed. As a result of these matters HT resolved that the Registrant should be more closely supervised on her return to work from maternity leave.
13. The Registrant returned to work on 28 June 2010. She attended a return to work meeting where she was allocated a new supervisor, JJ and was advised of the concerns that had arisen in her absence. At the return to work meeting the Registrant agreed that the key areas of her development needs were: making clinical decisions, critical evaluation of information and assessment. It was agreed that the Registrant would benefit from revisiting the Community Occupational Therapy process from the beginning, building up to the full range of Occupational Therapist duties and responsibilities, including manual handling, in the long term.
14. The Registrant was willing to participate in the development work. She acknowledged the importance of becoming a fully rounded Occupational Therapist and remained willing and enthusiastic in working towards achieving these goals.
15. The Registrant was allocated Occupational Therapy assessments in respect of minor works, known as Community Care Worker Assessments, when she first returned to work. These assessments could be undertaken by staff that were not qualified Occupational Therapists and generally involved less complex cases with minor aids and adaptation referrals.
16. By October 2010 the Registrant was working on the less complex Occupational Therapy assessments such as Adapted Housing Assessments. These required full functional assessments and recommendations in respect of future housing having regard to patient needs. All of the cases allocated to the Registrant were carefully screened to ensure that she could practise elements of her role without placing patients at undue risk. The Registrant continued to work on these less complex cases until she ceased to work as a Community Occupational Therapist and was redeployed in July 2012.
17. Between June and December 2010 further concerns were raised about the Registrant’s practice following a number of observed visits, known as L20 observations. The Department’s policy required all Occupational Therapists to undertake two such visits each year where a senior Occupational Therapist would observe them. Issues highlighted on these visits included a lack of knowledge in relation to medical conditions and Occupational Therapy skills, poor listening and interviewing skills and the production of subjective rather than factual functional assessment reports and documents.
18. In December 2010 the Registrant and HT held a number of meetings to discuss her work. It was agreed that the Registrant could type and edit her assessments before submitting them to her seniors. It was also agreed that observed visits would continue and seniors would intervene only where it was essential to do so.
19. On 2 February 2011 the Registrant was referred to occupational health for an urgent assessment of her abilities to undertake the role of Community Occupational Therapist. The Registrant was reviewed by occupational health on 15 February 2011 and referred for a thorough psychological assessment “to try and work out what her capabilities are and what adaptations would be required to keep her in the workplace.”
20. The assessment took place on 15 June 2011 and a report was produced dated 22 June 2011.
21. Following on from this report the Registrant was assessed by ‘Access to Work’ on 4 July 2011 and further recommendations, as to equipment which might assist her, were made.
22. On 19 July 2011 the Council received further occupational health advice which indicated that on balance some of the performance issues identified in relation to the Registrant were due to her underlying medical condition and supported the provision of various pieces of IT equipment to the Registrant. By 4 November 2011 the adaptations recommended in the Access to Work assessment had been provided to her.
23. TM attended observational visits with the Registrant on 16 and 21 December 2011 and on 11 January 2012. MW attended observational visits with the Registrant on 12, 14 and 15 December 2011. As a result of the observations made the Registrant was asked to undertake the even less complex work of disabled parking bay assessments.
24. The Registrant was on sick leave between 17 January 2012 and 8 February 2012. HT invited the Registrant to a meeting in March 2012 under the Council’s Capability procedure to discuss issues relating to her work performance. Her letter identified the issues which she wished to discuss at the meeting. They were:
• Gathering and recording factual assessment information;
• Clinical judgment/rationale and risk analysis to support recommendations;
• Conduct of the assessment; and
• Imparting accurate information to the client in respect of the grant/adaptation process.
25. HT conducted an informal capability interview with the Registrant and her trade union representative on 8 March 2012. An action plan was formulated and a support contract agreed on 14 March and both were put in place with effect from 21 March 2012. It was agreed that the Registrant would seek to demonstrate sound clinical reasoning and identify, justify and rationalise clinical decisions made in relation to client needs during the course of observed visits, two way reviews, discussions of recommendations and rationale on assessment reports. There would be constructive critique of the visits, outcomes and reflections. It was also agreed that supervisors would offer support by reviewing referral documents and assessment outcomes before the Registrant signed off her reports.
26. TM undertook further observational visits with the Registrant on 27 March and 30 April 2012. MW also undertook further observational visits with the Registrant on 22 March and 27 April 2012.
27. The action plan was reviewed at a meeting on 30 April 2012. At the meeting HT confirmed that the Registrant had not yet met an acceptable competency level in relation to the areas of concern. She told the Registrant that she could not consider any request to allocate her more complex cases because of a risk to clients.
