Ms Rowena M N Stone

: Radiographer

: RA21582

Interim Order: Imposed on 02 Nov 2015

: Final Hearing

Date and Time of hearing:10:00 27/11/2017 End: 17:00 01/12/2017

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

: Conduct and Competence Committee
: Suspended

Allegation

(as amended)
During the course of your employment as a Radiographer at Royal United Hospitals Bath NHS Foundation Trust, between 1 May 2012 and September 2015:
1. Having received a request on or around 29 May 2012 to x-ray patient A’s left wrist you incorrectly x rayed Patient A’s chest.

2. On or around 7 June 2012, you incorrectly booked Patient B onto the Computerised Radiology Information System (CRIS)

3. On 18 July 2012, you incorrectly marked Patient C’s right hand x-ray with a left marker.

4. In relation to Patient D, on 15 August 2012 you:
a) x-rayed the patient’s hands without the appropriate clinical justification.
b) Did not request a new referral for the hand x-ray.

5. On 12 September 2012, you did not conduct an open mouth view x-ray on Patient E as required.

6. On or around 18 September 2012, you placed images that did not belong to Patient F in that patient’s folder on PACS.

7. On or around 27 November 2012, you incorrectly put 2 x-ray images into Patient F’s file on PACS.

8. On or around 13 November 2012, incorrectly booked Patient G to have their left wrist x-rayed on CRIS.

9. In relation to Patient H, on or around 16 January 2013, you incorrectly annotated an x-ray of the patient’s right tibia and fibula as being of the left tibia and fibula;

10. On 05 July 2012, in the case of Patient K, you placed images in the wrong Patient’s folder on PACS and/or CRIS

11. In relation to Patient N on or around 14 December 2012 labelled their x- ray images with the incorrect name.

12. Having received a referral for Patient O to have an ultrasound you incorrectly x-rayed Patient O’s abdomen on 9 January 2013.

13. Your x-ray image of Patient P taken on 11 January 2013 had poor collimation.

14. On 14 February 2013, you incorrectly x-rayed Patient Q’s left shoulder when the request was for the right shoulder to be x-rayed.

15. On 20 February 2013 in relation to Patient R:
a) you x-rayed the patient’s spine and you:
i. did not follow Scoliosis protocol;
ii. did not show the form to a radiologist prior to exposing the patient to radiation
iii. took the x-ray image with the ruler for leg lengths still in situ;
iv. did not select the ‘whole spine’ algorithm on the Remote Operating Processor (ROP) for the first image;
b) Your oblique-view x-rays of the patient’s hands did not capture the whole of the right hand;
c) told the patient:
i. that you did not believe her whole back was affected by pain, or words to that effect;
ii. that she should not be having x-rays if she wanted to have children in the future, or words to that effect.

16. In relation to Patient S, on 10 June 2014, you incorrectly annotated/marked an X-ray of the patient’s left hip as being of the right hip.

17. In relation to Patient U, you:
a) on 27 May 2014, did not check the request card immediately prior to taking the patient’s x-ray;
b) on 27 May 2014, performed a chest x-ray that had not been requested
c) did not complete a Datix incident form regarding the incident in 17(b) above in a timely manner.

18. On 25 July 2014, in relation to Patient V, you took an x-ray cassette which had already been exposed and gave it to another Radiographer to use in a second x-ray of the Patient

19. The time it took you to image Patients was longer than what is considered to be reasonable:
a) on 25 June 2014, in relation to approximately 8 patients;
b) on 04 August 2014, in relation to approximately 8 patients.

20. On 26 June 2014 you did not annotate an x-ray of Patient W’s right knee to say that it was weight-bearing.

21. On 26 June 2014 in relation to Patient X:
a) you did not identify that an x-ray had not been taken until the image was processed
b) did not scan the x-ray cassette barcode on the ROP until prompted to do so by Colleague A;
c) you were required to take a lateral view x-ray of the patient’s right knee and:
i. the quality of your x-ray was poor;
ii. when prompted to repeat the x-ray by Colleague A, the quality of your second x-ray was worse than your first attempt;
d) you took an axial view x-ray of the patient’s knee which was poor quality in that it did not show the joint space under the knee cap sufficiently;
e) had to be prompted by Colleague A to move a clip marker so that it did not obscure the image;
f) when taking the x-rays, did not look at the patient through the window in the lead screen until prompted by Colleague A.

22. On 04 August 2014, demonstrated poor patient care in that while a patient was distressed you:
a) did not do anything to assist and/or calm the patient;
b) continued to ask the Patient to put their chin on top of the cassette to prepare for an x-ray.

