Ms Bethan M Williams

: Speech and language therapist

: SL01721

: Final Hearing

Date and Time of hearing:10:00 08/01/2018 End: 17:00 15/01/2018

: Chateau Rhianfa, Glyngarth, Beaumaris, Anglesey, LL59 5NS

: Conduct and Competence Committee
: Conditions of Practice

Allegation

(as amended at the Final Hearing)

Whilst working at the University Health Board in Bwrdd lechyd Prifysgol Betsi Cadwaladr between 14 September 2010 and 24 November 2014:

1. Did not record any, or any adequate journal entries on the TM electronic System regarding:

a) Service user A

b) Service user B from approximately September 2014 to November 2014

c) Service user C from approximately August 2014 to November 2014

d) Service user D

e) Service user E from approximately 26 August 2014 to November 2014

f) Service user F

2. Did not record any, or any adequate clinical information, assessments, reports and/or care plans in the following cases:

a) Service user G

b) Service user H

c) Service user I

d) Service user J

e) Service user K

f) Service user L

g) Service user M

h) Service user N

i) Service user 0

j) Service User P

k) Service User Q

3. Did not complete any or any adequate and/or contemporaneous record of a school visit for:

a) Service user R on 17 March 2014

b) Service user S on 17 March 2014, 7 April 2014 and/or 9 June 2014

c) Service User T on 17 March 2014

d) Service User U on 17 March 2014, 7 April 2014 and/or 9 June 2014

e) Service User V on 17 March 2014, and/or 9 June 2014

f) Service User W on 17 March 2014 and/or 7 April 2014

g) Service User X on 7 April 2014

4. The matters described in paragraphs 1-3 amount to misconduct and / or lack of competence.

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

Finding

Preliminary Matters

Application to amend the allegation

1. The Panel heard an application by Ms Manning-Rees, on behalf of the HCPC, to amend the allegation as set out above. The Registrant had been notified of the application in advance of the hearing and did not object to the amendments. The Panel received and accepted the advice of the Legal Assessor. It was satisfied that the amendments were necessary and desirable as they provided clarity, did not substantively change the nature of the allegation, and were not prejudicial to the Registrant.

Background

2. The Registrant was employed as a Speech and Language Therapist (SLT) by Bwrdd lechyd Prifysgol Betsi Cadwaladr University Health Board (BCUHB), in the West Area of the Paediatric SLT Service, from October 1996 to November 2014. She was responsible for providing services to children with additional learning needs who attended special schools in the Gwynnedd and Mon counties. In November 2014, a number of concerns were raised by schools and parents regarding SLT service delivery in the West Area. These were investigated by Colleague A. She concluded that there were either no or inadequate clinical records in respect of service users on the Registrant’s caseload.

3. Following the resignation of the Registrant, this caseload was reassigned to other members of Paediatric SLT Service. Due to the lack of clinical information available, the children on the caseload then had to be reassessed in order to provide effective SLT interventions. The Registrant had not been recording contacts with service users on Therapy Manager (TM), BCUHB’s electronic case note system, and the matter was referred to the HCPC on 28 November 2014. It took 18 months to review the Registrant’s caseload.

Decision on Facts

4. The Panel carefully considered all of the evidence in the case. It noted the submissions of Ms Manning-Rees on behalf of the HCPC and Mr Waymont on behalf of the Registrant. It accepted the advice of the Legal Assessor. On behalf of the HCPC, the Panel heard oral evidence from Colleague A, DL, and CS. The Registrant gave evidence.

5. The Panel received two bundles of documentation from the HCPC, comprising the witness statements of those who gave evidence and 612 pages of exhibits. The Registrant submitted 29 pages of testimonials and references, plus additional documents, including her reflections dated 9 January 2018.

6. The burden of proving the factual particulars is upon the HCPC and the standard of proof is the balance of probabilities.

Credibility of the Witnesses and Assessment of the Evidence

7. The Panel first made an assessment of the credibility of the witnesses and the reliability of all of the evidence presented to it.

HCPC Witnesses: Colleague A, DL, and CS

8. The Panel considered that the HCPC witnesses gave credible and consistent evidence in a fair manner. The witnesses gave live evidence which was consistent with statements previously submitted. The HCPC witnesses were:

• Colleague A, who investigated the above concerns from November 2014 to October 2015. Colleague A accepted BCUHB had obligations to its staff. She further said she had huge respect for the Registrant.

• DL (Interim Head of SLT West Area BCUHB and formerly Locality Lead for SLT services in Arfon Mon), who was the Registrant’s line manager from July to December 2014. DL pointed out that whilst she had not seen them, paper records had recently been found that related to the Registrant and there was therefore the possibility that they related to service users who were the subject of these allegations.

