Mrs Louise J Middleton
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Allegation
Allegations as proven at the Final hearing
During the course of your employment as a Dietitian with NHS Fife, on dates in or between February and August 2011, you:
1. On dates between May and June 2011 in relation to Case 1, you did not maintain accurate patient records, in that you:
(a) altered an electronic version of a dietetic letter originally dated 25 May 2011;
(b) destroyed the paper copy of the dietetic letter dated 25 May 2011, previously filed In the dietetic notes, and replaced It with the amended version;
(c) did not file three emails dated 1-3 June 2011 in the dietetic records
2. On dates between February and June 2011 in relation to Case 1, you did not conduct an adequate assessment of a Service User, In that you:
(a) did not take into account and/or adequately consider the case history of the service user when conducting your own dietetic assessment and plan;
(b) did not use the correct growth chart and/or did not plot growth chart correctly;
(c) did not sufficiently consider and/or review the information provided by the Health Visitor.
3. On dates between February and June 2011 in relation to Case 2, you:
(a) did not undertake an adequate assessment in respect of the Service User, in that you:
i. [Not proven]
ii. did not complete and/or plot the preterm growth chart correctly and/or accurately.
(b) did not formulate an appropriate dietetic plan, in that:
i. there was no and/or inaccurate information on the feeding requirements; and/or
ii. [Not proven]
iii. you did not adequately consider and/or identify that the Service User was being given diuretics and/or
iv. Identified 4 feeds a day as being adequate
(c) did not follow a jointly agreed dietetic plan;
(d) [Not proven]
4. In relation to Case 4:
(a) [Not proven]
(b) You did not undertake an accurate anthropometric assessment of the Service User in that, you:
i. did not calculate the infant's gestational age correctly; and/ or
i. did not plot the growth chart correctly.
(c) You did not undertake an adequate initial assessment in that, you:
i. did not assess and/or calculate the infant's actual consumed intake; and/ or
ii. did not assess and/or calculate information relating to feeds such as;
a. timing of feeds, and/or
b. length of time to complete feeds, and/or
c. sucking ability, and/or
d. feed losses
(d) You did not take appropriate account of the child's diagnosis and the likely impact on feeding;
(e) You did not make appropriate plans for frequency of review;
(f) You did not seek advice from and/or contact the Consultant medical staff.
5. On or around 5 May 2011 in relation to Case 5, you:
(a) did not follow the medical management plan;
(b) did not discuss a change of plan with the doctor and/or document reasons for a different course of action;
(c) did not undertake an adequate assessment of the Service User in that, you:
i. did not review and/or consider information in the medical notes, including blood results; and/ or
ii. [Not proven]
(d) did not undertake an accurate anthropometric assessment in that, you:
i. did not measure the Service User's height accurately; and/or
ii. did not plot the Service User's age correctly on the growth chart; and/or
iii. did not review the anthropometric data in the medical notes; and/ or
iv. did not correctly plot and/or interpret data relating to the Service User's nutritional status.
(e) [Not proven]
(f) [Not proven]
(g) requested that a GP undertake blood tests, including some that were unnecessary;
(h) [Withdrawn by HCPC]
6. In respect of Case 6, you:
(a) did not plot accurately the Service User's weight and/or height measurements on a growth chart;
(b) [Not proven]
(c) [Not proven]
(d) documented the need to discuss pump feeding with the Service User's parents, but did not document any such discussions
(e) did not advise the Service User's parents on an effective, practical feeding plan to achieve satisfactory weight gain.
7. In respect of Case 7, you:
(a) did not obtain any and/or sufficient information about the infant's recent feeding history;
(b) did not undertake an accurate anthropometric assessment in that you did not plot the growth chart correctly;
(c) did not appropriately discuss your findings with the doctor;
(d) did not re-assess nutritional intake to compare with requirements when you realised that despite your request to the GP to prescribe SMA High Energy formula, the baby was still consuming standard formula.
8. On dates between 25 May 2011 and 2 June 2011 in relation to Case 7, you:
(a) did not assess the Service User's actual nutritional intake and/or document nutritional aims;
(b) did not record in the dietetic record the date when the infant's feed changed to SMA High Energy formula;
(c) did not record in the dietetic record any advice given regarding maximum length of time to feed.