23. On 04 August 2014, when asked by Colleague B, you:
a) were unable to explain to Colleague B where the centering points were for a pelvic x-ray;
b) were unable to explain to Colleague B the correct exposure to set for an x-ray on a child’s tibia and fibula.

24. On or around 07 August 2014 you:
a) used an inefficient ‘no touch’ technique to position patients for their x-rays:
b) did not use alcohol gel and/or wash your hands between patients;

25. The matters set out in paragraphs 1 – 24 constitute misconduct and/or lack of competence.

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

Finding

Preliminary matters
Amendment application
1. The HCPC made an application to amend the stem and Particular 13 of the Allegation. The Panel accepted the advice of the Legal Assessor and considered whether there was any unfairness or prejudice to the Registrant, by reason of the proposed amendments, which serve to clarify the HCPC’s case in accordance with the evidence. There was no prejudice to her from this application and she has not raised any objection. The Panel granted the amendment application in order to clarify the HCPC’s case.

Application to adduce evidence by telephone
2. Mr Dite on behalf of the HCPC applied to adduce witness evidence by telephone from Witness CF. The application was opposed by the Registrant because she wished to cross-examine the witness face to face at the hearing or via video link. The Panel granted the HCPC application, because it was not appropriate for Witness CF to attend the hearing or a video conference venue, due to his inability to travel from 24 November 2017 to 4 December 2017 by reason of a health matter evidenced by a certificate from his General Practitioner. The Panel has a duty to deal with these proceedings expeditiously and fairly. The Panel was satisfied that a fair hearing could take place on the basis that the evidence of Witness CF would be given by telephone, because the Registrant would have the opportunity to cross-examine him. The Registrant had also indicated that she did not want the hearing adjourned.

Background
3. The Registrant was employed as a Band 5 Radiographer at Royal United Hospitals Bath NHS Foundation Trust (the Trust), between 14 May 2012 and 27 September 2015. Witness CF, Head of Radiology, had originally interviewed the Registrant when she applied for the position of community Radiographer.

4. In about June 2012 CF became aware of issues with her performance whilst the Registrant was working at community hospitals within the Trust. CF spoke to her informally about those issues. On 24 January 2013 a more formal process to support her performance began and CF arranged for her to work at the Royal United Hospitals, alongside colleagues who would supervise her practice. A meeting was arranged on 8 March 2013 under the Trust’s Formal Performance Management Policy.

5. Following the Registrant being absent from work, a phased return to work was arranged in about September 2013. A further phased return to work commenced towards the end of December 2013. In June 2014 a formal Performance Management Process began due to a re-occurrence of the performance issues and formal meetings were held on 25 June and 17 July 2014. The Registrant was moved from the community hospital to work at the Royal United Hospitals under the supervision of other radiographers. A formal review meeting was held on 11 August 2014 where concerns from other radiographers during this period were discussed.

6. The factual Particulars 1 to 15 relate to the period from May 2012 to February 2013 and Particulars 16 to 24 to the period from June to August 2014. They include taking x-ray images of incorrect body parts, poor quality images, failing to take appropriate images and the misfiling of images. The incidents involved some patients receiving unnecessary  irradiation.

7. The Panel has considered sequentially:
• whether the factual Particulars are proved;
• whether the proved facts amount to misconduct or lack of competence, and if so;
• whether the Registrant’s fitness to practise currently impaired.

8. The Panel accepted the advice of the Legal Assessor that the burden of proof is upon the HCPC on the balance of probabilities, in relation to findings of fact. Whether any proved facts in this case amount to the statutory grounds of misconduct or lack of competence and the issue of current impairment are not matters which need to be proved, but are matters of judgement for the Panel.

9. The Panel heard oral evidence from the following HCPC witnesses:
• CF, Head of Radiology, by telephone. He is a qualified radiographer although he has not practised in a clinical role for approximately 20 years. He holds a management position and is not an HCPC registrant. The Panel found him to be a credible, straightforward and measured witness, who referred the Panel to other witnesses when appropriate and did not speculate about matters outside of his knowledge.
• PC [Colleague A], Advanced Radiographic Practitioner whose interactions with the Registrant were from June to August 2014; but mainly in July 2014. The Panel found PC to be a credible witness. There were some contradictions between her written and oral evidence but the Panel accepted her explanations. She was balanced when challenged about her supervisory role and accepted she could have done some things differently during her supervision of the Registrant.
• HR [Colleague B], Specialist Radiographer was a credible and candid witness, who conceded there were discrepancies between her witness statement and the relevant records. HR conceded she had not seen the Registrant with the distressed patient referred to in Particular 22;
• RF, Radiology Clinical Manager, was a credible, balanced and thoughtful witness. She did not speculate, took her time over the questions asked and gave evidence which was consistent with her witness statement and the documentary evidence.
• KL [Colleague D], Specialist Radiographer gave evidence which was of limited value. There were inconsistencies between her written and oral evidence. She was confused in identifying her own signature on a supervision log and the number of the Registrant’s cases she had supervised. The Panel found this weakened her credibility.

