OT struck off for failing to demonstrate adequate clinical reasoning

HCPC strikes off OT following three periods of suspension

Published on 18th October 2019

An occupational therapist has been struck off the register following three periods of suspension for not demonstrating adequate clinical reasoning, failing to follow up actions and failing to maintain adequate records.

Miss Ruth E Yorkston, who worked as an occupational therapist for Tees, Esk and Wear Valleys NHS Foundation Trust from 2001 until 2012, did not demonstrate adequate clinical reasoning and/or skills in that she was unable to demonstrate an adequate understanding of the MOHOST tool and/or its rating system an was unable to demonstrate an adequate understanding of the Mayers Lifestyle Questionnaire.

She did not complete follow-up actions in that in relation to Case 1, she did not contact and/or did not adequately record her contact with the Service User's Care Coordinator as planned.

In relation to Case 2, having recorded a plan on 24 November 2011 to speak to the Service User’s Care Coordinator Miss Yorkston did not contact and/or adequately record contacting the Care Coordinator in a timely manner and did not inform and/or record informing the Care Coordinator of a potential risk to the Service User, in that a person who answered the phone indicated that he “did not live there” or words to that effect.

Miss Yorkston also failed to maintain adequate records.

In 2008, concerns arose relating to Miss Yorkston's ability to perform her job adequately. These concerns persisted throughout 2008 and into 2009. In November 2009, the Trust received an Occupational Health report, which outlined that Miss Yorkston suffered from a health condition. In light of this health concern, it was decided to redeploy her to a different team. The team to which she was moved was the South Durham Psychosis Team, based at the Goodall Centre. She moved to this team on 1 April 2010.

However, in 27 July 2010, it was reported that there were continuing concerns about Miss Yorkston's competence, and she was removed from clinical practice on 05 August 2010 and placed within the inpatient OT Team to complete project work not involving patient contact.
An investigation was initiated into her clinical practice.

In July 2011, the Professional Head of Allied Health Professionals with the Trust was asked to produce an action plan to support Miss Yorkston's clinical reasoning, clinical practice, and record-keeping, with a view to returning her to supervised practice. The plan contained 12 objectives. She was to be based in the Darlington Psychosis Team in October 2011 for three months to receive support and build up her caseload. Other objectives were for her to provide clear evidence of understanding and applying OT processes and to use the Mayers Lifestyle Questionnaire (MLQ) tool and Model of Human Occupational Screening Tool (MOHOST). Her placement was supervised by a Specialist OT and Miss Yorkston was restricted to working on five or six cases. Any work she did was to be supported by formal weekly supervision and informal daily supervision.

The action plan was formally reviewed in both November and December 2011. On 12 December 2011, her placement with the Darlington team was terminated owing to concerns about her practice and service user safety. The concerns were collectively referred to a disciplinary hearing, which took place on 03 April 2012.
Miss Yorkstonself-referred the concerns about her practice to the HCPC in June 2012. That referral eventually resulted in these proceedings.

A final hearing with a Health and Care Professions Tribunal Service anel in April 2017 concluded that Miss Yorkston's fitness to practise was impaired by reason of her lack of competence and the decision noted that she lacked insight and remediation. The Panel suspended Miss Yorkston for a 12 month period.

The panel suggested that a future panel reviewing the suspension would be helped by:

- Details of how Miss Yorkston had kept her skills and knowledge up-to-date during the period that she was working as an OT;

- Evidence of the learning she acquired;

- Evidence to demonstrate that Miss Yorkston had developed appropriate coping strategies to deal with work-related stress that may impact on her health conditions.

At the first review of the suspension order on 10 April 2018, the reviewing panel decided that Miss Yorkston's fitness to practise remained impaired and decided to impose a further suspension order for 12 months. It noted that, whilst some progress had been made, a risk to service users remained. That panel suggested that the next reviewing panel would be assisted by the following:

- A testimonial from any OT mentor that Miss Yorkston may find to assist her in addressing her shortcomings;

- Details of how she had kept her skills and knowledge up-to-date during the period that she was working as an OT, including proof of any CPD activity;

-  Any further evidence to demonstrate that Miss Yorkston had continued to develop appropriate coping strategies to deal with work-related stress that may impact on her health condition.

At the second review of the suspension order on 17 April 2019, Miss Yorkston's fitness to practise was found to be impaired and a suspension oprder was imposed for a further period of six months. 

At this review, Miss Yorkston gave evidence and told the Panel that she is unemployed. She told the Panel that being out of OT practice for so long created difficulties in terms of her keeping up-to-date with her professional knowledge and skills. She stated that she had made some enquiries about a return to practice course with two different universities, and acknowledged that she needed to undertake more investigation with regard to the return to practise course at the University of Derby, which seemed to offer the appropriate course. While cost had been an issue in the past, she stated that she was now in a better position financially.