9. On or around 18 May 2011 in relation to Case 8, you:
(a) did not make accurate records in that you did not make it clear whether the infant changed to SMA High Energy milk;
(b) [Not proven]
(c) [Not proven]
i. [Not proven]
ii. [Not proven]
iii. [Not proven]
iv. [Not proven]
v. [Not proven]
10. In respect to Case 9, you:
(a) did not communicate effectively with the Service User's parents in that, you:
i. provided the Service User's parents with conflicting and/or misleading information about the child's condition; and/ or
ii. gave the Service User's mother inadequate written supplementary information.
11. In respect of Case 10, you:
(a) did not measure the child's height accurately;
(b) did not plot available weights and lengths from medical correspondence and/or medical notes;
(c) did not carry out an adequate assessment in that you did not review and/or consider
i. the Service User's total fluid intake; and/or
ii. eating environment; and/or
iii. number of children in the household;
(d) did not provide appropriate advice based on nutritional strategies that are known to work with this service user group.
12. [Not proven]
13. The facts set out in paragraphs 1-12 constitute misconduct and/or a lack of competence.
14. By reason of your misconduct and/or lack of competence your fitness to practise is impaired.
Finding
The Skeleton Argument
1. For the purposes of this hearing, the HCPC has submitted and the Panel has read, a Skeleton Argument signed by Mr Mitchell Reece, Presenting Officer and dated 12 December 2021 [the Skeleton Argument]. Ms Welsh adopted the Skeleton Argument as her submission to the Panel.
Background as extracted from the Skeleton Argument.
2. The Registrant is a registered Dietitian with the HCPC. The Registrant commenced employment as a Band 7 Dietitian at Kirkcaldy and Levenmouth Community Health Partnership in December 2009.
3. On 19 January 2018, a panel of the Conduct and Competence Committee found that the Registrant’s fitness to practise was impaired by reason of her lack of competence, having found a breadth of failings across a wide range of skills expected of a Band 7 dietitian and in relation to ten patients as set out in the Allegation. These occurred during the course of a twelve-week return-to-work plan following a period of sick leave from May 2010 until February 2011. Prior to the period of sick leave, the Registrant had been under supervision due to perceived concerns about her ability to carry out the duties of a Band 7 Dietitian.
4. On 19 January 2018 the Panel imposed a twenty-four month Conditions of Practice Order, having found that the Registrant had the required level of insight and understanding to indicate that a Conditions of Practice Order would be adhered to and that such an order would minimise the risk of future harm to patients.
5. At the review hearing on 15 January 2020, the Registrant informed the Panel that she had been unable to obtain employment as a Dietitian because her prospective employers found the conditions to be too onerous to be workable. The Reviewing Panel therefore found that there was no evidence before it that the Registrant had complied with the conditions and therefore, she had not remedied the lack of competence previously found proved. The Reviewing Panel therefore found that the Registrant’s fitness to practise remained impaired. It therefore extended the Conditions of Practice order for a further period of 12 months in order to give the Registrant a further opportunity to seek employment and to comply with the conditions.
6. At the review hearing on 13 January 2021, the Registrant’s representative, Mr Toms, submitted that the Registrant had been unable to obtain employment as a Dietitian in the light of the restrictive nature of the imposed conditions and also the effects of the Covid-19 pandemic. Mr Toms advised the Panel that the Registrant had made efforts to comply with the conditions albeit not in a clinical setting. The Panel recognised the difficulties facing the Registrant since the last review, in obtaining employment as a Dietitian. It was impressed by the efforts that the Registrant made by way of engaging in course material and reading in order to maintain her knowledge. Although the Registrant had demonstrated that she had achieved progress in record-keeping, time-management and liaising with colleagues, this was only in relation to non-clinical matters. As such, the Panel found that there was nothing before it to indicate compliance with the conditions imposed, albeit this had not been due to any lack of endeavour by the Registrant. The Registrant had not been able to demonstrate that she could practise safely as a Dietitian. It therefore extended the Conditions of Practice order for a further period of 12 months. The order expires on 16 February 2022.
