Jeffrey D Hartopp
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During the course of your employment as a Paramedic at East Midlands Ambulance Service NHS Trust:
1. On 28 November 2013, you attended Patient A* and you:
a) Did not adequately complete the Patient Report Form (PRF) in that you did not record the:
i. Incident number;
ii. Times of the job;
iii. Call times;
iv. Patient’s age;
v. Patient’s ethnicity;
vi. Patient’s consent to treatment;
vii. Respiratory rate;
viii. Rationale for leaving Patient A* at home with a neighbour when she was suspected of suffering from a neck of femur injury;
ix. Patient’s medications and/or medical history.
b) Did not adequately complete the PRF in that you recorded only one set of observations for Patient A*.
c) Failed to carry out an adequate assessment of Patient A* in that you:
i. Did not carry out a trauma examination to exclude medical causes for the patient’s fall or collapse;
ii. Did not carry out a head, neck and back assessment.
d) Did not act in Patient A’s best interests, in that you left Patient A* at home with a neighbour instead of waiting until the Double Crewed Ambulance arrived to convey her to the hospital;
e) Did not provide Patient A* with adequate care and treatment in that you did not treat Patient A* for her injuries and/or give her pain relief.
2. On 28 November 2013, you attended Patient B*, and you:
a) Did not adequately complete the Patient Report Form (PRF) in that you did not record:
i. The patient’s telephone number;
ii. The patient’s next of kin details;
iii. The contact details of the patient’s next of kin;
iv. The patient’s age;
v. The patient’s gender;
vi. The patient’s ethnicity;
vii. The patient’s consent to treatment;
viii. The patient’s pupil reactivity;
ix. The time of the patient's first symptom;
x. The dosage of the patient’s medication;
xi. The patient’s allergies;
xii. The patient’s state or mind or normal level of communication;
xiii. The patient’s understanding and/or ability to make an informed decision;
xiv. The observations that were taken at 0215 hours;
xv. Your rationale for not transporting the patient to the hospital;
xvi. The clinical impression section of the PRF;
xvii. Whether the Out of Hours GP Service was recommended or declined;
xviii. Your discharge advice;
xix. The signature of the patient or carer;
xx. The patient's results on the AVPU scale.
b) Did not provide Patient B* with adequate care and treatment in that you:
i. Made a diagnosis of Urinary Tract Infection when the patient’s symptoms suggested possible sepsis;
ii. Did not question the patient’s last oral intake even though she had a blood glucose reading of 10.4;
iii. Did not carry out further investigation when you obtained a GCS (Glasgow Coma Scale) reading of 5;
iv. Did not assess the patient’s breath sounds even though she presented with a respiratory rate outside the normal limits.
c) Did not transport Patient B* to the hospital;
d) Made inappropriate comments to Patient B* and/or Person C*, in that you said:
i. “Don’t worry Patient B*, I’m not touching your tits” or words to that effect;
ii. “Oh well I don’t practice safe sex anyway” or words to that effect.
3. The matters described in paragraphs 1 to 2 constitute misconduct and/or lack of competence.
4. By reason of that misconduct and/or lack of competence your fitness to practise is impaired.
1. Mr Orpin-Massey made an application to amend particular 2 of the allegation to add the words “or around” to the date of 28 November 2013. The reason for the proposed amendment is that the evidence suggests the incident may have occurred in the morning of 29 November 2013. The Registrant was advised of this proposed amendment in a letter dated 1 June 2015. Ms Bald did not oppose the amendment.
2. The Panel agreed to allow this amendment because it is minor and there is no prejudice to the Registrant. The Panel also made an amendment to particular 2(a)(xii) to correct a minor typographical error. This particular should read “the patient’s state of mind or normal level of communication”.
3. In response to the allegation Ms Bald, on behalf of the Registrant, indicated that he admitted particulars 1(a), 1(b), 2(a), and 2(b)(i) and 2(c).
4. The Registrant was a long-term employee of East Midlands Ambulance Service (“EMAS”). At the time of the allegations he was working as a Bank Paramedic. Bank Paramedics are retained by EMAS on “zero hour” contracts, working flexibly when required.
5. Following a night shift that the Registrant worked on 28 to 29 November 2013, concerns were raised about his clinical practice, record keeping, and conduct towards two particular patients, both elderly. An investigation was commenced and was led by EK, Investigating Officer. It was noticed during the investigation that the Patient Report Forms (PRF) for both patients had not been fully completed. On 9 January 2014, as a result of the investigation, the Registrant’s contract with EMAS was terminated.
6. The Registrant attended Patient A on 28 November 2013 in a First Response Vehicle (FRV). Patient A had fallen over at home and was unable to stand up. When the Registrant arrived at the address, Patient A was attended by a neighbour. The Registrant entered details relating to his attendance to Patient A onto a paper PRF. The PRF is a template containing sections dealing with different assessments including details of the patient, initial clinical assessments, stroke assessment, presenting complaint details, clinical observations and management. Some sections of the PRF allow for boxes to be ticked or observations to be entered, other sections allow free text to be written by the Paramedic.
7. Patient A was lying on the floor and the Registrant identified that she had a possible fracture to the neck of the femur. He called for a Double Crewed Ambulance to transport Patient A to hospital. As first response Paramedic, it was the Registrant’s role to make the call and to decide on the appropriate level of urgency for the Double Crewed Ambulance. There are three levels of urgency, red, amber and green. A “green ambulance” is the lowest level of urgency and red the highest level. A green ambulance does not use lights or sirens and it may be diverted to a more urgent job at any time. The Registrant called a green ambulance and “called clear” to indicate that he was able to take another job. He left Patient A, lying on the floor, to wait for the ambulance with her neighbour. The green ambulance arrived over two hours later.