28. On 2 May 2012 the informal capability process was suspended at The Registrant’s request so that she could consider redeployment. On 15 May 2012 the Registrant met with HT, accompanied by her trade union representative and confirmed that she wished to be redeployed. In that meeting the Registrant accepted that she was unable to carry out her full role as an Occupational Therapist and confirmed that she had not worked across the full range of Occupational Therapist duties since 2011.
29. On 12 July 2012 the Registrant accepted a post as a support worker in the Council’s mental health team. She subsequently brought employment tribunal proceedings against her employer and left her employment with the Council under the terms of an agreed settlement of her claims. She has not worked as an Occupational Therapist since 2012 and is now running a child minding business.
30. On 3 May 2013 the Council’s Occupational Therapy department referred the Registrant to the HCPC.
31. The Final Hearing panel found that the particulars of the allegation found proved amounted to a lack of competence, and that the Registrant’s fitness to practice was impaired by reason of her lack of competence. On 1 July 2015, that panel imposed a 12 month Suspension Order. The Registrant did not attend the first review hearing which took place on 21 June 2016. The first review panel determined that the risks identified at the Final Hearing remained and that there was no evidence that the Registrant had deepened her insight or taken steps to address the inadequacies in her professional performance. The first review panel found that the Registrant’s fitness to practise remained impaired and imposed a further 12 month Suspension Order. The first review panel suggested that at the next review the reviewing panel may be assisted by:
• The Registrant’s attendance at the hearing.
• Evidence of insight into her inadequate professional performance, and the associated risks for service users.
• A clear statement by the Registrant concerning her intent to practicing in the future as an Occupational Therapist.
• Evidence of training and other activities undertaken to maintain and improve her professional skills as an Occupational Therapist.
• Any other evidence that the Registrant considers will assist the reviewing panel.
32. The review hearing that was scheduled to take place on 11 July 2017 was adjourned as the Registrant had not been provided with sufficient notice. Therefore, the review panel extended the Suspension Order for 3 months without making any decision on the merits of the case.
33. Mr Pandya, on behalf of the HCPC, outlined the history of this case. He acknowledged that the Registrant has been working with children and therefore is able to work with vulnerable people. However, he submitted that the HCPC is concerned that the Registrant has not worked in an Occupational Therapist role since 2012 and has taken no further steps to remedy the technical deficiencies in her practice. He further submitted that although the Registrant’s communication and writing skills may have improved, the importance of those attributes are more stark in a healthcare environment and as such they remain untested. He invited the Panel to conclude that the Registrant has not demonstrated that she would be capable of functioning safely and effectively and that as a consequence her fitness to practise remains impaired. Mr Pandya made no positive submission with regard to the sanction that the Panel should impose. However, he reminded the Panel that whilst the Registrant has taken no steps to remediate the deficiencies in her practice, she has continued to engage with the HCPC’s fitness to practise process and maintains that it is her intention to return to practice.
34. Mr Pandya informed the Panel that because the Registrant has been out of practice for more than 5 years, she will be required to undertake 60 days of updating prior to being eligible to return to work as a registered Occupational Therapist practitioner.
Registrant’s Evidence and Submissions.
35. The hearing bundle included a statement that the Registrant had prepared for the proceedings which were adjourned on 21 June 2017. In that statement the Registrant explained the difficulties she had experienced in settling into her role with the Council in 2008 and the ‘enormity of the transition from a mental health role to a physical one.’ The Registrant stated that she found the role extremely stressful. She also stated that when she returned from maternity leave in 2009 she was unable to consolidate the information and experience she had gained prior to her maternity leave. In her statement the Registrant confirmed that she has not worked in an Occupational Therapist role since she resigned in August 2012 and at present intends to concentrate on her career in childcare. However, she stated that next year, once she has completed her Level 5 NVQ Diploma in Childcare, the Registrant hopes to return to an Occupational Therapist role in mental health and has made enquiries with regard to an MSc course at Cardiff University and return to work courses. the Registrant stated that there is an overlap between the skills and knowledge required for childcare and the role of an Occupational Therapist.
36. The Registrant chose to give evidence under oath. During her oral evidence the Registrant stated that she now recognises that she was ‘out of her depth’ when she was working as an Occupational Therapist. She stated that her lack of competence placed patients at risk and resulted in cost implications for her employer. The Registrant informed the Panel that she ‘played the victim’ in her last year of employment with the Council and blamed senior management for failing to provide her with training. She stated that she has reflected on her errors and now takes full responsibility for her lack of competence.
