Mr John A Dowsing

Preliminary Matters - Proceeding in Absence

1. The Panel was satisfied that notice of today’s hearing had been served properly on the Registrant on 27 April 2023 at his email address registered with the HCPC.

2. The Panel considered Ms O’Connor’s application to proceed in the Registrant’s absence. She reminded the Panel it has found good service. The Registrant’s solicitor has e-mailed the HCPC today to confirm that her client was in agreement with the hearing proceeding in his absence and was agreeing to the amendment, discontinuance and the Voluntary Removal Agreement. She submitted that the Registrant had voluntarily absented himself and that it was in the public interest to proceed.

3. The Panel is aware that its discretion to proceed in absence is one which should be exercised with care. The Legal Assessor referred the Panel to GMC v Adeogba [2016] EWCA Civ 162 which makes clear that the first question the Panel should ask is whether all reasonable efforts have been taken to serve the Registrant with notice. Thereafter, the discretion whether or not to proceed must be exercised having regard to all the circumstances of which the Panel is aware, with fairness to the Registrant being a prime consideration, but balanced with fairness to the HCPC and the interests of the public.

4. The Panel decided to proceed in the Registrant’s absence. In reaching this decision, the Panel has noted there has been no request for an adjournment and a clear confirmation from the Registrant’s solicitor that neither they nor the Registrant will be attending the hearing and explicitly agreeing to the matter proceeding in his absence. It balanced fairness to the Registrant with fairness to the HCPC and the public interest and it concluded that the Registrant has waived his right to attend. In these circumstances, the Panel was satisfied that it is fair and appropriate to proceed in the Registrant’s absence.

Background
5. The Registrant is registered with the HCPC as a Paramedic. The Registrant was employed by the East Midlands Ambulance Service NHS Trust (“the Trust”) and had been employed by the Trust for 24 years and 8 months at the time the internal investigation commenced.

6. Colleagues originally raised concerns on 5 May 2020, stating that the Registrant was not taking a defibrillator into every job. Craig Priestnall, the Investigating Officer, spoke to the Registrant about these concerns and during that conversation further concerns were raised regarding the Registrant’s practice. As a result, Craig Priestnall organised a ride out with the Registrant on 18 May 2020, where he observed the Registrant on a shift.

7. From the ride out on 18 May 2020, Craig Priestnall identified clinical concerns around the Registrant’s safe managing of sepsis patients and cardiac chest pain patients (Patients 1 and 2 in the allegations). Craig Priestnall also conducted a review of the Registrant’s previous month’s records of patients he had attended through the patient report forms, and further concerns were identified regarding the Registrant’s record- keeping abilities.

8. Following this ride out, on 19 May 2020, the Registrant was taken off the road and placed on non-patient facing duties. Until 17 June 2020, he was allowed to return to patient facing duties with the requirement that he always worked with another paramedic, to ensure he was not the lead clinician. Craig Priestnall referred the Registrant to the HCPC on the Trust’s behalf on 10 June 2020.

9. Previous concerns about the Registrant’s practice were also raised. On 10 January 2019, the Registrant attended to a patient in cardiac arrest and is alleged to have not applied the Joint Royal College of Ambulance Liaison Committee (JRCALC) Resuscitation Guidelines on this patient.

10. On 10 June 2018 the Registrant was part of a job involving Child 1, with Colleague 1. During that call out, the Registrant is alleged to have failed to treat Child 1 as a time critical patient and also allowed Colleague 1, an underqualified colleague, to treat the patient during the conveyance to hospital, risking the patient’s health. These concerns were also referred to the HCPC by the Trust.

11. The Registrant attended an annual resuscitation revalidation workshop and during that session concerns were raised regarding the Registrant’s abilities to provide resuscitation. He was then sent on a resuscitation training and assessment day on 24 September 2020, which he failed.