8. Later in the same shift the Registrant attended Patient B. Patient B was the resident of a care home and suffered from advanced dementia. She had recently been treated for a Urinary Tract Infection (UTI) and staff at the care home called for medical assistance after she presented as being unwell again. The Registrant entered details relating to his attendance to Patient B onto a paper PRF. He recorded that he contacted the Out of Hours (OOH) GP. After speaking to the OOH GP, and making arrangements for a GP’s visit, the Registrant decided not to call an ambulance. Patient B was subsequently taken to hospital in the morning on 29 November 2013 after an ambulance was called again. Staff at the care home raised concerns to the paramedics that attended on this occasion about the Registrant’s conduct.
Application to admit hearsay evidence
9. Person C was summoned to attend the Panel, but did not attend. The Hearings Officer spoke to Person C on 27 July 2015 and asked her to be available to be contacted by telephone in the morning on 28 July 2015 at 9.45 a.m. Person C appeared to agree, but she did not answer her telephone when she was contacted on two occasions on 28 July 2015 at 9.45 a.m. and just before 10 a.m. Mr Orpin-Massey informed the Panel that in these circumstances he would make an application for Person C’s statement to be admitted as hearsay evidence. The Panel considered the position and decided that no further steps could be taken to contact Person C and that it was appropriate to hear the application.
10. Mr Orpin-Massey submitted that the Panel has power to admit Person C’s signed statement as hearsay evidence under Rule 10(1)(b) of the Health and Care Professions (Conduct and Competence Committee)(Procedure) Rules. He submitted that Person C provides the only evidence on particulars 2(d)(i) and 2(d)(ii) and that these are serious allegations. Person C has provided a signed statement confirming that her account is true. The HCPC has made exhaustive efforts to ensure that Person C gives evidence. He referred to the evidence provided in support of the HCPC application for a Witness Order for Person C.
11. Mr Orpin-Massey referred to circumstances relating to Person C’s private life. The Panel decided that this part of Mr Orpin-Massey’s submissions should be heard in private in order to protect Person C’s private life. Mr Orpin-Massey stated that in a telephone conversation with the HCPC Hearings Officer, Person C stated that she lived with her parents in a rural area, that it would be difficult for her to attend a hearing in London, that she suffered from a health condition, and that she was terrified to give evidence in person.
12. Mr Orpin-Massey further submitted that an important safeguard was that if the evidence was admitted, the Panel would treat that evidence with caution and consider carefully what weight may be attached to it.
13. Ms Bald submitted that the Panel should not admit the evidence of Person C. She emphasised the seriousness of the allegation and that the evidence of Person C was the only evidence on allegation 2(d)(i) and 2(d)(ii). Ms Bald raised a number of points about the reliability of Person C and the circumstances in which she provided a signed statement. She referred the Panel to attendance notes recording contact made between Kingsley Napley, solicitors instructed by the HCPC and Person C. She submitted that the efforts were focussed on obtaining a signed statement from Person C. Person C was informed, on more than one occasion, that if she signed the statement she would not have to attend a hearing. Ms Bald submitted that this was not appropriate, and it indicated that the HCPC were not taking sufficient steps to ensure that Person C attended the hearing. Further the HCPC did not take any steps to contact Person C after the Witness Order was served on her on 17 July 2015, even though they were aware of her reluctance to attend the hearing.
14. The Panel applied the advice of the Legal Assessor that it should make a careful assessment and weigh up the competing factors. Essentially the task for the Panel is to decide whether it is fair to admit the evidence of Person C as a hearsay statement.
15. The Panel considered each of the factors suggested in the case of Thorneycroft v NMC  EWCA 1565 in turn. The evidence of Person C is the sole evidence in support of allegation 2(d)(i) and 2(d)(ii). The evidence of Person C is challenged by the Registrant in its entirety. There is no suggestion in this case that Person C had a reason to fabricate the allegations. The Panel noted that Person C wrote her statement in the hours following the events and it was therefore contemporaneous. This might suggest that the statement is reliable, but in contact between the HCPC solicitors and Person C she has suggested that she was “uncomfortable” when writing this statement. There is therefore a question about the reliability of Person C’s written contemporaneous statement. Particulars 2(d)(i) and 2(d)(ii) are serious and they add a significant additional element to the overall seriousness of the allegation. The Panel decided that there was no good reason for the non-attendance of Person C. The Panel noted that despite the lengthy attempts to contact Person C from August 2014, she made no reference at all to her ill health and this was first mentioned by Person C, without any evidence in support, after she failed on 27 July 2015 to comply with the Witness Order requiring her to attend the hearing.
16. The Panel was not persuaded that the HCPC had taken reasonable steps to secure the attendance of Person C. Person C was clearly reluctant to be involved at all, and there were extensive efforts to contact her. Nevertheless the Panel was concerned that the response to Person C’s reluctance was to try to obtain a signed witness statement from her and that she was told on several occasions that she did not need to attend the hearing if she signed a statement. The Panel also agreed with Ms Bald’s submission that the HCPC did not do anything to try to secure Person C’s attendance after the Witness Order was served on her. There was no phone call or any contact with her prior to the hearing, despite the history showing her reluctance to attend. There was no canvassing of the possibility of Person C giving evidence by video link or telephone.
17. The Registrant had no prior notice that an application would be made to admit Person C’s statement as hearsay evidence. He expected Person C to attend the hearing in accordance with the Witness Order.