7. On 11 June 2021 the Registrant expressed a desire to pursue Voluntary Removal.
8. On 30 September 2021 the Registrant returned a signed disposal by consent proforma.
9. On 22 December 2021 the Registrant sent to the HCPC, by email, a signed copy of the Voluntary Removal Agreement.
Legal Framework as set out in the Skeleton Argument
10. The HCPC have set out in the Skeleton Argument guidance as to the nature and the consequences of a VRA. That guidance is expressed in the following terms;
A Voluntary Removal Agreement is an agreement between the HCPC and the Registrant. The principle terms of the agreement are that the HCPC will apply to have the Conditions of Practise Order against the registrant revoked on the basis of a signed request by the registrant to be removed from the Register, and a commitment that the Registrant will cease and desist from practising as a Dietitian and will not attempt to re-join the register within a period of 5 years.
If the Registrant were to apply to come back on to the Register, her application would be treated in the same way as someone who had been struck off.
Consent agreements, such as disposal of a matter by Voluntary Removal, are not provided expressly for under The Health Professions Order 2001, however, the HCPTS have produced a Practice Note that the HCPC has approved as a means of allowing matters, where suitable, to be disposed of by consent.
This Practice Note [ which has been seen and read by the Panel] states that a Panel should not agree to resolve a case in this way unless it is satisfied that:
i. The appropriate level of public protection is being secured; and
ii. That doing so would not be detrimental to the wider public interest
The Submissions of the HCPC
11. The submissions of the HCPC, as set out in the Skeleton Argument, adopted and amplified by Ms Welsh, are as follows;
The HCPC submits that, in all the circumstances, a voluntary removal from the Register would be an appropriate means of resolving this matter.
The Registrant has been provided with detailed information about the consent process and the effect of voluntary removal from the Register, should the application be granted. The Registrant has had time to review this information and query its implications with HCPC.
After receiving all relevant information about the Voluntary Removal Process and having taken sufficient time, the Registrant confirmed she wished to come off the Register by Voluntary Removal.
The Registrant has shown good insight at the previous review, and has signed the Voluntary Removal agreement admitting her fitness to practise is impaired, having taken due time and care to consider the implications of this act.
As outlined however there are two things the Panel must be satisfied of before granting any Voluntary Removal Agreement.
Public protection
In regards to public protection, given voluntary removal is equivalent in effect to a strike-off, and thus would prevent the Registrant from practising as a Dietitian in the United Kingdom, the HCPC submits that the necessary public protection would be ensured by this course of action.
Public interest
The HCPC submits that the wider public interest would not be put at risk should this matter be disposed of by way of consent.
In respect of the wider public interest, the HCPC submits that confidence in the profession and the regulatory process has been maintained by way of the findings of fact and sanction imposed at the final hearing, and the further sanction imposed at the substantive review hearing.
The Panel therefore may conclude that the only fair, expeditious and proportionate position to adopt in the circumstances, would be to grant this Voluntary Removal Application.
For the reasons outlined, the HCPC respectfully invites the Panel to approve the proposed agreement.
The position of the Registrant
12. The Panel has seen a Reflective statement from the Registrant which was sent to the HCPC on 30 September 2021 in support of her request for her name to be removed from the register. The Panel has read that statement. In the concluding paragraph the Registrant stated that “my plans are on a different career path and I have no intention to be a dietitian and to be removed from the register and retire from dietetics; ideally backdated as I have not practised as a dietitian even with conditions since 2011. I now practise in a different field. I am now a holistic therapist. What I used for personal self-care has now been successful enough to make me follow my own new happier path”
13. The Panel has also seen an “Agreed Statement” signed by the Registrant and dated 22 December 2021 which is in the following terms
Agreed Statement
Mrs Louise J Middleton (the Registrant) was the subject of an allegation to the effect that her fitness to practise was impaired due to misconduct and/or lack of competence regarding the inaccurate assessment and treatment of a number of patients and failures to maintain accurate records. That allegation was held to be well founded by a panel of the HCPC’s Conduct and Competence Committee and a Conditions of Practice Order was imposed for a period of twelve months on 19 January 2018. On 13 January 2020 a panel of the Conduct and Competence Committee reviewed the Order. That reviewing panel extended the existing Conditions of Practice Order for a further twelve months.