12. At its meeting on 7 April 2021, the Investigating Committee (IC) of the HCPC
determined that there was a case to answer in relation to an allegation of impairment of the Registrant’s fitness to practise. At that time the IC Panel confirmed the following allegations and referred the case to a fitness to practice hearing:-

Whilst registered as a Paramedic (PA14764) with the Health and Care Professions Council (HCPC) and during the course of your employment with the East Midlands Ambulance Service NHS Trust, you:
1. Did not display an adequate level of clinical knowledge and/or did not provide safe treatment to service users in that:
a) On 18 May 2020, you:
i.) Did not apply the EMAS Management of Cardiac Events
Procedures in that you failed to perform a 12-lead ECG on Patient 1,
who was presenting with chest pain, without prompt.
ii) Did not apply the Cardiac Chest Pain Care Bundle in Patient 1.
iii) Did not use the Paramedic Pathfinder Sepsis Toolkit in that you
failed to administer treatment of IV sodium chloride 0.9% to Patient 2, who was presenting sepsis symptoms.
iv) Did not use the Paramedic Pathfinder Sepsis Toolkit in that you
failed to pre-alert the receiving hospital in respect of Patient 2.
b) Did not take a defibrillator to every incident you responded to.
c) On 10 January 2019, in respect of Patient 3, who was in cardiac arrest,
you:
i)Did not apply the Joint Royal College of Ambulance Liaison
Committee (JRCALC) Resuscitation Guidelines in that you did not
commence cardiopulmonary resuscitation (CPR) immediately on
attending to Patient 3.
ii)Did not bring a defibrillator to Patient 3’s property on initial
attendance.
iii)Did not utilise a defibrillator on Patient 3 at the earliest possible
opportunity.
d)On 10 June 2018, in respect of Child 1, you:
i)Did not continually use emergency blue lights and sirens when conveying Child 1 to the hospital in an emergency vehicle.
ii)Did not treat Child 1 as a ‘Time Critical’ patient.
iii)Did not ensure that a 12-lead ECG was completed for Child 1.
iv)Did not accompany Child 1 in the back of the ambulance in order to oversee their care during conveyance to the hospital.
v)Left an underqualified colleague (Colleague 1) to provide care for Child 1 during conveyance to the hospital.
2. Between 13 April 2020 and 13 May 2020 your completion of and/or recording of Electronic Patient Report Forms (EPRFs) was inadequate in that:
a)In a sample of four EPFRs which were audited you:
i.) Did not record your use of the Paramedic Pathfinder on two of the audited EPRFs.
ii.)Did not correctly document instances of patient refusal and/or discharge on scene in the appropriate box on two of the audited EPRFs.
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iii.)Did not record the patient’s National Early Warning Score (NEWS) on three of the audited EPRFs.
b) On 18 May 2020, you did not record your rationale for failure to complete
the Cardiac Chest Pain Care Bundle on the EPRF of Patient 1.
3. On 24 September 2020 you attended a resuscitation revalidation workshop and refresher training and were unable to meet safe practice for the resuscitation of cardiac arrest patients, in that you:
a)Did not display and/or apply adequate clinical knowledge of:
i.) Intubation and/or the use of a bougie to assist intubation.
ii.) Ventilation control.
iii.)The two-person BVM technique.
iv.) The process of pit-crew approach.
v.) Crew resource management.
vi.)The management of a cardiac arrest procedures.
vii.) Ventricular fibrillation.
b) Made a statement to the effect of “I would never use an EZIO”.
4. You did not inform the Health and Care Professions Council (HCPC) that your employer had put restrictions on your practice on or around 19 May 2020.
5. You informed your employer that you would inform the HCPC about the restrictions on your practice on or around 26 May 2020 but you did not.
6. The matters set out in particulars 1, 2, and 3 constitute lack of competence and/or misconduct.
7. The matters set out at particulars 4 and 5 were dishonest.
8. The matters set out at particulars 4, 5 and 7 constitute misconduct.
9. By reason of lack of competence and/or misconduct your fitness to practise is impaired.
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The proposed amended allegation
13. Kingsley Napley LLP was instructed by the HCPC to conduct an investigation into the allegation referred by the IC. That investigation has been completed and the HCPC now seeks that the Panel exercise its discretion to partially discontinue and amend the allegation against the Registrant so that it reads as follows (additions in bold, deletions in strikethrough) :-