18. The Panel balanced all the factors and decided that the majority of them, particularly the absence of a good reason for the non-attendance of Person C and the Panel’s view that reasonable steps have not been taken, indicated that the evidence should not be admitted. The Panel took into account Mr Orpin-Massey’s submission that the absence of Person C can be reflected in the weight to be given to her evidence, but decided that this was not a sufficient reason in this case to the objections to admissibility put forward by Ms Bald. The Panel’s overall assessment is that it would not be fair to admit the hearsay evidence of Person C when the Registrant will have no opportunity to test that evidence by cross examination.
Half time submission
19. Ms Bald made a half-time submission in relation to particular 2(c) and particulars 2(d)(i) and 2(d)(ii). She submitted that there was no evidence to support particulars 2(d)(i) and 2(d)(ii) because the Panel has decided not to admit the hearsay statement of Person C. She submitted that there was no case to answer on particular 2(c) because, on a straightforward interpretation of the particular, the criticism of the Registrant is that he did not transport Patient B to Hospital. The evidence of Mr Mursell was that the Registrant was driving a First Response Vehicle, which is a single crewed vehicle, and that this vehicle is not appropriate for transporting Patient B to Hospital. The transport to Hospital would be in a Double Crewed Ambulance. Ms Bald pointed out that there was a difference with the HCPC allegation for Patient A, particular 1(d), where the allegation is that the Registrant did not act in Patient A’s best interests, in that he left Patient A at home with a neighbour instead of waiting until the Double Crewed Ambulance arrived. She submitted that the HCPC had the option to word 2(c) more specifically had they chosen to do so at an earlier stage.
20. Mr Orpin-Massey accepted that the Panel may conclude that there is no evidence to support particulars 2(d)(i) and 2(d)(ii). He submitted in respect of particular 2(c) that the word “transport” is wide enough to include arranging for transport by Double Crewed Ambulance. In support of this submission he referred the Panel to documentary evidence where “transport” is given this wide interpretation. In the alternative Mr Orpin-Massey made an application to amend particular 2(c). The proposed wording of the amendment is “did not call for a Double Crewed Ambulance to take Patient B to Hospital”. Mr Orpin-Massey submitted that the Registrant is not prejudiced by this proposed amendment because he has always known the case against him from the case summary and the witness statements.
21. Ms Bald opposed the application to amend. She submitted that the HCPC has sufficient resources to ensure that the case is properly pleaded and that an amendment should not be allowed at this late stage in the process.
22. The Panel accepted the advice of the Legal Assessor that when deciding whether there is a case to answer it should consider first whether there is any evidence to support the particular. The Panel should not take into account any information submitted by the Registrant. The Panel has discretion to amend the allegation if the Registrant is not prejudiced. The Panel should take into account the timing of the application to amend and its implications. The Legal Assessor referred the Panel to the case of PSA v HCPC (Doree)  EWCA 822 and the guidance in that case that “amending the charge retrospectively after the evidence had been heard and considered, in order to secure a guilty finding, would have been a gross breach of fair hearing procedure”.
23. The Panel decided that there was no HCPC evidence to support particulars 2(d)(i) and 2(d)(ii). Therefore there was no case to answer on these two particulars.
24. The Panel considered first the literal interpretation of particular 2(c) suggested by Ms Bald. There is evidence that the Registrant did not transport Patient B to Hospital. However, the evidence of Mr Mursell is that it would not have been appropriate for the Registrant to transport Patient B in his First Response Vehicle. The Panel decided that no reasonable Panel could conclude that what is alleged amounts to misconduct or lack of competence.
25. The Panel carefully considered the wider interpretation of particular 2(c) suggested by Mr Orpin-Massey, but did not accept this interpretation. The Registrant should not have to second guess what is meant by a particular. It is not sufficiently clear to the Registrant from the wording of the particular, that it extends to making arrangements for transport of Patient B.
26. The Panel considered the application to amend particular 2(c), but did not agree to the amendment. The Panel decided that this would be a retrospective amendment and that it was inappropriate and unfair to allow the amendment at this late stage after the evidence of the HCPC witnesses has been heard.
Application for adjournment
27. Before opening the case for the Registrant Ms Bald made an application for a short adjournment of the case. The grounds for her application were that she expected to receive a response from Central Nottinghamshire Clinical Services (CNCS) to an HCPC order dated 17 July 2015 for CNCS to produce documents. The limited information available suggested that CNCS was consulting solicitors and that something would be sent in the post to arrive in the morning on 29 July 2015. The information sought is relevant to the Registrant’s case because it concerns his contact with the Out of Hours doctor in relation to Patient B.
28. Mr Orpin-Massey did not oppose a short adjournment until the morning of 29 July 2015.
29. The Panel decided that it would be fair and appropriate to allow an adjournment until the morning on 29 July 2015.
Decision on facts
30. The Panel considered carefully the documentation in the HCPC exhibits bundle and the documents produced by the Registrant. For the HCPC the Panel heard evidence from IM, Consultant Paramedic, EMAS, and EK. The Panel found that the evidence of IM was credible. The Panel’s assessment was that on occasions he slightly overstated the criticism of the Registrant, but when this evidence was tested he made appropriate concessions. The Panel found that EK was a credible witness and made appropriate admissions about the limits of the investigation she had carried out. The Panel heard evidence from the Registrant and found that his evidence was credible. The Panel found him to be genuine and open and his account was consistent. Occasionally his answers to questions were muddled, but the Panel’s view is that this was because he did not always understand what he had been asked.