The Committee revoked that Order on 14 January 2022 on the basis that the Registrant wished to be removed from the HCPC Register voluntarily. The Registrant admitted the allegation and has undertaken not to practise as a Dietitian or use any title associated with that profession. If the Registrant seeks to return to the HCPC Register at any time the application would be treated as if the Registrant had been struck off as a result of that allegation.
14. The documents set out in paragraphs 12 and 13 were drafted in the context of preparing the VRA. The implementation of the agreement, as set out in the Agreed Statement, is subject to the approval of the Panel. The VRA was signed by the Registrant and by an official of the HCPC on 20 December 2021.
15. Ms Brown on behalf of the Registrant, endorsed and supported the application to approve the VRA.
The Skeleton Argument
1. For the purposes of this hearing, the HCPC has submitted and the Panel has read, a Skeleton Argument signed by Mr Mitchell Reece, Presenting Officer and dated 12 December 2021 [the Skeleton Argument]. Ms Welsh adopted the Skeleton Argument as her submission to the Panel.
Background as extracted from the Skeleton Argument.
2. The Registrant is a registered Dietitian with the HCPC. The Registrant commenced employment as a Band 7 Dietitian at Kirkcaldy and Levenmouth Community Health Partnership in December 2009.
3. On 19 January 2018, a panel of the Conduct and Competence Committee found that the Registrant’s fitness to practise was impaired by reason of her lack of competence, having found a breadth of failings across a wide range of skills expected of a Band 7 dietitian and in relation to ten patients as set out in the Allegation. These occurred during the course of a twelve-week return-to-work plan following a period of sick leave from May 2010 until February 2011. Prior to the period of sick leave, the Registrant had been under supervision due to perceived concerns about her ability to carry out the duties of a Band 7 Dietitian.
4. On 19 January 2018 the Panel imposed a twenty-four month Conditions of Practice Order, having found that the Registrant had the required level of insight and understanding to indicate that a Conditions of Practice Order would be adhered to and that such an order would minimise the risk of future harm to patients.
5. At the review hearing on 15 January 2020, the Registrant informed the Panel that she had been unable to obtain employment as a Dietitian because her prospective employers found the conditions to be too onerous to be workable. The Reviewing Panel therefore found that there was no evidence before it that the Registrant had complied with the conditions and therefore, she had not remedied the lack of competence previously found proved. The Reviewing Panel therefore found that the Registrant’s fitness to practise remained impaired. It therefore extended the Conditions of Practice order for a further period of 12 months in order to give the Registrant a further opportunity to seek employment and to comply with the conditions.
6. At the review hearing on 13 January 2021, the Registrant’s representative, Mr Toms, submitted that the Registrant had been unable to obtain employment as a Dietitian in the light of the restrictive nature of the imposed conditions and also the effects of the Covid-19 pandemic. Mr Toms advised the Panel that the Registrant had made efforts to comply with the conditions albeit not in a clinical setting. The Panel recognised the difficulties facing the Registrant since the last review, in obtaining employment as a Dietitian. It was impressed by the efforts that the Registrant made by way of engaging in course material and reading in order to maintain her knowledge. Although the Registrant had demonstrated that she had achieved progress in record-keeping, time-management and liaising with colleagues, this was only in relation to non-clinical matters. As such, the Panel found that there was nothing before it to indicate compliance with the conditions imposed, albeit this had not been due to any lack of endeavour by the Registrant. The Registrant had not been able to demonstrate that she could practise safely as a Dietitian. It therefore extended the Conditions of Practice order for a further period of 12 months. The order expires on 16 February 2022.
