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Failure to maintain adequate records

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 of conduct, performance and ethics (updated in August 2012)

  • Standard 1. You must act in the best interests of service users. (…) You are responsible for your professional conduct, any care or advice you provide, and any failure to act. (…) You must protect service users if you believe that any situation puts them in danger
  • Standard 7. You must communicate properly and effectively with service users and other
  • Standard 10. You must keep accurate records

Standards of proficiency for occupational therapists (1 September 2023)

  • Standard 2.9 understand the scope of a professional duty of care, and exercise that duty
  • Standard 4.1 recognise that they are personally responsible for, and must be able to justify, their decisions and actions
  • Standard 4.2 use their skills, knowledge and experience, and the information available to them, to make informed decisions and/or take action where necessary
  • Standard 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
  • Standard 4.4 make and receive appropriate referrals, where necessary
  • Standard 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 was 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 her 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 her failings.

Measures we put in place to protect the public

The Conduct and Competence Committee imposed a twelve-month caution order.


Learning material
Case study
Registrants, Employers
Occupational therapists
Page updated on: 18/12/2023