10. The Panel also heard oral evidence from the Registrant. The Panel found the Registrant to be a truthful witness who made concessions, but at times she appeared to find it difficult to articulate her thoughts clearly.

Decision on facts
Particular 1 – found proved
11. The Registrant did not admit this Particular at the outset. This incident occurred just after the commencement of her employment with the Trust on 14 May 2012. CF stated that as seen on the Radiology Referral Form on 29 May 2012 a Consultant made a request for Patient A to have a left wrist x-ray. On 31 May 2012 the Registrant carried out x-rays on Patient A as indicated by the signatures and other handwriting on the Referral Form. The x-rays performed on Patient A included x-rays of the left wrist and chest, despite a chest x-ray not being requested. It was subsequently established that this was not so serious that it needed to be reported to the Care Quality Commission (CQC). Although the Registrant did not admit this Particular at the outset of this hearing, the Panel notes she had accepted that she made this error in an email on 13 June 2012 and in her evidence to the Panel. The Panel finds this Particular is proved.

Particular 2 – found proved
12. The Registrant did not admit this Particular at the outset. RF stated the Radiology Referral Form demonstrated that Patient B was a “walk-in” patient on 7 June 2012 dealt with by the Registrant. The Registrant should have booked this patient into the CRIS system herself. RF sent an email regarding this incident on 13 June 2012 in which she noted that the patient had been incorrectly booked onto the system. In her evidence she explained that it would not be unusual to have walk-in patients at community hospitals and for radiographers to have to telephone the main hospital to obtain hospital numbers, so that patients could be correctly booked onto the CRIS system. It is clear that the Registrant had not correctly booked Patient B onto the CRIS system because the patient had to be re-x-rayed on 8 June 2012, when the x-rays that were taken by the Registrant on 7 June 2012, could not be located. Although the Registrant did not admit this Particular at the outset of the hearing, the Panel notes she had provided an explanation in an email of 13 June 2012 in which she implicitly accepted that she made this error and she also accepted that she made this error in her evidence to the Panel. This incident occurred just after the commencement of her employment with the Trust on 14 May 2012 and although she may have been having difficulty with an unfamiliar system, it was her responsibility to resolve this difficulty before completing the task. Accordingly this Particular is proved.

Particular 3 – found proved
13. The Registrant admitted this Particular at the outset of the hearing.  CF stated the x-rays for Patient C show that originally they were marked with “left” markers despite being of the right hand. The Registrant accepted that she made this error in an email dated 20 July 2012 in which she noted that she had subsequently corrected the images. This incident occurred at an early stage in her employment with the Trust and the Registrant admitted her error; although she did not correct it until the error was drawn to her attention. The Panel finds this Particular is proved.

Particulars 4(a) and 4(b) – found proved
14. The Registrant admitted Particulars 4(a) and 4(b) at the outset of the hearing. She accepted x-raying the Patient’s hands without clinical justification, in an email dated 24 September 2012. CF stated a Radiographer is responsible for justifying x-ray requests and although the Radiology Referral Form requested x-rays of Patient D’s hands and right foot, the form did not include clinical reasoning to justify x-rays of the hands. The Registrant signed the referral form and x-rayed the patient’s hands but did not record any justification for the hand x-rays, nor did she request a new referral for the hand x-ray containing clinical reasoning. Accordingly Particulars 4(a) and 4(b) are proved.

Particular 5 – found proved
15. The Registrant admitted this Particular at the outset of the hearing. The Radiology Referral Form for Patient E requested an x-ray of the patient’s cervical spine following an episode of trauma. CF and RF stated that one of the views always required to be taken in these circumstances was an open mouth view as was made clear in the hospital protocol. The Registrant undertook the x-rays in this case by taking two views but did not include an open mouth view because she decided it was not clinically necessary. In an email dated 24 September 2012 sent to RF, the Registrant conceded she should have done an open mouth view. The Panel notes that the Registrant did not follow the relevant protocol and did not provide any reason to justify not doing something which was standard practice. Accordingly this Particular is found proved.

Particular 6 – found proved
16. Although the Registrant did not admit this Particular at the outset of this hearing, in an email dated 26 September 2012 she noted that there were images that were not related to Patient F in that patient’s folder on  PACS (Picture Archive & Communication System) and had asked for them to be deleted. RF was forwarded this email and noted that the incident had already been dealt with. The Registrant accepted that she made this error in her evidence to the Panel but she had later corrected it. Accordingly this Particular is proved.