Whilst registered as a Paramedic (PA14764) with the Health and Care Professions Council (HCPC) and during the course of your employment with the East Midlands Ambulance Service NHS Trust, you:
1. Did not display an adequate level of clinical knowledge and/or did not provide safe treatment to service users in that:
a) On 18 May 2020, you:
i.) Did not apply the EMAS Management of Cardiac Events Procedures in that you failed to perform a 12-lead ECG on Patient 1, who was presenting with chest pain, without prompt.
ii) Did not apply the Cardiac Chest Pain Care Bundle in Patient 1.
iii) Did not use the Paramedic Pathfinder Sepsis Toolkit in that you:

a. Failed to administer treatment of IV sodium chloride 0.9% to Patient 2, who was presenting with sepsis symptoms
Iv Did not use the Paramedic Pathfinder Sepsis Toolkit in that you
b. Failed to treat Patient 2 as a “Time Critical” patient in that you
i. Failed to pre-alert the receiving hospital in respect of Patient 2.
ii. Did not ensure Patient 2 was conveyed to hospital using emergency blue lights and sirens.

b) On or around 5 May 2020 you did not take a defibrillator to every incident you responded to.

c) On 10 January 2019, in respect of Patient 3, who was in cardiac arrest, you:
i)Did not apply the Joint Royal College of Ambulance Liaison Committee
(JRCALC) Resuscitation Guidelines in that you did not commence cardiopulmonary resuscitation (CPR) immediately upon attending to Patient 3’s cardiac arrest.
ii)Did not bring a defibrillator to Patient 3’s property on initial attendance.
iii)Did not utilise a defibrillator on Patient 3 at the earliest possible opportunity.
iv) Delayed delivering defibrillation to Patient 3.
d)On 10 June 2018, in respect of Child 1, you:
i)Did not continually use emergency blue lights and sirens when conveying Child 1 to the hospital in an emergency vehicle.
ii)Did not treat Child 1 as a ‘Time Critical’ patient.
iii)Did not ensure that a 12-lead ECG was completed for Child 1. [HCPC APPLICATION TO DISCONTINUE]
iii)Did not accompany Child 1 in the back of the ambulance and left an underqualified colleague (Colleague 1) in order to oversee their care during conveyance to the hospital.
iv)Left an underqualified colleague (Colleague 1) to provide care for Child 1 during conveyance to the hospital. [HCPC APPLICATION TO DISCONTINUE]

2. Between 13 April 2020 and 138 May 2020 your completion of and/or recording of Electronic Patient Report Forms (EPRFs) was inadequate in that:
a)In a sample of four three EPFRs which were audited you:
i.) Did not record your use of the Paramedic Pathfinder on two of the audited EPRFs.
ii.)Did not correctly document instances of patient refusal and/or discharge on scene in the appropriate box on two of the audited EPRFs.
iii.)Did not record the patient’s National Early Warning Score (NEWS) on three of the audited EPRFs.
i) In relation to Patient 4, you failed to adequately record:
a. A full assessment, or an explanation as to why a full assessment could not have been undertaken
b. The patient’s NEWS scores or an explanation as to why these could not have been calculated
c. Complete observations or an explanation as to why these could not have been undertaken
d. Details relating to examination of the patient’s wound or an explanation as to why it could not have been examined
e. A treatment plan
f. A clear care plan or follow up advice
g. Rationale for patient disposition
h. Adequate safety netting advice
i. Follow up advice in respect of wound care and head injury

ii) In relation to Patient 5, you failed to adequately record:
a. A full history
b. Whether a clinical examination had taken place and if so, the results of that
c. Whether a 12-lead ECG had been carried out and if not, the rationale
d. The advice provided to the patient as a result of their non-conveyance to hospital
e. A full assessment and/or examination