• CS (Area Head of SLT East Area BCUHB), who was the Registrant’s interim line manager from May to July 2014.

The Registrant

9. The Panel found the Registrant to be a credible witness. At times she struggled to remain focused and did not deal fully with some of the issues raised by the questions put to her. She accepted the factual particulars were proved and that there were issues with her record-keeping.

Hearsay Evidence

10. The Panel received and accepted advice from the Legal Assessor that hearsay evidence is admissible in these proceedings under Rule 10 (1)(b) and (c) of the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003. However, the Panel approached the hearsay evidence with caution because it had not been tested by cross-examination. The Panel carefully considered what weight to afford to the hearsay evidence before it.

11. In general, the Panel exercised caution in considering the hearsay evidence and attached weight to it only to the extent that was appropriate, in particular where the hearsay evidence was corroborated or consistent with other evidence received.

Findings in Relation to the Factual Particulars of the Allegation

 Particular 1 – Proved

12. The Registrant admitted that whilst working at BCUHB between 14 September 2010 and 24 November 2014, she did not record any, or any adequate, journal entries on the TM electronic system regarding:

• Service User A, who was a Looked After Child who had poor attention, global developmental delay and visual difficulties. The Registrant did not record any entries on TM from September to November 2014 despite providing a document suggesting she had provided services to Service User A in that period;

• Service User B had delayed and disordered development. The Registrant did not record any entries on TM from September to November 2014 despite providing a document suggesting she had provided services to Service User B in that period;

• Service User C was diagnosed with autism and had limited communication. The Registrant did not record any entries on TM from August to November 2014 despite providing a document suggesting she had provided services to Service User C in that period;

• Service User D was diagnosed with Autistic Spectrum Disorder and cognitive and communication difficulties. The Registrant did not record any entries on TM despite providing a document suggesting she had provided services to Service User D, who was referred to the SLT service on 29 October 2014;

• Service User E had profound speech and language delay and behavioural difficulties. The Registrant did not record any entries on TM despite providing a document suggesting she had provided services to Service User E. His case was transferred to her on 26 August 2014 and he had started school in September 2014;

• The Registrant did not record any entries on TM for Service User F despite providing a document suggesting she had provided services to Service User F. There was no record of an open episode of care for Service User F, suggesting that care was being provided without full consent.

13. The Registrant accepted the facts had been proved at the close of the HCPC’s case.

14. The Panel found particulars 1(a) to 1(f) inclusive proved, based upon both the documentary evidence and live testimony of the HCPC witnesses and the subsequent admissions of the Registrant. The documents showed each of these children was referred to the Registrant between August and November 2014 and that there were outline details of interventions, but no corresponding entries on the TM system.

Particular 2 – Proved

15. The Registrant admitted that whilst working at BCUHB between 14 September 2010 and 24 November 2014, she did not record any, or any adequate, clinical information, assessments, reports and/or care plans in the following cases:

• Service User G, who had global physical and learning disabilities and was transferred onto TM in April 2013. The Registrant recorded 12 clinical entries between June and October 2014 and provided a document suggesting she had provided services to Service User G, but there were no clinical assessments, reports or care plans on TM;

• Service User H had a rare genetic disorder, resulting in severe mental and physical disability, and was transferred onto TM in April 2013. The Registrant recorded seven clinical entries from January to September 2014 and provided a document suggesting she had provided services to Service User H, but there were no clinical assessments, reports or care plans on TM;

• Service User I had Autistic Spectrum Disorder and his case was open from September 2012. The Registrant recorded two entries in July and September 2014 and provided a document suggesting she had provided services to Service User I, but there were no clinical assessments, reports or care plans on TM;

• Service User J had Autistic Spectrum Disorder and was transferred to the Registrant’s caseload in July 2013. The Registrant recorded one entry in 2014 and provided a document suggesting she had provided services to Service User J, but there were no clinical assessments, reports or care plans on TM;

• Service User K was initially seen in July 2014. The Registrant recorded one entry in September 2014 and provided a document suggesting she had provided services to Service User K, but there were no clinical assessments, reports or care plans on TM;

• Service User L had developmental delay and behavioural difficulties, and was transferred to the Registrant’s caseload in August 2012. The Registrant recorded two entries in June and July 2014 and provided a document suggesting she had provided services to Service User L, but there were no clinical assessments, reports or care plans on TM;

• Service User M had attention and concentration difficulties and was transferred to the Registrant’s caseload in August 2012. The Registrant recorded two entries in January and June 2014 and provided a document suggesting she had provided services to Service User M, but there were no clinical assessments, reports or care plans on TM;