Particular 7 – found proved
17. The Registrant did not admit this Particular at the outset of the hearing. However, the Registrant sent an email on 27 November 2012 asking for the images to be deleted because she had stored them incorrectly on PACS. In addition, in an email dated 3 December 2012 CF asked the Registrant to complete an incident report form which she subsequently did. The Registrant also accepted that she made this error in her evidence to the Panel. The Panel notes this error was corrected on the same day and the images were stored incorrectly. This Particular is proved.

Particular 8 – found proved
18. RF and CF state the Radiology Referral Form requested x-rays of Patient G’s right wrist, which the Registrant performed. However, in CRIS the patients attendance had been marked as for the left wrist. Although the Registrant did not admit this Particular at the outset of this hearing, she in fact accepted that she made this error in emails sent on 22 and 23 November 2012. The Registrant also accepted that she made this error in her evidence to the Panel. The Panel finds this Particular proved.

Particular 9 – found proved
19. The Registrant did not admit this Particular at the outset of the hearing. On 16 January 2013 Patient H had his right tibia and fibula x-rayed. The Registrant signed the Radiology Referral Form and the image was originally given a “left” marker and then a “right” marker was added digitally after the image had been taken. The presence of two markers could have given rise to misinterpretation. The Registrant accepted that she made this error in her evidence to the Panel. The Panel finds that the Registrant was aware of the relevant protocol following the incident giving rise to Particular 3 above. The correction she made to the marker was sufficient in the Registrant’s view, although she accepted it could still be ambiguous. The Panel finds this Particular proved.

Particular 10 – found proved
20. The Registrant did not admit this Particular at the outset of the hearing. Patient K’s Radiology Referral Form requested a chest x-ray. Two patients with the same surname were seen by the Registrant on the same day, she originally placed the x-rays in relation to the other patient in Patient K’s folder on the system but then asked for these to be deleted. Although the Registrant did not admit this Particular at the outset of this hearing, the Panel notes that she had accepted the error in an email dated 5 July 2012 asking for “the foot images” to be deleted from Patient K’s folder. The Registrant also accepted that she made this error in her evidence to the Panel. The Panel finds this Particular proved.

Particular 11 – found proved
21. The Registrant admitted this Particular at the outset of the hearing and accepted that she made this error in an email on 14 December 2012. On 14 December 2012 Patient N had a chest x-ray but another patient’s images were incorrectly saved into Patient N’s folder on PACS. She noted that there were two ankle images in the folder for Patient N, which were incorrect. The Registrant completed an incident reporting form in relation to this error which was corrected on the same day. The Panel finds this Particular proved.

Particular 12 – found proved
22. The Registrant did not admit this Particular at the outset of the hearing. The Radiology Referral Form for Patient O requested a “Non Obs U/S”. However, on 9 January 2013, the Registrant x-rayed the patient’s pelvis/abdominal area although an ultrasound, not an x-ray, was requested. Due to the radiation unnecessarily received by the patient this incident was reported to the CQC. The Registrant accepted that she made this error in her evidence to the Panel. The Registrant also conceded in her evidence that the clinical details provided would not have been appropriate justification for an x-ray. The Panel finds this Particular proved.

Particular 13 - found proved
23. The Registrant did not admit this Particular at the outset of this hearing. In relation to Patient P, a child, the Radiology Referral Form requested a chest x-ray. The Registrant signed the referral form and completed an x-ray of the patient on 11 January 2013. This x-ray had poor “collimation”, in that the image included parts of the patient’s head and abdomen, causing unnecessary irradiation to those areas. The Panel also notes that in an email sent on 11 February 2013 she stated that “the collimation should have been much closer to the area requested”. The Registrant accepted that she made this error in her evidence to the Panel. The Panel finds this Particular proved.

Particular 14 – found proved
24. The Registrant admitted this Particular at the outset of the hearing. The Radiology Referral Form for Patient Q requested a chest x-ray and a right shoulder x-ray. However, on 14 February 2013 the Registrant performed a left shoulder x-ray on the patient. Due to this unnecessary radiation dose the incident was reported to the CQC. The Panel finds this Particular proved.

Particulars 15(a) and 15(b) – found proved
Particular 15(c) – found not proved
25. The Registrant admitted Particulars 15(a) and 15(b) at the outset of the hearing. The Panel was told that all referrals for x-rays relating to patients with scoliosis should be confirmed by a Radiologist, although the Trust’s scoliosis guide does not explicitly state this. On 20 February 2013, a Radiology Referral Form in relation to Patient R requested “XR Whole Spine (Scoliosis)”. The Registrant performed x-rays of the patient’s spine but had not selected the “whole spine” option as detailed in the guide and so she did not produce a complete image of the spine. In addition the attempted scoliosis image was obscured by a ruler. The ruler was only intended for leg x-rays. The Registrant admitted in her evidence that she had not used the  equipment to x-ray a patient with scoliosis before and had not checked the protocols. PC stated that the guide for correctly x-raying patients with scoliosis was located on the wall by the console in the x-ray room.