31. The Panel noted that the Registrant admits particular 1(a).
32. The Panel carefully reviewed the whole of the PRF and found that the Registrant had failed to record the incident number (1)(a)(i). The Panel’s view was that there was duplicity in particular 1(a)(ii), the recording of the times of the job, and 1(a)(iii), the call times. The Panel found that there was a failure to record the times of the job 1(a)(ii), but not in addition a failure to record the call times 1(a)(iii). The Panel noted that although on the bottom of the PRF page times of “allocation” and time “clear” appeared to be jotted, this was not in the correct part of the form and therefore the PRF was not itself adequately completed. There was a failure to record Patient A’s age (1(a)(iv)), though the date of birth was recorded. There were failures to record Patient A’s ethnicity (1(a)(v)), consent to treatment (1(a)(vi), respiratory rate (1(a)(vii)), and rationale for leaving Patient A at home with a neighbour when she was suspected of suffering from a fractured neck of femur (1(a)(viii)). On particular 1(a)(ix) the Panel found that there was not a failure to record the medications, but there was a failure to record her medical history.
33. The Panel found that the PRF was not adequately completed taking into account the number of the omissions on the PRF as set out above, and the guidance set out in the EMAS Clinical Record Keeping Policy. The Panel therefore found that particular 1(a) is proved, with the exception of particular 1(a)(iii).
34. The Panel noted that the Registrant admits particular 1(b).
35. The Panel considered the relevant part of the PRF and noted that only one set of observations is recorded, whereas two sets are required. The two sets of observations are required for the Paramedic to inform ongoing care and treatment of the patient. They allow the Paramedic to monitor whether the patient is stable, and whether any interventions are working. A failure to record two sets of observations on the PRF is therefore inadequate completion of the PRF. The Panel found that particular 1(b) is proved.
36. Particular 1(c)(i) concerns the alleged failure to carry out a trauma examination to exclude medical causes for Patient A’s fall or collapse. The Panel considered the Joint Royal Colleges Ambulance Liaison Committee (“JRCALC”) policy for Trauma Emergencies. It recommends that Paramedics should carry out a primary survey and follow the “ABCDE” approach. On the PRF there is a section for the Paramedic to complete for the initial assessment which follows this approach, checking airway, breathing, circulation and disability. This section of the PRF was completed by the Registrant. This is consistent with the Registrant’s evidence that he carried out a trauma assessment. The only evidence that the Registrant did not carry out a trauma assessment is that there is no narrative of the assessment in box 7 of the PRF. The Panel were not willing to infer solely from the absence of a narrative description that a trauma assessment was not completed.
37. On particular 1(c)(ii), the alleged failure to carry out a head, neck and back assessment, the Panel accepted the Registrant’s evidence that he did carry out an assessment which was concurrent with the trauma examination. The Panel was satisfied that his recollection of his attendance to Patient A was sufficient on these details, and that he was not simply describing his normal practice. There is no record on the PRF that the Registrant carried out a head, neck and back assessment, but the Panel was not willing to infer that the Registrant did not carry out the assessment because of the absence of a record on the PRF.
38. The Panel took into account the inadequate completion of the PRFs for both Patient A and patient B in reaching this conclusion.
39. On particular 1(d) the Registrant accepts that he left Patient A with a neighbour instead of waiting until the Double Crewed Ambulance arrived. His evidence is that at the time he thought that this was in the best interests of Patient A because she was stable, a neighbour was present, and his expectation was that a Double Crewed Ambulance would arrive within an hour. On reflection, the Registrant accepts in hindsight that he should have stayed with Patient A. Although the Registrant’s expectation was that a green ambulance would arrive within an hour, there is no guarantee that this would happen because response time can vary for a green ambulance and there is no time within which it must arrive. During the time waiting for the green ambulance there would be no management or monitoring of Patient A’s condition and a potential risk that she might deterioriate.
40. The EMAS On-scene Assessment and Management Guide provides clear guidance that patients with a significant fractured limb, eg neck of femur, should be transported to hospital with the aim of a minimum of fifteen minutes on scene. This guidance reinforces the evidence of IM that it was not appropriate to call a green ambulance and to leave Patient A. The Panel’s assessment of the evidence is that the Registrant’s recognition in hindsight that he should have stayed with Patient A is correct because this would be in Patient A’s best interests. The Registrant’s initial view that it was appropriate to leave involved taking an unacceptable risk that the green ambulance would not arrive quickly and this was not in the best interests of Patient A. The Panel therefore found that particular 1(d) is proved.
41. The Registrant did not treat Patient A for her injuries. However, this was not a failure to provide adequate care and treatment because there is no evidence identifying any treatment, other than pain relief, that could have been provided by the Registrant.
42. The Panel accepted the Registrant’s evidence that his recording on the PRF of a score of a pain score of 5 on a scale of 0-10, indicated Patient A’s level of pain when her hip was palpated. Patient A did not indicate that she was in pain when she was sitting still. In these circumstances the Registrant had good clinical reasons not to administer pain relief to Patient A. Patient A may have needed pain relief when she was moved, but the assessment of what level of pain relief might be appropriate would depend on the clinical assessment at that time. Although it was possible that Patient A could have developed pain after the Registrant left her, there is no evidence before the Panel that there was any increase in her pain level. On the evidence available, the Panel found that particular 1(e) is not proved.
43. The Panel noted that the Registrant admits paragraph 2(a).
44. The Panel carefully reviewed the whole of the PRF and found that the Registrant had failed to record the patient’s telephone number (2)(a)(i). There was no record of the next of kin details 2(a)(ii) or the contact details of the next of kin 2(a)(iii). However, this was not a failure to adequately complete the PRF because these details are not clearly asked for on the PRF. There was a failure to record Patient B’s age (2)(a)(iv)), though the date of birth was recorded. There were failures to record Patient B’s gender (2(a)(v), ethnicity (2(a)(vi)), consent to treatment (2(a)(vii), pupil reactivity (2(a)(viii)), time of first symptom (2(a)(ix), dosage of medication (2(a)(x)), and allergies (2(a)(xi)).
