Our case studies are based on real life fitness to practise concerns we have received
Type of concern: Failure to maintain adequate records
Profession: Occupational therapist
Standards
When these events happened, previous versions of the standards were in place (standards of proficiency for occupational therapists 2013 and standards of conduct, performance and ethics 2012). To avoid confusion the most recent versions are shown.
Standards of conduct, performance and ethics (1 September 2024)
- 1.1 You must treat service users and carers as individuals, respecting their privacy and dignity.
- 6.1 You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues, as far as possible.
- 6.2 You must not do anything, or allow someone else to do anything, which could put the health or safety of a service user, carer or colleague at unacceptable risk.
- 10.1 You must keep full, clear and accurate records for everyone you care for, treat or provide other services to.
- 10.2 You must complete all records promptly and as soon as possible after providing care, treatment or other services.
- 10.3 You must keep records secure by protecting them from loss, damage or inappropriate access.
Standards of proficiency for occupational therapists (1 September 2023)
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2.9 understand the scope of a professional duty of care, and exercise that duty
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4.1 recognise that they are personally responsible for, and must be able to justify, their decisions and actions
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4.2 use their skills, knowledge and experience, and the information available to them, to make informed decisions and/or take action where necessary
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4.3 make reasoned decisions to initiate, continue, modify or cease treatment, or the use of techniques or procedures, and record the decisions and reasoning appropriately
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4.4 make and receive appropriate referrals, where necessary
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8.19 work in appropriate partnership with service users in order to evaluate the effectiveness of occupational therapy intervention
Case study
An occupational therapist’s employer raised concerns relating to their clinical practice and conduct, following a number of incidents relating to nine different cases. The concerns included a failure to maintain adequate case files, not completing case notes about contacts with service users, assessment reports and care plans.
The registrant was not present at the hearing nor were they represented. The Panel found that the registrant had breached significant parts of the standards. In addition, incidents involved in the allegation related to vulnerable service users in complex and/or urgent cases. The Panel concluded that the proven facts did not amount to a lack of competence, as it was not satisfied that the allegation represented a fair sample of the registrant’s work. It also found that the registrant competently dealt with other cases. However, having proven some of the facts the Panel determined that the matters constituted misconduct.
The Panel felt that the registrant was aware of the risks and the impact on vulnerable services users of not recording their actions and decisions. They agreed that the registrant displayed a reckless disregard for the risk in failing to record her actions and decisions about service users. The Panel found that the registrant’s failings were remediable, but had no evidence of any steps the registrant had taken to address the failings. The Panel reached the view that the registrant had not demonstrated insight or remorse, and posed a risk of repetition. The Panel considered that a finding of impairment was necessary in order to protect members of the public, to uphold proper standards and to protect the reputation of the profession and the regulator.
The Panel then went on to consider which sanction to impose to protect the public. It identified aggravating and mitigating factors, and considered the sanctions available to them in ascending order. It noted that there was nothing that may have prevented the registrant from remedying their failings and concluded a suspension order was appropriate in this case. The Panel was of the view that a period of six months would be appropriate and proportionate to protect the public, to satisfy the wider public interest and to allow the registrant an opportunity to demonstrate full insight and remediate their failings.
Measures we put in place to protect the public
The Conduct and Competence Committee imposed a six-month caution order.
- Cyhoeddwyd:
- 14/01/2019
- Resources
- Learning material
- Is-gategori:
- Case study
- Audience
- Cofrestredig, Employers
- Profession
- Occupational therapists