26. The Panel saw that the image taken by the Registrant was an oblique view of the patient’s hands which did not capture the whole of the right hand. The Panel finds Particulars 15(a) and 15(b) are proved.

27. In relation to Particular 15(c), Patient R made a complaint about the Registrant, in an email dated 20 February 2013. Patient R was not called as a witness by the HCPC and therefore the accuracy of her email has not been tested at this hearing. The Registrant had made frank admissions about other Particulars but disputed the words attributed to her in Particular 15(c). The Panel accepted the Registrant’s account and found Particular 15(c) not proved.

Particular 16 – found proved
28. The Registrant admitted this Particular at the outset of the hearing. In relation to Patient S the Registrant incorrectly marked a left hip x-ray as a right hip x-ray. RF sent the Registrant an email regarding this on 10 June 2014 noting that the error had been picked up by the Orthopaedic team and the image was then rectified electronically. In her reply, the Registrant accepted that she made this error. The Panel finds this Particular proved.

Particulars 17(a), 17(b) and 17(c) – found proved
29. At the outset of the hearing, the Registrant admitted Particulars 17(a) and 17(b), but not 17(c). On 27 May 2014 the Registrant x-rayed Patient U’s left shoulder and chest. The Radiology Referral Form, signed by the Registrant only requested x-rays of the patient’s left shoulder. The Registrant accepted making the errors described in Particulars 17(a) and 17(b) in emails dated 9 and 20 June 2014 because she had not checked the request card before performing the x-ray. Due to the unnecessary radiation dose this incident was reported to the CQC. In relation to Particular 17(c), the Registrant made a “Datix” incident report after an email was sent to her on 9 June 2014. In her email in reply the Registrant accepted that she probably needed to do a Datix report. The Registrant had noticed the error on 27 May 2014, the day of the examination, but did not report it until 9 June 2014. The Panel finds this incident was serious and the reporting policy required it to be reported within 24 hours. The Panel noted that the Registrant was aware of the requirement to report the incident within 24 hours as it had seen evidence of her having done so previously.  The Registrant knew that she had made the mistake on 27 May 2014 and conceded that she should have reported it earlier. The Panel finds Particulars 17(a), 17(b) and 17(c) are proved.

Particular 18 – found proved
30. The Registrant admitted this Particular at the outset of the hearing. RF sent an email on 25 July 2014 stating Patient V received an unnecessary dose of radiation because the Registrant passed a previously exposed cassette to another Radiographer for use in a second x-ray of the patient. As a result of this error another x-ray had to be taken causing unnecessary irradiation. The Panel finds this Particular proved.

Particulars 19(a) and 19(b) – found proved
31. The Registrant admitted Particulars 19(a) and 19(b) at the outset of the hearing. On 26 June 2014, PC supervised the Registrant and said that the Registrant saw approximately 8 patients. She took a long time to x-ray each patient and was generally slow in her work. On 4 August 2014 the Registrant was supervised by HR who stated that the Registrant may have seen 9 patients rather than the 8 recorded on the supervision folder. HR said that the Registrant was extremely slow and took significantly more time than was reasonable to image patients, based upon the average rate of working. The Panel heard that the Registrant had been advised by her union representative to slow down her work rate. The Panel finds Particulars 19(a) and 19(b) are proved.

Particular 20 – found proved
32. The Registrant admitted this Particular at the outset of the hearing. On 26 June 2014 PC supervised the Registrant who x-rayed Patient W’s right knee while the patient was standing but did not annotate the images as “weight-bearing”. PC suggested that the Registrant resend the images with the necessary annotation and request the old images be deleted, which the Registrant then did. The Registrant stated in her evidence that it had not been her practice to annotate images with “weight bearing”. The Panel finds this Particular is proved.

Particulars 21(a) – 21(e) – found proved
Particular 21(f) – found not proved
33. At the outset of the hearing the Registrant did not admit 21(a) - 21(e). However, in her evidence she accepted the sub-Particulars did occur or could have happened. PC was supervising the Registrant on 26 June 2014 and observed her x-ray Patient X.