7. On 11 June 2021 the Registrant expressed a desire to pursue Voluntary Removal.
8. On 30 September 2021 the Registrant returned a signed disposal by consent proforma.
9. On 22 December 2021 the Registrant sent to the HCPC, by email, a signed copy of the Voluntary Removal Agreement.
Legal Framework as set out in the Skeleton Argument
10. The HCPC have set out in the Skeleton Argument guidance as to the nature and the consequences of a VRA. That guidance is expressed in the following terms;
A Voluntary Removal Agreement is an agreement between the HCPC and the Registrant. The principle terms of the agreement are that the HCPC will apply to have the Conditions of Practise Order against the registrant revoked on the basis of a signed request by the registrant to be removed from the Register, and a commitment that the Registrant will cease and desist from practising as a Dietitian and will not attempt to re-join the register within a period of 5 years.
If the Registrant were to apply to come back on to the Register, her application would be treated in the same way as someone who had been struck off.
Consent agreements, such as disposal of a matter by Voluntary Removal, are not provided expressly for under The Health Professions Order 2001, however, the HCPTS have produced a Practice Note that the HCPC has approved as a means of allowing matters, where suitable, to be disposed of by consent.
This Practice Note [ which has been seen and read by the Panel] states that a Panel should not agree to resolve a case in this way unless it is satisfied that:
i. The appropriate level of public protection is being secured; and
ii. That doing so would not be detrimental to the wider public interest
The Submissions of the HCPC
11. The submissions of the HCPC, as set out in the Skeleton Argument, adopted and amplified by Ms Welsh, are as follows;
The HCPC submits that, in all the circumstances, a voluntary removal from the Register would be an appropriate means of resolving this matter.
The Registrant has been provided with detailed information about the consent process and the effect of voluntary removal from the Register, should the application be granted. The Registrant has had time to review this information and query its implications with HCPC.
After receiving all relevant information about the Voluntary Removal Process and having taken sufficient time, the Registrant confirmed she wished to come off the Register by Voluntary Removal.
The Registrant has shown good insight at the previous review, and has signed the Voluntary Removal agreement admitting her fitness to practise is impaired, having taken due time and care to consider the implications of this act.
As outlined however there are two things the Panel must be satisfied of before granting any Voluntary Removal Agreement.
Public protection
In regards to public protection, given voluntary removal is equivalent in effect to a strike-off, and thus would prevent the Registrant from practising as a Dietitian in the United Kingdom, the HCPC submits that the necessary public protection would be ensured by this course of action.
Public interest
The HCPC submits that the wider public interest would not be put at risk should this matter be disposed of by way of consent.
In respect of the wider public interest, the HCPC submits that confidence in the profession and the regulatory process has been maintained by way of the findings of fact and sanction imposed at the final hearing, and the further sanction imposed at the substantive review hearing.
The Panel therefore may conclude that the only fair, expeditious and proportionate position to adopt in the circumstances, would be to grant this Voluntary Removal Application.
For the reasons outlined, the HCPC respectfully invites the Panel to approve the proposed agreement.
The position of the Registrant
12. The Panel has seen a Reflective statement from the Registrant which was sent to the HCPC on 30 September 2021 in support of her request for her name to be removed from the register. The Panel has read that statement. In the concluding paragraph the Registrant stated that “my plans are on a different career path and I have no intention to be a dietitian and to be removed from the register and retire from dietetics; ideally backdated as I have not practised as a dietitian even with conditions since 2011. I now practise in a different field. I am now a holistic therapist. What I used for personal self-care has now been successful enough to make me follow my own new happier path”.
13. The Panel has also seen an “Agreed Statement” signed by the Registrant and dated 22 December 2021 which is in the following terms
Agreed Statement
Mrs Louise J Middleton (the Registrant) was the subject of an allegation to the effect that her fitness to practise was impaired due to misconduct and/or lack of competence regarding the inaccurate assessment and treatment of a number of patients and failures to maintain accurate records. That allegation was held to be well founded by a panel of the HCPC’s Conduct and Competence Committee and a Conditions of Practice Order was imposed for a period of twelve months on 19 January 2018. On 13 January 2020 a panel of the Conduct and Competence Committee reviewed the Order. That reviewing panel extended the existing Conditions of Practice Order for a further twelve months.
The Committee revoked that Order on 14 January 2022 on the basis that the Registrant wished to be removed from the HCPC Register voluntarily. The Registrant admitted the allegation and has undertaken not to practise as a Dietitian or use any title associated with that profession. If the Registrant seeks to return to the HCPC Register at any time the application would be treated as if the Registrant had been struck off as a result of that allegation.