45. The Panel did not find that the Registrant failed to record the patient’s state of mind or normal level of communication ((2(a)(xii)) because he had recorded on the PRF that she was “calm”. There was no record of the patient’s understanding and/or ability to make an informed decision (2(a)(xiii)).
46. The second set of observations taken at 02.15 hours is recorded on the top copy of the PRF which was returned to EMAS. However, the observations are not recorded on the carbon copy of the PRF which was left at Patient B’s care home. The explanation for this discrepancy is that the Registrant handed the carbon copy of the PRF to the care home staff before he had recorded his second set of observations. The Registrant did not adequately complete the PRF because all copies of the PRF should be identical.
47. The Panel were satisfied that the record in box 7 “OOH G.P Dec” and “contact GP in morning” was sufficient record of the Registrant’s rationale for not transporting Patient B to hospital (2)(a)(xv)). This was also sufficient to record whether the Out of Hours GP Service was recommended or declined. The Registrant did not complete the clinical impression section of the PRF (2(a)(xvi)). There was no record of the Registrant’s discharge advice (2)(a)(xviii)), the signature of the patient or carer (2)(a)(xix) or the patient’s results on the AVPU scale (2)(a)(xx)).
48. The Panel found that the PRF was not adequately completed taking into account the number of the omissions on the PRF as set out above, and the guidance set out in the East Midlands Ambulance Service Clinical Record Keeping Policy. In summary particular 2(a) is proved, with the exception of particulars 2(a)(ii), 2(a)(iii), 2(a)(xii), 2(a)(xv) and 2(xvii).
49. The Panel noted that at the outset of the hearing the Registrant admitted particular 2(b). The PRF is consistent with the Registrant’s evidence that he diagnosed a Urinary Tract Infection. An EMAS clinical bulletin issued on 17 October 2012 contains a pre hospital assessment screening tool. Applying this flowchart, the observations recorded by the Registrant indicated that sepsis was possible. The Panel found that Patient B’s symptoms suggested possible sepsis.
50. Ms Bald submitted that the Registrant’s diagnosis did not mean that he had failed to provide Patient B with adequate care and treatment. She submitted that, as there were no symptoms indicating septic shock, the screening tool stated that the appropriate treatment was to evaluate the need for transfer to hospital and ensure same day assessment by a medical professional in primary or secondary care. She submitted that the Registrant had followed this even though he had not identified sepsis. The Panel did not accept this submission because making the correct diagnosis is critical. Sepsis is likely to require more urgent assessment than a UTI, so diagnosis is very important in the assessment of treatment. The diagnosis could have a significant impact on the clinical reasoning both of the Registrant and the Out of Hours Doctor. The Panel therefore concluded that the Registrant did not provide Patient B with adequate care and treatment and that particular 2(b)(i) is proved.
51. On particular 2(b)(ii) Mr Orpin-Massey submitted that the Panel should infer that the Registrant did not question the Patient B’s last oral intake from the absence of any record in the PRF. The Panel did not draw this inference. The record of the Registrant’s consultation with the OOH doctor shows records that Patient B had a “poor appetite”. This is not specific about the details of the last time Patient B ate or drank, but it indicates that the Registrant obtained information either from the care staff or from Patient B’s records. The Panel is not satisfied that the HCPC has proved on the balance of probabilities that the Registrant did not question the patient’s last oral intake. Particular 2(b)(ii) is therefore not proved.
52. On the PRF the Registrant made an error when completing his first set of observations. He did not fully complete the boxes when recording the Glasgow Coma Scale (“GCS”) and this is acknowledged by IM as the most likely explanation. This is apparent from the form where the third box is not complete. For his second set of observations the Registrant recorded a GCS of 13. The Panel found that the Registrant did not obtain a GCS of 5. Therefore further investigation was not required and particular 2(b)(iii) is not proved.
53. On particular 2(b)(iv) the Panel decided not to draw the inference that the Registrant did not assess Patient B’s breath sounds because there was no record on the PRF. The Panel noted the records made by the OOH GP “chest clear, no cough or wheeze, no crackles”. This information was provided or inferred from information given by the Registrant. This supports the Registrant’s account that he did assess Patient B’s breath sounds. The Panel found that particular 2(b)(iv) is not proved.
Decision on grounds
54. The Panel accepted the advice of the Legal Assessor that there is no burden of proof and that misconduct and/or lack of competence is a matter for the judgment of the Panel. There is no definition of misconduct, but the Panel applied the guidance in the case of Roylance v GMC that “misconduct is a word of general effect involving an act or omission which falls short of what would be proper in the circumstances. The standard of propriety may often be found by reference to the rules and standards ordinarily required to be followed by a …practitioner in the particular circumstances”. The misconduct must be serious in that the conduct is well below the standards expected. Negligent acts or omissions may amount to misconduct, but the negligence must be to a high degree. Lack of competence is a standard of professional performance which is unacceptably low. A single incident, unless very serious, is unlikely to constitute lack of competence. The standard expected is that applicable to the post the Registrant held, i.e. a Paramedic. The standard is objective and any circumstances individual to the Registrant such as his character or lack of training should not be taken into account.
55. The Registrant has worked for EMAS for forty years, as a Paramedic from 1993. He has worked in a wide variety of roles, including Clinical Team Leader, and was experienced in acting as the first responder. The Panel’s assessment of the Registrant, is that he has the ability to complete PRFs, to act in the best interests of his patient and the knowledge of his obligation to keep up to date in clinical practice and policies, such as that related to sepsis. The Registrant’s evidence was that the PRFs he completed for Patients A and B were unusual, by his standards, and he described them as “disgusting”. The Registrant has sufficient understanding and knowledge such that he is capable of following guidelines and applying clinical reasoning. The facts found are limited to one shift. The Panel does not have a series of events or a pattern which might indicate that there is an area of weakness in the Registrant’s knowledge, skills or ability which underlies the failure to meet the standards required. The Panel found that the facts do not constitute a lack of competence.