37. The Registrant accepted that her fitness to practise is currently impaired. She informed the Panel that the Level 5 Diploma in Childcare that she is currently undertaking contains modules, such as communication, which are similar to an Occupational Therapy degree course and referred the Panel to the programme specification from Bournemouth University. She confirmed that for financial reasons she would not be able to undertake the MSc course at Cardiff University and there are no return to work courses in her area. The Registrant informed the Panel that although she has not worked in an Occupational Therapist role since 2012 her confidence and self-esteem has improved. She stated that she is committed to the profession and invited the Panel to replace the Suspension Order with a Conditions of Practice Order.
38. When questioned by the Panel, the Registrant accepted that she had not prioritised a return to Occupational Therapy practice and not taken any practical steps, to improve her skills and knowledge in that area. In her closing submission, the Registrant stated that she should have been more proactive and invited the Panel to give her another opportunity to demonstrate her commitment to returning to the profession.
39. In undertaking this review, the Panel took into account the documentary evidence, including the programme specification for the BSc (Hons) Occupational Therapy course provided by Bournemouth University, which was provided by the Registrant immediately prior to the commencement of the hearing. The Panel also took into account the Registrant’s oral evidence and the submissions from both parties.
40. The Panel accepted and applied the advice it received from the Legal Assessor as to the proper approach it should adopt. In particular that:
• The purpose of the review is to consider the issue of impairment based on the previous panel’s findings of fact, the extent to which the Registrant has engaged with the regulatory process, the scope and level of her insight, and the risk of repetition.
• In terms of whether the Registrant’s lack of competence has been sufficiently and appropriately remediated, relevant factors include whether the Registrant:
i) fully appreciates the gravity of the previous panel’s finding of impairment;
ii) has maintained her skills and knowledge;
iii) is likely to place patients at risk if she were to return to unrestricted practise.
• The Panel should have regard to the HCPTS Practice Note: Finding that Fitness to Practise is “Impaired” and must take account of a range of issues which, in essence, comprise two components:
(i) the ‘personal’ component: the current competence, behaviour etc. of the individual registrant; and
(ii) the ‘public’ component: the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession.
• It is only if the Panel determine that the Registrant’s fitness to practise remains impaired, that the Panel should go on to consider sanction by applying the guidance as set out in the HCPC Indicative Sanctions Policy (ISP), and the principles of proportionality which require the Registrant’s interests to be balanced against the interests of the public.
41. The Panel was encouraged by the Registrant’s attendance. The Panel recognised that it is difficult to publicly acknowledge a lack of competence, which placed patients at risk of harm, and accept that the attempt to blame others for these deficiencies was wrong. The Panel took the view that the Registrant should be given full credit for acknowledging her shortcomings and for recognising the impact that her inability to perform her role to the required standard had on her employer. The Panel accepted that the Registrant was facing difficult personal circumstances at the time and that, if such a situation were to arise again in future, she would bring it to the attention of her line manager rather than try to manage it on her own.
42. The Panel noted that the Registrant has not performed the full range of Occupational Therapist duties since 2011 and has not worked as an Occupational Therapist in any capacity since August 2012. The Panel also noted that the deficiencies in the Registrant’s practise as identified at the substantive hearing are core skills required of all registered Occupational Therapists. Although the Panel accepted that the Registrant has reflected on the circumstances, which had led to the finding of lack of competence, there was no evidence before the Panel that the Registrant fully appreciates that her knowledge and skills will be even further below the standard required of a registered Occupational Therapist than when she resigned in August 2012. The Panel acknowledged that all professions provide opportunities to demonstrate transferrable skills and that the Registrant’s ability to communicate may well have improved whilst pursuing her childcare role. However, the Panel concluded that, the Registrant, in order to demonstrate that she is fit to return to the register unrestricted is required to provide evidence that she has kept her specific Occupational Therapy skills and knowledge up to date. There was no such evidence before the Panel. The Registrant assured the Panel that she would prioritise a return to practise in future but it was clear that she had not done so in the last two years.
43. There was no evidence before the Panel that the Registrant had focussed on her learning and development needs as identified by the Final Hearing panel. In these circumstances, the Panel concluded that if the Registrant were to return to practise she would place patients at risk of harm and that the risk of repetition is high. Therefore, the panel concluded that the Registrant’s fitness to practise is impaired on the basis of the personal component.
44. The Panel went on to consider the wider public interest. The Panel concluded that the public would be concerned if the Registrant was permitted to return to the register unrestricted, despite being found to lack competence in 2012 and despite failing to provide evidence that her deficiencies have been remedied. In these circumstances, the Panel was satisfied that public confidence in the profession would be undermined if there was no finding of impairment. As a consequence, the Panel determined that the Registrant’s fitness to practise is impaired based on the public component.