iii) In relation to Patient 6, you failed to adequately record:
a. A full history
b. A full clinical examination and/or assessment, or the Patient’s
withholding of consent to be examined
c. Details of whether the Patient has tried to harm themselves in any other way
d. Details of the advice provided to the Patient in terms of risks of refusing treatment and/or transportation to hospital and safety netting advice
e. Your making of a safeguarding referral

b) On 18 May 2020 in relation to Patient 1, you failed to adequately record on their ePRF: , you did not record your rationale for failure to complete the Cardiac Chest Pain Care Bundle on the EPRF of Patient 1.
i) Your rationale for failure to complete the Cardiac Chest Pain Care Bundle
ii) A full history
c. On 18 May 2020 in relation to Patient 2, you failed to adequately record on their ePRF:
i) The presence of red and amber sepsis flags
ii)Rationale for why sepsis treatment had not been administered
iii) Rationale for failing to pre-alert the receiving hospital

3. On 24 September 2020 you attended a resuscitation revalidation workshop and refresher training and were unable to meet safe practice for the resuscitation of cardiac arrest patients, in that you:
a)Did not display and/or apply adequate clinical knowledge of:
i.) Intubation and/or the use of a bougie to assist intubation.
ii.) Ventilation control.
iii.)The two-person BVM technique.
iv.) The process of pit-crew approach.
v.) Crew resource management.
vi.)The management of a cardiac arrest procedures.
vii.) Ventricular fibrillation.
viii) Use of an EZIO
b) Made a statement to the effect of “I would never use an EZIO”. [HCPC
APPLICATION TO DISCONTINUE]

4. You did not inform the Health and Care Professions Council (HCPC) that your employer had put restrictions on your practice on or around 19 May 2020.

5. You informed your employer that you would inform the HCPC about the restrictions on your practice on or around 26 May 2020 but you did not. [HCPC APPLICATION TO DISCONTINUE]

6.5. The matters set out in particulars 1, 2, and 3 constitute lack of competence and/or misconduct.

7. The matters set out at particulars 4 and 5 were was dishonest.

6. The matters set out at particulars 4 constitutes misconduct.

9.7 By reason of lack of competence and/or misconduct your fitness to practise is impaired

Submissions for the HCPC
14. Ms O’Connor referred to the detailed written application, and made an application to discontinue allegation 7. She explained that the HCPC had, this morning, decided to seek discontinuance of the entire dishonesty allegation. She advised the Panel that the Registrant had always denied any dishonesty and on the basis of the proposed discontinuance and amendment the Registrant had agreed to a Voluntary Removal Agreement (VRA).

15. Ms O’Connor referred to the detailed written application and extensive evidence bundle and applied to:-
• Adduce expert evidence
• Discontinue part of the allegation
• Amend the allegations
• Grant a Voluntary Removal Agreement (VRA)

Adduce Expert Evidence
16. On 1 July 2021, Mr Timothy Kilner was formally instructed to prepare a report on behalf of the HCPC in relation to the allegations. He was instructed to review the documentation and provide his opinion as to whether the Registrant’s actions and/or omissions in each situation met the standard expected of a registered paramedic, and to review the Registrant’s ePRFs audited by Craig Priestnall and comment on their adequacy.

17. Mr Kilner’s expert report provides an expert opinion in relation to the Registrant’s actions and/or omissions in respect of those patients and in respect of a defibrillator. Mr Kilner also provides an opinion on the quality of the Registrant’s record-keeping in respect of the ePRFs completed for Patients 1, 2, 4, 5, 6 and 7.

18. Ms O’Connor submitted that the evidence of Mr Kilner is required to present to the Panel the opinions and conclusions of an expert in the field on the central issues to be decided in this case, namely the Registrant’s actions and/or omissions during and consequent to clinical examination of patients. She submitted that these allegations relate to clinical matters that are properly commented upon by an expert and that his report should be adduced as it is of assistance to the Panel.