Miss Yorkston told the Panel about further training done as directed by her work coach at the job centre. In respect of the concerns about her OT practice, she had asked those who have criticised her practice at her last place of employment about what she had done, but did not know what she had done wrong. In addition, she told the Panel that she would like to try and find a return to practice course and would like to return to practice as an OT in the future.

The Panel also read a reference about some voluntary work undertaken for a Mind Charity shop and a testimonial from a member of Miss Yorkston's church.

The Panel took into account that Miss Yorkston has not worked as an OT since 2012. The Panel also bore in mind the practical limitations which she has had recently, namely financial difficulties, physical difficulties, and also difficulties in accessing a computer.

The Panel felt Miss Yorkston presented as a sincere person who was willing to engage with her Regulator. However, the Panel was of the view that there were no further steps which she had taken since the last review hearing in terms of remediation of the lack of competence found proved. In this regard, the Panel noted that Miss Yorkston has been given a significant amount of guidance and information by the HCPC.

In addition to the recommendations made by previous panels about the kind of material which may assist the next panel, today’s Panel noted that on the day of the last review, 17 April 2019, the HCPC sent Miss Yorkston an email outlining helpful steps which she could take to prepare for the latest hearing. Two further emails designed to assist her in a similar way were sent to her on 26 July 2019 and 16 September 2019.

Miss Yorkston was questioned specifically about the steps she has taken to address the concerns in record-keeping, clinical reasoning, and report writing, but she was unable to point to anything tangible which she had done to address these concerns.

She told the Panel that she had made some enquiries about the return to practice course, and spoke about the course at Derby University which seemed promising to her. When asked as to what steps she had taken in relation to investigating that course, she conceded that she did not go far enough in her efforts.

The Panel also considered insight. When Miss Yorkston was asked by the Panel what she would do differently if she found herself in the same circumstances as she was in at the Trust, she stated that she would have resigned if she had known she was going to go through the experience which she had been through.

In addition, the Panel was of the view that she had a tendency to apportion blame rather than face the concerns about her practice in any meaningful or direct way. For example, on several occasions during her evidence when she was asked how she had addressed her fitness to practise concerns, she spoke about her previous employer’s flaws and the risks emanating from the organisation, rather than from her own practice as an autonomous practitioner.

Despite appearing to try her best to answer several questions on the topic of insight, the Panel was unable to find any evidence of insight into why the lack of competence occurred, and what could be done to ensure that it was not repeated.

As a result, the Panel was of the view that there remains a real risk of repetition of the lack of competence, and therefore a real risk of harm to service users.

The Panel considered a suspension order and considered paragraph 121 of the SP, which states as follows: “A suspension order is likely to be appropriate where there are serious concerns which cannot be reasonably addressed by a conditions of practice order, but which do not require the registrant to be struck off the Register. These types of cases will typically exhibit the following factors:

• the concerns represent a serious breach of the Standards of conduct, performance and ethics;

• the registrant has insight;

• the issues are unlikely to be repeated; and

• there is evidence to suggest the registrant is likely to be able to resolve or remedy their failings.”

The Panel was mainly concerned that miss Yorkston did not show any insight at the latest hearing. They felt that there remains a real risk of repetition of the lack of competence. Having considered Miss Yorkston's oral and documentary evidence very carefully, the Panel concluded that she is unable to acknowledge or resolve the concerns. The underlying issues of a lack of insight, remediation, and the ongoing real risk of repetition led the Panel to conclude that suspension would not be appropriate or sufficient to protect the public or uphold the wider public interest.

The Panel considered the following paragraphs of the SP: “A striking off order is a sanction of last resort for serious, persistent, deliberate or reckless acts.

A striking off order is likely to be appropriate where the nature and gravity of the concerns are such that any lesser sanction would be insufficient to protect the public, public confidence in the profession, and public confidence in the regulatory process. In particular where the registrant:

• lacks insight;

• continues to repeat the misconduct or, where a registrant has been suspended for two years continuously, fails to address a lack of competence; ...”

"Despite several opportunities given to the Registrant to demonstrate these matters, as well as several examples of written guidance and suggestions by way of communications from the HCPC in an effort to assist the Registrant, there is a lack of evidence of insight and remediation. The Panel is of the view that the Registrant is unable to address the concerns. This is to be seen within the context of the extension of the Suspension Order on two occasions since 2017 without any tangible, clear, and direct steps taken by the Registrant to address the concerns. There remains a real risk of harm to service users. All of these factors led the Panel to decide that Striking Off is the only way in which the public can be protected and which can uphold the wider public interest," the Panel concluded.


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