34. In relation to Particular 21(a), PC said that the mobile x-ray machine did not beep when the Registrant first took the patient’s x-ray. PC said that  the Registrant did not realise that the x-ray had not been taken because the image was processed and after two minutes of processing, no image resulted. The Registrant accepted this happened in her evidence to the Panel and noted that she had used this type of machine before but she stated the beeps and whirrs can be different from one device to another.

35. In relation to Particular 21(b), PC said the Registrant was about to process Patient X’s x-ray image without having first scanned the cassette barcode to allocate that image to the patient. PC saw the Registrant moving to put the cassette into the processor and intervened to remind her to scan the barcode.

36. In relation to Particular 21(c), the first image taken of the lateral view of the patient’s right knee was poor and PC said the Registrant took a second image which was worse than the first and so the first image was used.

37. In relation to Particular 21(d), PC said that the axial view of the patient’s knees that was taken was of poor quality and did not show the joint space under the knee cap sufficiently. PC also said that the Registrant then took a second image, which was correct.

38. In relation to Particular 21(e), the Registrant had placed a clip marker on the cassette of the first axial view prior to radiation exposure thereby obscuring the image. PC had to inform the Registrant of this and the Registrant then altered the marker position.

39. The Panel accepted the evidence of PC which was supported by the documentation and finds Particulars 21(a) – 21(e) proved.

40. In relation to Particular 21(f), PC stated that during the first axial x-ray in relation to Patient X, the Registrant did not look through the lead screen window at the patient but did so during the second x-ray when she was prompted. The Registrant said in her evidence that she could not remember if this happened. PC could not recall clearly what had happened and the Panel therefore decided that there was insufficient evidence to establish that this Particular has been proved.

Particulars 22(a) and 22(b) - found not proved 
41. The Registrant did not admit this Particular at the outset of the hearing. On 4 August 2014 the Registrant was supervised by HR. One patient seen that day was described by HR as suffering a panic attack in the x-ray room. The Registrant in her evidence maintained that she had spoken to the patient prior to the x-ray being conducted and the patient had become less distressed and did not panic. The Registrant stated she did assist the patient but stood back when HR took over. HR stated that the Registrant did not appear to comfort or calm the patient and she felt the need to intervene. However HR could only remember the Registrant asking the patient to put her chin on top of the cassette once and conceded that she had not observed the conversation that had taken placed between the Registrant and the patient prior to commencing to conduct the x-ray and was therefore not aware of the whole situation. The Panel accepted the evidence of the Registrant that she had tried to calm the patient before HR had been present and that she had not continued to request the patient to put her chin on top of the cassette to prepare for the x-ray. Therefore Particulars 22(a) and 22(b) are not proved.

Particulars 23(a) and 23(b) - found proved
42. The Registrant did not admit this Particular at the outset of the hearing. On 4 August 2014, the Registrant was supervised by HR who asked the Registrant various questions relating to her practice. HR states that the Registrant was unable to explain the “centering point” for a pelvic x-ray or the correct exposure settings for an x-ray of a child’s tibia and fibula. These concerns were corroborated by an email from HR dated 5 August 2014. In her evidence to the Panel, the Registrant accepted that these factual Particulars were correct. The Panel finds Particulars 23(a) and 23(b) are proved.

Particulars 24(a) and 24(b) – found not proved
43. The Registrant did not admit this Particular at the outset of the hearing. This Particular is based upon the evidence of KL who recorded some observations of working with the Registrant on 7 August 2014. She sent an email to CF with her further observations. In relation to Particular 24(a), KL said she did not observe the Registrant touch the patient but instead she used verbal instructions and one patient had looked confused while being given verbal instructions by the Registrant and KL felt she had to intervene. In her evidence to the Panel, the Registrant maintained that this factual Particular was not correct and that she did not adopt a “no touch” technique and her technique varied depending on the situation. The Panel found the evidence of KL was of limited value. There were inconsistencies between her written and oral evidence. She was confused in identifying her own signature on a supervision log and the number of the Registrant’s cases she had assessed. The Panel found this weakened her credibility and it therefore chose to accept the evidence provided by the Registrant. In relation to Particular 24(b), KL said she did not see the Registrant wash her hands or use alcohol gel between every patient but her evidence was generally vague and it has not been proved that the Registrant did not use gel and/or wash her hands between patients on 7 August 2014. The Panel finds Particulars 24(a) and 24(b) are not proved.