• Service User N had general global developmental delay and was transferred to the Registrant’s caseload in August 2012. The Registrant recorded one entry in January 2014 and provided a document suggesting she had provided services to Service User N, but there were no clinical assessments, reports or care plans on TM;

• Service User O had severe atypical Autism and attention and concentration concerns, and was transferred to the Registrant’s caseload in March 2010. The Registrant recorded two entries in June 2014 and provided a document suggesting she had provided services to Service User O, but there were no clinical assessments, reports or care plans on TM;

• Service User P had Autistic Spectrum Disorder and was transferred to the Registrant’s caseload in July 2013. The Registrant recorded one entry in 2014 and provided a document suggesting she had provided services to Service User P, but there were no clinical assessments, reports or care plans on TM;

• Service User Q had a genetic condition causing delayed language and speech difficulties. The case was open to the Registrant from 2011. The Registrant recorded two entries in June and October 2014 and provided a document suggesting she had provided services to Service User Q, but there were no clinical assessments, reports or care plans on TM.

16. The Registrant accepted the facts had been proved at the close of the HCPC’s case.

17. The Panel found particulars 2(a) to 2(k) inclusive proved, based upon both the documentary evidence and live testimony of the HCPC witnesses and the subsequent admissions of the Registrant. These service users were available to the Registrant at various points from 2010 to 2014 and each one had some kind of entry on TM in 2014 which was written by the Registrant. However, these entries were not adequate for clinical purposes, did not contain any assessments, reports or care plans, and would not have enabled a practitioner other than the Registrant to maintain continuity of care.

Particular 3 – Proved

18. The Registrant admitted that whilst working at BCUHB between 14 September 2010 and 24 November 2014, she did not complete any, or any adequate and/or contemporaneous, record of school visits for:

• Service User R, who was visited by the Registrant on 17 March 2014, but no clinical notes of the contact were made;

• Service User S, who had language and general cognitive delay and was visited by the Registrant on 17 March 2014, 7 April 2014 and 9 June 2014, but no adequate clinical notes of the contacts were made;

• Service User T, who had speech and language difficulties and was visited by the Registrant on 17 March 2014, but no clinical notes of the contact were made;

• Service User U, who had Attention Deficit Hyperactivity Disorder and was visited by the Registrant on 17 March 2014, 7 April 2014 and 9 June 2014, but no adequate clinical notes of the contacts were made;

• Service User V, who had cerebral palsy and was visited by the Registrant on 17 March 2014 and 9 June 2014, but no adequate clinical notes of the contacts were made;

• Service User W, who had global speech and language difficulties and was visited by the Registrant on 17 March 2014 and 7 April 2014, but no adequate clinical notes of the contacts were made;

• Service User X, who had a neurological disability and was visited by the Registrant on 7 April 2014, but no clinical notes of the contact were made.

19. The Registrant accepted the facts had been proved at the close of the HCPC’s case.

20. The Panel found particulars 3(a) to 3(g) inclusive proved, based upon both the documentary evidence and live testimony of the HCPC witnesses and the subsequent admissions of the Registrant, in relation to each service user with which the Registrant had individual appointments marked in her TM diary. The notes recorded in TM were insufficient due to their lack of clinical detail, and inadequate paper records were available.

Decision on Grounds

21. The Panel next determined whether the facts found proved amounted to misconduct and/or lack of competence. The Panel accepted the advice of the Legal Assessor that there is no standard of proof to be applied at this stage, and whether the threshold for misconduct has been reached is a matter of judgment for the Panel. Misconduct involves a serious act or omission which falls short of what would be proper in the circumstances and which would attract strong public disapproval.

22. The TM system had been introduced into the organisation in Central Locality in 2009 and subsequently rolled out into the Registrant’s Locality in 2013. The Panel accepted that there were some issues with the operational functionality of the TM system, as evidenced by Colleague A. However, it was clear that the Registrant knew how to and had accessed the TM system on numerous occasions. The Registrant worked peripatetically between three special schools and she had been given clear advice in order to facilitate access to the TM system. This included returning to the NHS base on a weekly basis. The Panel was satisfied that the Registrant was aware that in the event of not being able to access the electronic TM system, paper records should be utilised.

