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HCPC suspends social worker who failed to maintain adequate records

Social worker suspended for nine months after failing to make visits or record details of them

Published on 26th April 2018

A social worker has been suspended from the Health and Care Professions Council register after failing to maintain adequate case files regarding a number of service users.

Stuart Hill was working as a social worker at Defence Primary Health Care when allegations were made that he did not undertake any contact and/or make any record of contact with numerous service users and failed to maintain adequate records.

Mr Hill began his employment as a locum senior worker at the Department of Community Mental Health (DCMH) in the Defence Mental Health Social Service within Defence Primary Health Care, Ministry of Defence in 2007. His role became permanent in 2014 and as a senior social worker, he was considered an experienced practitioner.

Mr Hill was dealing with service users who consisted of Armed Services personnel and eligible veterans, all with serious mental health problems and some with additional health issues. The service provides mental health care and treatment and, as a social worker within the DCMH, his role would mainly be to support service users through the medical discharge pathway.

The allegations came to light when Mr Hill was suspended from his role pending investigation into a matter unrelated to the current allegation in May 2016. At a disciplinary hearing on 20 July 2016, he was dismissed, although he successfully appealed the decision to dismiss him and was reinstated in January 2017.

However, as a result of the dismissal, his line manager reviewed his caseload after he left and audited his case notes, identifying a number of concerns. These related to cases for which there was no recorded contact made at all with service users following referral to the service and cases where there was no follow up contact made or recorded with service users following initial appointments. A referral was made to the HCPC in respect of these concerns.

Witness 1 told the Panel that in April 2016, prior to his 20 July 2016 dismissal, Mr Hill had agreed to have weekly supervision sessions with her in order to bring his caseload up to date. She said that in a supervision session on 11 April 2016 he advised her that he knew what he needed to do in respect of each of his service users.

Witness 1 told the Panel that when she reviewed Mr Hill’s caseload and audited his case notes after his dismissal on 20 July 2016, she found that there were issues on around 90 per cent of all his cases. She said these related to cases where he had made no contact with service users after they had been referred into the service and where he had not recorded follow up actions after conducting initial visits or appointments.

She stressed that at no point was there any concern with the content of the notes he did make, which were of good quality.

Following Mr Hill’s return to work in January 2017, Witness 1 discussed the issue of his record keeping with him. She said he acknowledged that there were failings in his record keeping practice but told her that he was unable to offer any explanation for these. Witness 1 said that he never expressed remorse for his failings and that, in her view, he demonstrated no insight into those failings. She told the Panel that he had informed her of personal problems and health issues that might have impacted on his performance. However, there were no issues with Mr Hill’s training or IT abilities which might explain his failings and he had never sought additional training.

All new referrals to the service were to be contacted within 15 working days of receipt of referral, however, when Witness 1 searched the DMICP records for each of the service users identified for this allegation, she found that in some instances no contact had been recorded months after Mr Hill had been allocated their case. In some instances she found that other healthcare professionals had recorded being informed of contact having been made by Mr Hill, but that no such contact had been recorded by him.

“Witness 1 told the Panel that the Registrant’s failure to contact Service Users allocated to him raised a significant risk that the care of those service users would be jeopardised. She said that where the Registrant did contact a service user but failed to upload a consultation note, he put such service users at risk because the case notes would not be an accurate reflection of the case, other professionals would not be aware of what action had been taken, what the action plan was or even when the service user had last been visited,” said the Panel.

Witness 1 told the Panel that in the case of Service User 8, it was clear from the DMICP records that Mr Hill had made no entry at all on the system. However, the record shows that when the case was followed up by a social work colleague during one of his periods of suspension, Service User 8 had informed the colleague that Mr Hill had visited him at home and had been due to visit again but had not done so. Service User 8 is recorded as having reported that Mr Hill “did a fantastic job and had told him exactly what to get on with”.

In respect of Service User 35, Witness 1 told the Panel that the Service User had been particularly vulnerable and had been placed on the Risk Register. Although it was clear that Mr Hill had interacted with the Service User on a number of occasions in 2015 and 2016 there were alarming gaps in the records where it was either not clear whether or not scheduled meetings or visits had taken place, or where there was no record made by Mr Hill as to what had transpired in such meetings or visits. Witness 1 told the Panel that Mr Hill’s record keeping failures in respect of Service User 35 could have had extremely serious consequences and it was a matter of good fortune that the service user had apparently not suffered harm.

There were a further 19 service users where Mr Hill had clearly interacted with them, however, there were numerous gaps in the records of the service users, making it impossible to determine what might have transpired in terms of information gathered, advice given and/or action taken.

“The Panel considered that the Registrant has demonstrated no meaningful insight into his failings. His engagement with the regulatory process has been minimal and he chose not to attend this hearing. While reportedly telling Witness 1 that he accepted there were failings in his record keeping practice, he was apparently unable to provide any explanation for those failings, and told her that she was partly to blame as she had been his line manager,” said the Panel.

“In the Panel’s view, the Registrant had taken a persistently cavalier attitude to his record keeping responsibilities. While there were no concerns about the quality of his record keeping entries when he chose to make them, he apparently prioritised his field work over his record keeping responsibilities, and on numerous occasions put Service Users at risk by failing to record visits, plans and actions in DMCIP. In the Panel’s view, his actions and omissions not only demonstrated a lack of understanding of the importance of keeping records accurate and up to date, but also an attitudinal problem in deliberately failing to make records when he knew he was required to do so,” the Panel added.

The Panel decided to suspend Mr Hill for a period of nine months which they felt was sufficient, necessary and proportionate and allowed Mr Hill an opportunity to reflect on his failings and decide whether he wishes to engage with his regulator for the purpose of remediating those failings.

After the nine months suspension, a reviewing panel will consider the case and would be assisted by:

• Mr Hill’s  engagement with the process and attendance at the hearing;

• evidence of any relevant training activities and/or professional development undertaken by him during the period of suspension;

• a reflective piece from Mr Hill, following a recognised model. This should demonstrate his reflection on the gravity of his failings, the importance of maintaining consistent contact with Service Users and of maintaining full and up to date records, and the potential impact of failure to do so on Service Users and colleagues, and on the reputation of the profession and public confidence in the profession.

• testimonials relating to any work undertaken in an employment and/or voluntary capacity after this hearing that evidences Mr Hill’s performance in working effectively and consistently with colleagues and/or members of the public.

 

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