14. The documents set out in paragraphs 12 and 13 were drafted in the context of preparing the VRA. The implementation of the agreement, as set out in the Agreed Statement, is subject to the approval of the Panel. The VRA was signed by the Registrant and by an official of the HCPC on 20 December 2021.
15. Ms Brown on behalf of the Registrant, endorsed and supported the application to approve the VRA.
Decision of the Panel made on 14 January 2022
16. The Panel has considered the submissions of the HCPC as set out in the Skeleton Argument and adopted by Ms Welsh. The Panel has taken account of the position of the Registrant as stated in the documents identified above together with the submissions of Ms Brown. The Panel has further considered all the other documents that have been submitted.
17. The Panel heard and accepted the advice of the Legal Assessor.
18. In deciding whether or not approve the agreement for VRA, the Panel has had regard to the Practice Note published by the HCPTS in March 2018 and entitled Disposal of Cases by Consent together with the policy document annexed to it as Annex A.
19. The Panel has concluded that the VRA should be approved and that an order should be made in the terms set out below. Its reasons are as follows;
⦁ The Registrant admitted the allegation and has undertaken not to practise as a Dietitian or use any title associated with that profession.
⦁ The public will be adequately protected by the voluntary removal of the Registrant’s name from the register, which will have the same effect as if she had been struck off. Such an outcome is also in the interests of the Registrant. Moreover, the VRA addresses and safeguards the public interest. In the latter context the Panel took into account the length of time that these matters had been the subject of regulatory proceedings and the desirability of bringing the process to a conclusion.
⦁ There are no public interest reasons to require a continuation of these proceedings.
⦁ The Panel has concluded that a well-informed member of the public would conclude that this matter is properly disposed of by the consensual outcome sought by both the Registrant and the HCPC.
20. For all the reasons that are set out above, the Panel has determined to approve the outcome sought in the VRA with immediate effect and that the name of the Registrant shall forthwith be removed from the Register.
16. The Panel has considered the submissions of the HCPC as set out in the Skeleton Argument and adopted by Ms Welsh. The Panel has taken account of the position of the Registrant as stated in the documents identified above together with the submissions of Ms Brown. The Panel has further considered all the other documents that have been submitted.
17. The Panel heard and accepted the advice of the Legal Assessor.
18. In deciding whether or not approve the agreement for VRA, the Panel has had regard to the Practice Note published by the HCPTS in March 2018 and entitled Disposal of Cases by Consent together with the policy document annexed to it as Annex A.
19. The Panel has concluded that the VRA should be approved and that an order should be made in the terms set out below. Its reasons are as follows;
⦁ The Registrant admitted the allegation and has undertaken not to practise as a Dietitian or use any title associated with that profession.
⦁ The public will be adequately protected by the voluntary removal of the Registrant’s name from the register, which will have the same effect as if she had been struck off. Such an outcome is also in the interests of the Registrant. Moreover, the VRA addresses and safeguards the public interest. In the latter context the Panel took into account the length of time that these matters had been the subject of regulatory proceedings and the desirability of bringing the process to a conclusion.
⦁ There are no public interest reasons to require a continuation of these proceedings.
⦁ The Panel has concluded that a well-informed member of the public would conclude that this matter is properly disposed of by the consensual outcome sought by both the Registrant and the HCPC.
20. For all the reasons that are set out above, the Panel has determined to approve the outcome sought in the VRA with immediate effect and that the name of the Registrant shall forthwith be removed from the Register.
Order
ORDER: The existing Order against the Registrant shall be revoked with immediate effect and the name of the Registrant shall forthwith be removed from the Register.
Notes
No notes available
Hearing History
History of Hearings for Mrs Louise J Middleton
| Date | Panel | Hearing type | Outcomes / Status |
|---|---|---|---|
| 14/01/2022 | Conduct and Competence Committee | Voluntary Removal Agreement | Voluntary Removal agreed |
| 13/01/2021 | Conduct and Competence Committee | Review Hearing | Conditions of Practice |
| 15/01/2020 | Conduct and Competence Committee | Review Hearing | Conditions of Practice |