Discontinuance
19. Ms O’Connor referred the Panel to the extensive bundle of evidence of some 1293 pages. She referred to the written application in respect of discontinuance. The HCPC submit that particulars 1(d)(iii), 1(d)(v) and 3(b) are not supported by the evidence from Mr Kilner, Mr Priestnall, Colleague 1 and Karl Anderson, and therefore have no realistic prospect of success.

20. Ms O’Connor submitted that the HCPC had now concluded that in light of the evidence that there is no reasonable prospect of proving dishonesty as alleged in particular 7. She referred the panel to the witness statements and evidence of Mr Priestnall and Mr Smith. She submitted that these make clear that the Registrant was not sure what he had done wrong and so had said that he would not be referring himself to the HCPC. However, it is clear from the evidence that he was well aware that his employer would do so. She submitted therefore that the Registrant had not been dishonest on both the subjective and objective tests as set out in Ivey v Genting Casinos (UK) Ltd t/a Crockfords [2017] UKSC 67.

Proposed Amendments
21. Ms O’Connor submitted that the amendments set out in the written application (and detailed above) were appropriate, properly, and more fairly reflected the evidence. The Registrant was in agreement. In her written application Ms O’Connor made detailed reference to the evidence in respect of each proposed amendment.

22. Ms O’Connor submitted that the proposed deletions and additional particulars better reflect the evidence obtained and the concerns regarding the Registrant’s actions, particularly in light of the evidence from Mr Priestnall and Mr Kilner. She submitted that these amendments do not change the nature of the case, nor do they make the case against the Registrant significantly more serious. For these reasons, the HCPC submitted that that the proposed amendments could be made without prejudice to the Registrant.

The proposed VRA

23. Ms O’Connor advised the panel that the Registrant has signed a VRA proposal form on 6 January 2023 admitting the allegations, as amended, misconduct and impairment of his fitness to practise, on the basis that the dishonesty allegation is discontinued. She invited the Panel to allow the discontinuance, grant the amendments, and to grant authority to the VRA and so therefore allow the Registrant to be removed from the Register.

24. Ms O’Connor referred to the HCPTS Practice Note and to the HCPC’s overarching statutory objective being the protection of the public. The Practice Note states that a Panel should not agree to resolve a case by VRA in unless it is satisfied of two things:- firstly, that the appropriate level of public protection is being secured and, secondly, that doing so would not be detrimental to the wider public interest. She submitted the VRA met those tests given the agreement of the Registrant clearly expressed by his solicitor. It was therefore appropriate to grant the VRA.

Decision on Applications
25. The Panel considered the submissions and the detailed and comprehensive written application. It accepted the advice of the Legal Assessor who reminded the Panel of the relevant HCPTS Practice Notes and the need to be mindful of the public interest. He also reminded the Panel about the guidance in Ivey.

26. Expert Evidence -The Panel was satisfied that Mr Kilner’s evidence would be of assistance. This is an allegation concerned with clinical failings and the Panel found that the report of Mr Kilner was of high quality and clearly of assistance. It is a relevant, impartial and detailed expert report on the allegations and the Panel decided that it was appropriate to allow the expert evidence of Mr Kilner to be adduced.

27. Discontinuance – The Panel considered the detailed submissions in respect of each of the proposed discontinued particulars of the allegation, each one cross referred to the evidence. The Panel was mindful of the Practice Note and that it should consider whether there were realistic prospects of success of proving those parts of the allegation.

28. The Panel was satisfied that in respect of Particular 1(d)(iii); Particular 1(d)(v); Particular 3(b) and Particular 5 that the evidence did not support what is alleged. There is therefore no realistic prospect of proving these particulars.

29. The Panel had particular regard to particular 5 which is alleged at particular 7 to be dishonest:- “You informed your employer that you would inform the HCPC about the restrictions on your practice on or around 26 May 2020 but you did not.” The Panel was mindful of the guidance in Ivey. The Panel was satisfied that there is no evidence that the Registrant intended to deceive or to conceal, not least as he was well aware that his employer would refer him to the HCPC, as confirmed by the evidence of Mr Priestnall and Mr Smith. The Panel was also satisfied that objectively a member of the public would not consider that these facts indicate dishonesty.