45. Having determined that the Registrant’s fitness to practise is impaired the Panel went on to consider what sanction, if any, should be imposed. The Panel bore in mind that the purpose of a sanction was not to punish the Registrant but to protect the public.
46. The Panel first considered taking no action. The Panel concluded that, in view of the nature and seriousness of the Registrant’s lack of competence which has not been remedied and in the absence of exceptional circumstances, it would be inappropriate to take no action. Furthermore it would be insufficient to protect the public, maintain public confidence and uphold the reputation of the profession.
47. The Panel then considered a Caution Order. The Panel noted paragraph 28 of the ISP which states:
“A caution order is an appropriate sanction for cases, where the lapse is isolated, limited or relatively minor in nature, there is a low risk of recurrence, the registrant has shown insight and taken appropriate action.”
48. The Registrant’s persistent inability to meet the standards required of a competent Occupational Therapist practitioner was not minor in nature and had the potential to have wide-ranging adverse consequences. Furthermore, the Registrant has not demonstrated that any of the skills or knowledge, specifically relevant to Occupational Therapy practice, have been addressed. Therefore the Panel concluded that a Caution Order would be inappropriate and insufficient to meet the public interest.
49. The Panel went on to consider a Conditions of Practice Order. The Panel noted that paragraph 33 of the ISP states:
‘Conditions will rarely be effective unless the registrant is genuinely committed to resolving the issues they seek to address and can be trusted to make a determined effort to do so. Therefore, conditions of practice are unlikely to be suitable in cases:
• where there are serious or persistent overall failings;’
50. The Panel noted that because the Registrant has not practised for more than five years she will be required to undertake 60 days of updating which may take the form of formal courses, informal learning and/or work placements. The Panel concluded that as this pre-condition has not been undertaken a Conditions of Practice Order would not be workable or appropriate. Furthermore, conditions require a willingness on the part of the Registrant to comply with them and a determined effort. The Panel took the view that given the Registrant’s failure to provide any evidence that she has kept her Occupational Therapy skills and knowledge up to date, this Panel could have no confidence that she would comply with a Conditions of Practice Order. In the absence of any evidence of willingness and readiness to prioritise a return to Occupational Therapy practice the Panel concluded that there were no conditions it could devise which would be workable or appropriate.
51. The Panel next considered extending the current Suspension Order for a further period of time. A Suspension Order would send a further signal to the Registrant, the profession and the public re-affirming the standards expected of a registered Occupational Therapist practitioner. The Panel noted that a Suspension Order would prevent the Registrant from practising during the extended suspension period, which would therefore protect the public and the wider public interest. A Suspension Order would also provide the Registrant with the opportunity to consider her future and decide whether she is prepared to develop the skills and knowledge required to return to practice.
52. The Panel took into account paragraph 41 of the ISP states:
‘If the evidence suggests that the registrant will be unable to resolve or remedy his or her failings then striking off may be the more appropriate option. However, where there are no psychological or other difficulties preventing the registrant from understanding and seeking to remedy the failings then suspension may be appropriate.’
53. The Panel took the view that the above paragraph applies to the Registrant. The Panel determined that the Registrant should be given a further opportunity to consider carefully the decision of the Final Hearing panel and this Panel and properly focus on the issues that have been identified.
54. The Panel determined that the Suspension Order should be imposed for a period of 6 months. The Panel was satisfied that this period would be sufficient for the Registrant to demonstrate that she is committed to addressing the deficiencies in her practise and return to practise. If she is unable or unwillingly to prioritise updating her skills and knowledge within that time frame it is highly unlikely that she will ever be able to do so.
55. The Panel decided that the appropriate and proportionate order is a Suspension Order. A Striking Off Order, at this point in time, would be disproportionate as the shortcomings in the Registrant’s practice are capable of being remedied and there remains a possibility that the Registrant is willing and able to demonstrate remediation. This Panel cannot bind a future panel but it is highly likely that if the Registrant fails to take advantage of this further opportunity to demonstrate that she has addressed the deficiencies in her practise the outcome may be a Striking Off Order.
56. The extended Suspension Order will be reviewed shortly before expiry. A future reviewing panel would expect the Registrant to attend the review hearing and provide evidence that she has made significant steps to undertake training that would facilitate a safe and effective return to practise, which may include:
(i) Evidence of up to date Occupational Therapy specific skills and knowledge, such as:
• Short courses (online or otherwise)
• Reading journals
(ii) Volunteering or work shadowing;
(iii) Testimonials from individuals able to comment on the Registrant’s skills and knowledge relevant to an Occupational Therapist role;
(iv) A reflective statement on skills and knowledge that the Registrant has acquired.
The Order imposed today will apply from 29 October 2017.
This Order will be reviewed again before its expiry on 29 April 2018.