56. The Panel considered whether there were any external factors that explained the Registrant’s performance on the night of 28 to 29 November 2013. It was a busy shift, but this is not exceptional and the Panel did not accept the Registrant’s explanation that he was tired, given that Patient A’s consultation was at the start of the shift and Patient B’s from 01.00 and 03.00 hrs.
57. The Panel considered the extent to which the Registrant’s conduct fell below the standards expected and whether this was sufficiently serious. The Panel’s view is that the missing information in the PRF was extensive. Some of the missing information is less clinically significant, such as the missing incident number. Some of the information is provided in another form, so that age could be worked out from the date of birth. However, there are significant omissions in the clinical information, such as the omission of the second set of observations for Patient A, the respiratory rate for Patient A, and the rationale for leaving both patients A and B at home. All the information is relevant, but the omission of the clinical information creates risks for the patients. There is an impact on the continuity of care because the next clinician will rely on the information provided in the PRF. There are risks to patients of incorrect diagnosis or incorrect treatment if information is not recorded in the PRF. The failure to complete the PRF as found by the Panel was also in breach of the EMAS Clinical Record Keeping Policy.
58. The Panel’s overall assessment of the PRFs is that they were poor and that the Registrant’s description of them as “disgusting” clearly indicates that they fell well below the standards expected of a Paramedic.
59. The Registrant’s decision to leave Patient A was not in her best interests. It was in breach of the EMAS on-scene and assessment guide. The Policies were available to the Registrant and it was his responsibility to ensure that he kept up to date, which he did not do. This is not acceptable for a Paramedic. It was also inappropriate for him to rely on an assumption that the green ambulance would arrive quickly. The consequence of the Registrant’s decision was that an elderly patient with a suspected fractured neck of femur was left on the floor for over two hours with no assessment or monitoring. The decision falls well below the standards expected of Paramedics.
60. The Registrant did not take into account the clinical bulletin on sepsis when he made his diagnosis of Patient B. Again as a Paramedic it was his responsibility to ensure that he kept up to date with such important updates. This failure to keep up to date is the underlying reason for his failure to identify the possible sepsis. The failure to identify possible sepsis could cause risk for the patient. It may have led in this case to a delay in transporting Patient B to hospital. In the most extreme case a failure to identify possible sepsis by a Paramedic could be life threatening. The Registrant’s failure to identify sepsis because he had failed to keep himself up to date falls well below the standards expected of Paramedics.
61. The Panel found in respect of all the facts found there was a breach of the HCPC Standards of Conduct, Performance and Ethics standards 1, 5 and 7 and in respect of the failure to adequately complete PRFs, a failure to comply with standard 10. The Panel also found a breach of the Standards of Proficiency for Paramedics standard 2.b.5 in respect of the PRFs, 2.c.1 in respect of particular 1(d) and the whole of 2.a. in respect of particular 2(b)(i).
62. The failures by the Registrant in the shift on 28 and 29 November relate to sloppy and inadequate clinical record keeping and errors in two decisions made which could have been avoided if the Registrant had kept himself up to date. When considered together the failures are more serious than the failures in Spencer v the General Osteopathic Council, which were limited to record-keeping.
63. The Panel found that the facts are sufficiently serious to constitute misconduct.
Decision on Impairment
64. The Panel applied the guidance in the HCPC Practice Note “Finding that Fitness to Practise is Impaired”. The Panel bore in mind the purpose of fitness to practise procedures, which is not to punish the practitioner for past actions, but to protect the public against the actions of professionals who are not fit to practise.
65. The Panel was provided with a witness statement from an HCPC Case Manager, exhibiting a copy of a decision of a Conduct and Competence Committee on 11 and 12 October 2011. That Panel found that, whilst employed by EMAS as a Paramedic on 23 November 2009 when attending on Patient A, the Registrant stated to her “just have a fag and you will be fine” or words to that effect, on 23 November 2009 accepted the mobile telephone number of Patient A, on or around 24 November 2009, had contact with Patient A by mobile telephone, on or around 28 November 2009 had contact with Patient A by mobile telephone and on or around 1 December 2009, attended at Patient A’s home address. That Panel found that these matters constituted misconduct and that, by reason of misconduct, the Registrant’s fitness to practise was impaired. That Panel decided that the appropriate and proportionate sanction was a Caution Order for a period of five years. The Caution Order is due to expire on 9 November 2016.
66. This Panel has disregarded the particulars of the allegation considered by the Conduct and Competence Committee on 11 and 12 October 2011 that were found not proved.
67. The Registrant has been working as a paramedic on a part time casual basis for a private ambulance company, Heart First Aid Ambulance Service. In the last two months he has also worked, again on a part time casual basis, for another private ambulance company, First Aid Cover. The work undertaken has included cover for sports events, music concerts and transfers of patients to hospital following injuries sustained abroad.
68. The Registrant gave evidence that he has undertaken reflective practice and further study which relates to the facts found by the Panel. He has provided certificates from four training courses relating to sepsis. He described how he put this knowledge into practice when a friend became ill; the Registrant said he identified sepsis and the need for his friend to be admitted to hospital as an emergency. The Registrant has also undertaken a course on neck of femur fractures. He has undertaken a reflective practice study on patient record keeping. The Registrant provided evidence of comprehensive CPD.