30. The Panel was satisfied that it has received a full and detailed explanation of the evidence before it, and it has considered the extensive bundle of evidence. It was satisfied, given the evidence, that there is no under-prosecution in the discontinuance sought. There is no public interest in proceeding with allegations that have no realistic prospect of success. The Panel therefore granted the application to discontinue the particulars as sought.

31. Proposed Amendments - The proposed amendments are sought to better particularise and clarify the facts, the misconduct and/or lack of competence alleged. The Panel was mindful that the key consideration is fairness to the Registrant, and it took account that the Registrant has agreed to the proposed amendments on the basis that he has signed the VRA proposal form in anticipation of these amendments. The Panel has now had sight of the VRA signed by the Registrant on 28 June 2023 attaching the allegation as amended above.

32. The Panel was satisfied that it had received a full and clear explanation for each of the proposed amendments which was supported by reference to the evidence, in particular the expert evidence of Mr Kilner. The Panel was satisfied that the proposed amendments do not alter the overall nature or the gravity of the allegation. The Panel agreed with the submissions that these amendments better particularise the case and better reflect the evidence.

33. The Registrant is aware and has signed the VRA on the basis of the proposed discontinuance and amendments. The Panel found that there was no prejudice to him in allowing those amendments. The Panel therefore decided to allow the proposed amendments which were fair and appropriate in the circumstances and in the interests of justice.

34. The Panel allowed amendment of the particulars as sought and as highlighted in the above allegations. The Panel made the required numbering changes to the final particulars of the allegation to make proper sense of the amendment and discontinuance of earlier particulars.

Voluntary Removal Agreement
35. The Panel was mindful of the Practice Note. The Registrant has admitted in full the allegation, as amended, and the allegation of dishonesty has now been discontinued. The Panel noted that on 9 December 2022, the Registrant’s solicitor, Julie Norris, wrote to Kingsley Napley stating that the Registrant was not willing to admit to the dishonesty element as explained in previous correspondence.

36. On 6 January 2023, Julie Norris confirmed to Kingsley Napley LLP that the Registrant wished to proceed on this basis of voluntary removal. The Registrant completed and signed consensual disposal request pro-forma which is before the Panel. It makes clear that the Registrant admits the entire allegation, except for dishonesty, and he has agreed to the proposed VRA.

37. The Panel has seen the email to the HCPC of 28 June 2023 from the Registrant’s solicitor which states:-
“The issue about which we were concerned was that we were informed by …. Kingsley Napley that there was consent to enter into the Voluntary Withdrawal Agreement without the need to admit dishonesty but the latest information was that this was not the case. The registrant continues to agree to the consensual disposal request (appendix T of the bundle) which he has signed provided that all allegations involving dishonesty as set out in paragraph 7 are removed. …We understand that you will be applying to remove the dishonesty allegations and my client is and always was, content with the voluntary withdrawal on the basis that the dishonesty allegations are removed.”

38. The Panel was mindful of the Practice Note and it decided that the proposed VRA is not detrimental to the wider public interest. The Registrant has fully accepted the amended allegation and he has admitted that his fitness to practice is impaired. The Panel has now received the VRA signed by the Registrant and the HCPC.

39. The Panel was satisfied that removal of the Registrant from the Register will secure protection of the public and that the proposed VRA does not raise wider public interest concerns. The Panel noted that the Registrant is now retired and will be removed from the Register and cannot reapply for five years.

40. The Panel is satisfied that the VRA is an appropriate and expeditious way of dealing with this matter and will serve to both protect the public and the wider public interest. The VRA is granted. That concludes this hearing.

The VRA is granted. 

This Voluntary Removal Agreement hearing took place via videoconference on 28-29 June 2023.

History of Hearings for Mr John A Dowsing