Decision on grounds
44. Misconduct is a word of general effect, involving some serious act or omission which falls short of what would be proper in the circumstances. The standard of propriety may often be found by reference to the rules and standards ordinarily required to be followed by a practitioner. The rules and standards ordinarily required to be followed by the Registrant would have been the HCPC Standards of Conduct, Performance and Ethics which include the following standards:
Standard 1  You must act in the best interest of service users;
Standard 5  You must keep your professional knowledge and skills up to date;
Standard 6  You must act within the limits of your knowledge, skills, and experience and, if necessary, refer the matter to another practitioner

45. The Registrant denies misconduct but admits lack of competence.

46. The factual Particulars fall within three general categories: Firstly, Particulars 1, 5, 12, 14, 17, and 18 where either unnecessary exposure to radiation resulted or (in the case of Particular 5) the Registrant failed to follow the hospital protocols and exercised her own judgement as to what images were required, without any clinical basis. Secondly Particulars 2, 3, 6, 7, 8, 9, 10, 11, 16, 20, 21(a), 21(b) and 21(e) involve errors in annotating images. Thirdly Particulars 4, 5, 13, 15(a), 15(b), 19, 21 and 23 concern poor clinical practice techniques.

47. When viewed in isolation, the individual Particulars, referred to in category 1 above, would not necessarily be regarded as deplorable by other members of the profession. However taken collectively they do amount to misconduct in the judgment of the Panel. In respect of Particular 1 the Registrant ignored the documented justification for the x-ray referral. In Particular 12 she ignored the fact that the x-ray was not justified and she x-rayed a patient who should not have been given an x-ray. The Registrant failed in the basic and crucial task of checking the Referral form and ensuring that the x-ray performed was clinically justified. Taken together factual Particulars 1, 5, 12, 14, 17, and 18 amount to misconduct, in that they constitute a repeated and serious falling short of what would be proper in the circumstances. These Particulars establish that the Registrant engaged in conduct which falls far below the standard expected of a reasonably competent Radiographer. The Panel finds that the Allegation of misconduct arising from these proved factual Particulars is well founded.

48. The 2012 version of the HCPC Standards of Conduct were in force up to January 2016. The factual Particulars 1 to 15 relate to the period from May 2012 to February 2013. The HCPC Standards of Proficiency for Radiographers (2012 edition) is relevant to Particulars 1 to 15 and the 2013 edition is relevant to Particulars 16 to 24 which cover the period from June to August 2014.

49. The HCPC Standards of Proficiency for Radiographers, 2013 include the following Standards:
Standard 1.1 know the limits of their practice and when to seek advice or refer to another professional;
Standard 3.3 understand both the need to keep skills and knowledge up to date and the importance of life-long learning;
Standard 4.1 be able to assess 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 4.4 recognise that they are personally responsible for and must be able to justify their decisions;
Standard 13 understand the key concepts of the knowledge base relevant to their profession;
Standard 14 be able to draw on appropriate knowledge and skills to inform practice

50. A lack of competence connotes a standard of professional performance which is unacceptably low and which (save in exceptional circumstances) has been demonstrated by reference to a fair sample of work. The standard to be applied is that applicable to the post to which a registrant had been appointed and the work they were carrying out. In this case the Registrant was employed as a Band 5 Radiographer.

51. In relation to the Particulars in categories 2 and 3 above, the Panel finds there was a pattern of behaviour over the relevant period, despite supervision, in which mistakes were repeated. The Registrant’s professional performance over the relevant period of time was unacceptably low and these factual particulars demonstrate a pattern of failings. CF stated that: “everyone makes mistakes however the mistakes are not usually as serious or repetitive as the Registrant’s”. The number of mistakes made by the Registrant led RF to be extremely concerned. RF confirmed that in comparison with other staff members, the Registrant had the highest error rate RF had ever seen. Given this pattern of failings, the Panel finds the statutory ground of lack of competence is well founded in respect of category 2 (Particulars 2, 3, 6, 7, 8, 9, 10, 11, 16, 20, 21(a), 21(b) and 21(e) and category 3 (Particulars 4, 5, 13, 15(a), 15(b), 19, 21 and 23). Accordingly the Panel is satisfied that these Particulars demonstrate a serious falling short of the standards of proficiency to be expected of a Band 5 Radiographer giving rise to a lack of competence but not misconduct.

Decision on impairment 
52. The Panel considered the Practice Note on ‘Finding that Fitness to Practice is Impaired’. In determining whether fitness to practise is impaired, Panels must take account of a range of issues which, in essence, comprise two components:
1. the ‘personal’ component: the current competence, behaviour etc. of the individual registrant; and
2. the ‘public’ component: the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession.

53. The HCPC submits that the Registrant’s fitness to practise is impaired on public and personal grounds. The Registrant admits the allegation that her fitness to practise is currently impaired.

54. Mrs Justice Cox in the case of CHRE v (1) NMC and (2) Grant stated that: “In determining whether a practitioner’s fitness to practise is impaired by reason of misconduct, the relevant panel should generally consider not only whether the practitioner continues to present a risk to members of the public in her or her current role, but also whether the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular circumstances.”