23. The Registrant was a highly experienced SLT who had been practising since 1995. The Registrant knew what clinical information should be recorded in the SLT case notes but failed to comply with her record-keeping obligations. She would have been aware that it was not possible to practise safely and effectively without keeping adequate records which were accessible to her health colleagues. The Panel noted that for some service users, there were no assessment details, indiviual communication plans or clinical narrative. As an autonomous practitioner, it was her responsibility to maintain her records to the required standard. The Registrant’s record-keeping was below the standard to be expected of all practising SLTs, in respect of the electronic and paper records before the Panel, giving rise to breaches of the following:

The HCPC Standards of Conduct, Performance and Ethics (2012):

1 You must act in the best interest of service users.

7 You must communicate properly and effectively with service users and other practitioners.

10 You must keep accurate records.

The HCPC Standards of Proficiency for Speech and Language Therapists effective from 6 January 2014 (the 2007 Standards of Proficiency for Speech and Language Therapists are in similar terms and also applicable to parts of the periods covered by particular 2):

Registrant speech and language therapists must:

1.2 recognise the need to manage their own workload and resources effectively and be able to practise accordingly

2.2 understand what is required of them by the HCPC

2.7 be able to exercise a professional duty of care

3.1 understand the need to maintain high standards of personal and professional conduct

3.3 understand both the need to keep skills and knowledge up to date and the importance of career-long learning

4.2 be able to make reasoned decisions to initiate, continue, modify or cease treatment or the use of techniques or procedures, and record the decisions and reasoning appropriately

7.2 understand the principles of information governance and be aware of the safe and effective use of social health information

9.4 be able to contribute effectively to work undertaken as part of a multi-disciplinary team

10 be able to maintain records appropriately

10.1 be able to keep accurate, comprehensive and comprehensible records in accordance with applicable legislation, protocols and guidelines

10.2 recognise the need to manage records and all other information in accordance with applicable legislation, protocols and guidelines

11 be able to reflect on and review practice

11.1 understand the value of reflection on practice and the need to record the outcome of such reflection

12 be able to assure the quality of their practice

12.4 be able to maintain an effective audit trail and work towards continual improvement

24. The Panel determined that the facts found proved amounted to serious failings in respect of fundamental responsibilities of a SLT. The standards of the Registrant’s practice fell far short of what would be expected in terms of the recording of clinical information required to underpin effective practice. The Registrant’s conduct amounted to a breach of the SLT professional standards for record-keeping. DL stated that owing to the inaccessibility of the Registrant’s records to other therapists, it took 18 months to reassess the relevant children in order to determine the appropriate SLT intervention to meet individual children’s communication needs. The Panel was satisfied that the Registrant’s actions would attract a strong degree of public disapproval. Accordingly, it determined that the Registrant’s actions amounted to misconduct and constituted a serious falling short of what would be proper in the circumstances.

25. The Panel was satisfied that the Registrant knew how to perform her professional duties competently but failed to do so. The Panel considered that the Registrant’s actions were more appropriately identified as misconduct rather than lack of competence.

26. Accordingly, the proved facts did not arise from a lack of competence.

Decision on Impairment

27. The Panel accepted the advice of the Legal Assessor and had regard to the HCPTS Practice Note “Finding that Fitness to Practise is ‘Impaired’”. The misconduct identified was serious.

28. The Panel first considered whether the Registrant’s fitness to practise is currently impaired on a personal basis. It noted that the failings identified are, in principle, remediable. The Panel also considered the Registrant’s oral evidence and the submissions of Mr Waymont on her behalf. The Registrant has not previously been the subject of HCPC investigation. Whilst the Panel accepted that many aspects of her professional practice are highly respected, the record-keeping issues identified have not been resolved. She now accepts that she should have kept SLT records on the TM system and not relied upon records being held in schools. The IT issues raised have been noted by the Panel but, despite that, the fact remains that adequate clinical records, whether paper or electronic, were not available to the SLT team, of which she was a part. There has been some remediation and the Registrant has undertaken voluntary work and actively engaged in the HCPC process. She is held in high regard, as demonstrated by the testimonials and character references she has produced to the Panel, including references from the parents of service users, from other practitioners and from university and educational institutions. The Registrant has apologised to the Panel and reflected upon the issues raised during the course of the hearing. The Panel has taken these matters fully into account, together with difficult personal circumstances.

29. However, there remains a gap in her practice, giving rise to a current impairment of her fitness to practice. She has partial insight but her written reflective piece tabled on the third day of the hearing has raised some concerns as to the extent of her remediation and full insight into the importance of record-keeping and keeping skills up-to-date. Her lack of knowledge of the need for effective record-keeping is not indicative of her senior status and experience. During her oral evidence, the Panel had to prompt the Registrant to provide evidence of record-keeping training undertaken and, as such, concludes that a risk of repetition remains. The Registrant has demonstrated some remorse and has made admissions in respect of the facts, but not until the conclusion of the HCPC’s case. The Panel accepts that hearing the HCPC witnesses’ evidence has helped the Registrant to understand and acknowledge the impact of her misconduct on colleagues and service users. The Registrant has not yet fully remediated her misconduct and is currently impaired under the personal component. The Panel has taken into account the testimonials provided, but is not satisfied that the Registrant is currently reaching the standard required of a SLT in the context of NHS practice. The Panel acknowledges she has shown insight into the importance of record-keeping in her current non-NHS work.