69. The Panel considered and took into account in its deliberations the positive testimonials of Mr Frisby, a community first responder who worked alongside the Registrant when the Registrant was employed by EMAS, and Ms Page who provided a character testimonial. The Panel also noted the evidence provided by the Registrant of positive reports on his clinical work prior to November 2013 including the EMAS award of Person of the Year for 2006. The Panel noted that there are no testimonials or any evidence from anyone other than the Registrant relating to the quality of the Registrant’s work as a Paramedic after November 2013.
70. The Panel considered the Registrant’s current fitness to practise firstly looking at his current conduct, and then considering the wider public interest considerations.
71. The Registrant’s misconduct put both Patient A and Patient B at risk of harm. Both patients were at risk of harm because of the failure to adequately complete the PRFs, which had the potential to affect continuity of care, and because of the the decisions made by the Registrant relating to their care.
72. In the Panel’s view the misconduct in this case has the potential for remediation. However, it is not as easily remediable as a lack of competence. Gaps in knowledge and skill can be more easily covered by additional study and training, but in this case there is an attitudinal issue which needs to be addressed.
73. Although the Registrant has demonstrated his willingness to address his misconduct, the Panel was not satisfied that the misconduct has been remedied. The key to remedying the misconduct in this case is the development of insight. In his reflection and his remediation the Registrant has focussed on the particular issues in the allegation. For example he has acknowledged his failure to diagnose possible sepsis and he has attempted to remedy his lack of knowledge and understanding of sepsis. However, in the Panel’s view, the Registrant in his evidence at this hearing has shown little understanding of why he did what he did, or why his completion of the PRFs was inadequate. There is a connection between all the Registrant’s failures in the shift on 28 and 29 November 2013. In the Panel’s view, the connection is a sloppiness and lack of rigour in his approach both to completion of PRFs and to keeping up to date with relevant policies and guidance. In the Panel’s judgment, the Registrant did not demonstrate in his evidence that he understands the professional obligation to keep himself up to date with all guidance and policies relevant to his practice as a registered Paramedic. In the Panel’s judgment the Registrant has limited insight.
74. The Panel was concerned that there is no independent evidence on the quality of his work as a Paramedic after November 2013, including the quality of his PRFs. The Panel has seen one PRF completed by the Registrant after November 2013 which is included in his reflective study. There is no evidence to demonstrate or confirm that the Registrant’s PRFs are completed to an adequate standard other than the limited evidence in his study. Despite the evidence that the Registrant has completed CPD, the Panel was concerned that he has not demonstrated the application of the learning to his practice. There is no independent evidence to support the Registrant’s assertion to the Panel that he now ensures that he keeps up to date with new policies and bulletins relevant to his practice. Although the Registrant’s study on PRFs refers expressly to confidentiality, the Panel was concerned that some of his answers in cross-examination, and the provision of a completed PRF dated 26 April 2015 indicated that he is not applying sufficient care with confidential patient information. This did not reassure the Panel that the Registrant has fully remedied the sloppiness and lack of rigour which the Panel identified as the underlying basis of the misconduct.
75. The Registrant has assured the Panel that there would not be a repetition of a failure to diagnose sepsis or a failure to take an elderly patient with a neck of femur fracture to hospital. However, the Panel concluded that there is a risk of repetition of misconduct because of the Registrant’s lack of full insight and incomplete remediation.
76. The Panel’s view is that the Registrant’s misconduct has brought the profession into disrepute. A member of the public would be concerned that the Registrant did not stay with an elderly patient with a neck of femur fracture and that as a result the patient was left on the floor for over two hours without any monitoring. A member of the public would also be concerned that a Paramedic did not identify possible sepsis, where such a diagnosis will be relevant to the urgency of care provided for the patient.
77. The Registrant’s previous Caution is relevant to the Panel’s assessment of the public policy issues. The previous Caution is also for misconduct. Although it relates to non-clinical conduct, the previous Caution is relevant particularly because the finding relates to the Registrant’s attitude. A member of the public would be extremely concerned that the Registrant committed a further act of misconduct when under a Caution for misconduct. The Panel therefore, finds that “critically important public policy issues” are pertinent to this case, in particular the need to protect individual service users, maintain confidence in the profession and to declare and uphold proper standards of conduct and behaviour.
78. On both the personal component, which is the Registrant’s current conduct, and the public component, which is the wider public interest considerations, the Panel decided that the Registrant’s fitness to practise is currently impaired.
Decision on Sanction:
79. The Panel applied the guidance in the HCPC Indicative Sanctions Policy and the advice of the Legal Assessor. The primary function of any sanction is to address public safety. The Panel should also give appropriate weight to the wider public interest which includes the reputation of the profession, public confidence in the regulatory process and the deterrent effect to other Registrants. The Panel applied the principle of proportionality and balanced the Registrant’s interests and the public interest. The sanction should be the least restrictive which is sufficient to provide the necessary degree of public protection. The Panel therefore considered the sanctions in ascending order of severity.
80. In addition to the Registrant’s documents submitted in July 2015 within bundle R1 and character witness statements, the Panel carefully read and took into account the additional documents submitted by the Registrant demonstrating that he has undertaken further CPD.
81. The Panel identified the following aggravating circumstances:
a. Numerous omissions in the PRFs, some of which created a potential risk of harm to patients
b. Serious errors in clinical decision making for two patients which created the risk of harm to both patients, and a particularly grave risk for Patient B
c. An attitudinal issue which underlies all the findings of misconduct
d. The fact that the misconduct took place when the Registrant was subject to an existing HCPC caution.