55. Mr Justice Silber stated in R (on the application of Cohen) v General Medical Council, there is a need to declare and uphold proper standards of conduct and behaviour so as to maintain public confidence in the profession.
56. There is also a need to uphold the HCPC Standards of Proficiency for Radiographers and for ensuring that public confidence in the profession would not be undermined if a finding of impairment is not made.

57. The Panel notes that the Registrant has not been working as a radiographer. However, she has not provided information as to any steps she has taken to remediate her impairment for example by undertaking relevant training. She lacks insight as to the extent to which the deficiencies in her practice and her lack of knowledge impacted upon patients, her colleagues and the Trust’s reputation.

58. The Panel has concluded that there is currently a high risk of repetition. The public would lose confidence in the profession and the regulatory process, if a finding of current impairment was not made in this case. It is also  necessary to make such a finding in order to uphold and declare proper standards in the profession. The Panel therefore finds the Registrant’s fitness to practise is impaired under the personal and public components.

Decision on sanction
59. The purpose of fitness to practise proceedings is not to punish registrants, but to protect the public. In coming to its decision on sanction the Panel has given careful consideration to all the circumstances of this case and all the evidence which contributed to its findings on the facts, the statutory grounds and current impairment.

60. It has considered the submissions made on behalf of the HCPC and the Registrant and has accepted the advice of the Legal Assessor. In accordance with that advice the Panel has had due regard to the HCPC Indicative Sanctions Policy (ISP), the Panel has noted that any sanction must be proportionate that it is not intended to be punitive, and that it should be no more than is necessary to meet the legitimate purposes of providing adequate protection to the public and meeting the wider public interest, namely: to protect the reputation of the profession, maintain confidence in the regulatory system, and declare and uphold proper professional standards.

61. The Panel first identified the aggravating and mitigating factors that it should take into account.

62. The mitigating factors are:
• The Registrant’s extensive admissions.
• In respect of the Particulars she denied, which have been found proved, her purpose was to explain the context and not to cover up her mistakes.
• Her previous good character.
• She has engaged with these proceedings.
• The finding of misconduct is based upon the serious cumulative effect of failings which did not individually amount to misconduct
• She has expressed a willingness to comply with conditions of practice.
• The Panel found her to be a truthful witness.

63. The aggravating factors are:
• The repeated serious failings.
• Her lack of awareness of the importance of following protocols  and ensuring accuracy in documentation as fundamental of a radiographer’s role.
• The Registrant did not make adequate use of the supervision available to her, for example: she did not ask for help to use the scoliosis machine.
• She failed to realise the extent of the inadequacies in her practice.
• She demonstrated a limited understanding of the breadth and scope of her role: the multiple tasks required and the time span available.

64. Taking no action and mediation would not be appropriate in this case.

65. The Panel has decided that a Caution Order is not an appropriate sanction in this case due to the lack of remediation. The Registrant has not demonstrated sufficient insight and the risk of repetition remains high. A Caution Order would not address these concerns, would not be in the public interest and would not safeguard the reputation of the profession.

66. The Registrant’s failings, theoretically, could be remedied and she has expressed her willingness to comply with conditions of practice. The Panel gave careful consideration to whether conditions could be identified to address the concerns identified and the ongoing risks associated with those concerns. In the Panel’s view, onerous conditions would be required due to the nature of the Registrant’s misconduct and lack of competence, combined with her limited insight. The Registrant would require significant retraining. Such conditions of practice would not be workable or realistic. The Panel also concluded that the findings amounted to persistent and general failings and therefore conditions would not be appropriate in this case.

67. The Panel concludes that a Suspension Order for 12 months is the appropriate sanction. Suspension is required, in view of the seriousness of the misconduct and the lack of competence. Such an order will protect the public, maintain public confidence and demonstrate the need to uphold proper standards. The Panel has considered imposing a Striking Off Order but decided not to do so. Striking off is a punitive sanction of last resort which would be disproportionate.

68. The Suspension Order will be reviewed by another panel before it expires. The reviewing panel is likely to be assisted by the Registrant’s attendance at the review hearing. In addition it is likely that the Registrant will need to demonstrate significant evidence of learning, during the period of her suspension, which encompasses all aspects of radiography practice and is not just limited to the IR(ME)R regulations.

Order

That the Registrar is directed to suspend the registration of Ms Rowena M N Stone for a period of 12 months from the date this order comes into effect.

Notes

This order will be reviewed again before its expiry on 29 December 2018 .

Hearing history

History of Hearings for Ms Rowena M N Stone

Date Panel Hearing type Outcomes / Status
27/11/2017 Conduct and Competence Committee Final Hearing Suspended