30. Accurate record-keeping is a fundamental tenet of the profession. The Registrant’s misconduct was such that it presented a risk to service users and to the reputation of the profession as a whole. The wider public interest in upholding proper professional standards and public confidence in the profession and the regulatory process would therefore be undermined if a finding of impairment were not made in these circumstances. Accordingly, the Panel finds that the Registrant’s fitness to practise is also currently impaired on the public component.

Decision on Sanction

31. The Panel considered the submissions made by Ms Manning-Rees and Mr Waymont and accepted the advice of the Legal Assessor. The Panel is aware that the purpose of any sanction is not to be punitive, though it may have a punitive effect. The Panel’s primary function at this stage is to protect the public, while deciding what, if any, sanction is proportionate, taking into account the wider public interest and the interests of the Registrant. The Panel has taken into account the HCPC Indicative Sanctions Policy (“the ISP”) and applied it to this case. The starting point for the Panel was that the misconduct was serious and constituted a breach of the HCPC Standards in relation to a fundamental tenet of SLT professional practice. The Panel identified the following aggravating factors in this case:

• The Panel has found that the Registrant’s fitness to practice is currently impaired on personal and public policy grounds and there is a risk of repetition.

32. The Panel identified the following mitigating factors:

• The Registrant has engaged in the regulatory process;

• There have been no previous adverse regulatory findings;

• The Registrant has demonstrated some insight and that her record-keeping fell below the standard expected;

• The Registrant is highly regarded, with a large number of positive testimonials and references.

33. It would not be appropriate to take no further action in this case due to the nature and extent of inadequate record-keeping, and therefore taking no further action is not appropriate.

34. A Caution Order would be insufficient to mark the seriousness of the Panel’s findings. It would offer no restriction on the Registrant’s practice and would therefore be insufficient to protect the public and uphold the wider public interest. There is a continuing risk of repetition, a lack of full insight and this is not an isolated incident.

35. The Panel concluded that it would be possible to formulate workable and practicable Conditions of Practice that would adequately address the risk and the public policy issues identified and also be proportionate to the misconduct.

36. The Panel has identified that the Registrant’s record-keeping failures are capable of being remedied and is satisfied that allowing the Registrant to remain in practice, albeit subject to conditions, will protect the public and is in the Registrant’s own interests. Furthermore, given the proactive way in which the Registrant has engaged thus far, the Panel is confident that she will comply with conditions which focus upon her personal development to avoid any future repetition. Such conditions will also enable a future reviewing panel to determine whether such conditions have been complied with.

37. In the judgement of the Panel, a Suspension Order would be disproportionate and unduly punitive in the circumstances. Accordingly, the Panel determined that a Conditions of Practice Order was the necessary and proportionate Order.

38. This Order will be reviewed before it expires. The reviewing panel is likely to be assisted by evidence of the steps the Registrant has taken to improve her speech and language therapy record-keeping.

Order

The Registrar is directed to annotate the Register to show that for 12 months from the date that this Order comes into effect (the Operative Date) you, Ms Bethan M Williams, must comply with the following Conditions of Practice:

1. Within 3 months of the Operative Date you must satisfactorily complete training relating to record-keeping which meets the requirements of the HCPC Standards of Proficiency for Speech and Language Therapists and forward a copy of your evidence of completion and details of the course undertaken to the HCPC.

2. You must work with an HCPC-registered SLT supervisor to formulate a Personal Development Plan (PDP) to remedy the deficiencies in your record-keeping practice.

3. Within 3 months of the Operative Date you must forward a copy of your PDP to the HCPC.

4. You must meet with your supervisor on a monthly basis to consider your progress towards achieving the aims set out in your PDP.

5. You must allow your supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your PDP, including examples of your record-keeping practise.

6. You must promptly inform the HCPC if you cease to be employed by your employer, or take up any other or further employment.

7. You must promptly inform the HCPC of any disciplinary proceedings taken against you by your employer.

8. 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 the application); and

C. any prospective employer (at the time of your application).

Notes

This Order will be reviewed again before its expiry.

Hearing history

History of Hearings for Ms Bethan M Williams

Date Panel Hearing type Outcomes / Status
08/01/2018 Conduct and Competence Committee Final Hearing Conditions of Practice