82. The Panel identified the following mitigating circumstances:
a. The misconduct occurred during one shift, there was no pattern of behaviour, the Registrant had 30 years of practice with no other clinical incident of misconduct reported to the HCPC
b. The Registrant has put significant time and effort into educational study and maintaining his CPD since November 2013
c. The Registrant’s admissions and full engagement with the regulatory process
d. Positive testimonials and letters from patients stating that the Registrant has a caring attitude to patients and dedication to his work.
83. The Panel considered carefully Mr Jordan’s submission that the Registrant is reflective and that he has continued to develop insight. The Panel did not accept that this is a mitigating factor. In the Panel’s judgment, the Registrant has not demonstrated that he is reflective. The Panel’s view was that the documents produced by the Registrant are predominantly descriptive rather than reflective. They contain little analysis and are of poor quality. For example the Registrant provides a description of a job and his summary is that the job “went well”. This is not an analysis of the clinical decision making process, how the job demonstrates that learning was put into practice, or an analysis of what could be improved. The Registrant’s study on record keeping includes large sections of text taken from the internet, and there is nothing in it which shows reflection.
84. In the Panel’s judgment there are public protection issues in this case because the Panel has decided that there is a risk of repetition. Taking no action would not provide sufficient protection for the public and is therefore inappropriate. Mediation is not appropriate in this case.
85. The Panel next considered a Caution Order. The Panel has concluded that the Registrant has limited insight, has not provided evidence that he has remediated his misconduct, and there is a risk of repetition. If the Panel were to make a Caution Order the Registrant would be free to practise without any monitoring or restriction. In the Panel’s judgment a Caution Order would not be sufficient to protect the public.
86. The Panel next considered a Conditions of Practice Order. The Panel’s judgment was that, in principle, the Registrant could work safely under conditions. However, those conditions would need to be restrictive because of the potential for very serious harm to a patient if similar misconduct was repeated. In the Panel’s judgment a level of supervision which was limited to monitoring the Registrant’s work after the work has taken place would not be sufficient to protect the public. This is because such monitoring would not prevent the risk of an error in clinical decision making in an emergency situation. The Panel has therefore drafted conditions which require “direct supervision” which means that the Registrant is required to work with another registered healthcare professional when attending to patients. The direct supervision may be carried out by more than one supervisor at different times so that this condition is workable.
87. The Panel is aware that restrictive conditions requiring a high level of supervision are unlikely to be workable for the Registrant in the work that he is currently undertaking. The Panel also bore in mind that conditions should not be so restrictive that they operate as a suspension. Although the conditions the Panel are very restrictive, the Panel’s view was that it would still be possible for the Registrant to work as a Paramedic with the assistance of a supportive employer or contractor. The Panel recognises that in practice it will be difficult for the Registrant to obtain a suitable position as a Paramedic under the conditions, particularly as he is now working in a contracted capacity. The Registrant might choose to work as an ambulance technician for a period in order to build a portfolio of his work and up to date references to submit to a reviewing Panel.
88. The Panel considered the more severe sanction of a Suspension Order. The Panel considered this option with care because the Panel has found that there is a risk of repetition. The Panel decided that the Registrant can work safely under conditions and that a Suspension Order would be disproportionate. The Panel took into account the Registrant’s interests. His interests include that he has the opportunity to demonstrate to a reviewing Panel that he has developed insight and that the risk of repetition is low. It will be easier for him to provide the necessary evidence if he can continue to work, either in a paid or voluntary capacity, and provide to a Panel independent evidence of the quality of his work.
89. The Panel decided that the appropriate period for the Conditions of Practice Order is a period of nine months because it gives a reasonable time for the appointment of workplace supervisors and the provision of relevant reports.
90. A future reviewing Panel may be assisted by the following:
a. Up to date reports from the workplace supervisor or supervisors detailing progress in relation to record keeping and clinical decision making
b. Evidence of reflection on clinical decision making using a recognised reflective model.
91. If the Registrant has not worked as a Paramedic a reviewing Panel may be assisted by:
a. Evidence of progress in relation to record keeping and clinical decision making
b. Evidence of reflection on clinical decision making using a recognised reflective model.
The Registrar is directed to annotate the Register to show that for a period of nine months the registration of Jeffrey Hartopp is subject to the following conditions of practice.
1. You must place yourself and remain under the direct supervision of a workplace supervisor or supervisors, registered by the HCPC or other appropriate statutory regulator. Direct supervision means you must work alongside a workplace supervisor whenever you are contact with patients.
2. You must attend upon that supervisor as required and follow their advice and recommendations.
3. You must supply details to the HCPC of your workplace supervisor or supervisors within 7 days of the appointment of the workplace supervisor or supervisors.
4. You must work with your workplace supervisor or supervisors to formulate a personal development plan designed to address the deficiencies in the following areas of your practice:
A. Clinical decision making;
B. Risk management and “red flags”;
C. Record keeping;
5. Within one month of the appointment of the workplace supervisor or supervisors you must forward a copy of your personal development plan to the HCPC.
6. You must meet with your workplace supervisor on a monthly basis to consider your progress towards achieving the aims set out in your personal development plan.
7. You must forward to the HCPC every three months a report from your workplace supervisor about your progress towards achieving the aims set out in your personal development plan.
8. You must promptly inform the HCPC if you cease to be employed/contracted or take up any other or further employment/contracts.
9. You must promptly inform the HCPC of any disciplinary proceedings taken against you by your employer/anyone contracting with you to undertake professional work.
10. You must inform the following parties that your registration is subject to these conditions:
A. Any organisation or person employing or contracting with you to undertake professional work;
B. Any agency you are registered with or apply to be registered with (at the time of your application);
C. Any prospective employer (at the time of your application).
11. You will be responsible for meeting any and all costs associated with complying with these conditions.
12. Any condition requiring you to provide information to the HCPC is to be met by you sending the information to the offices of the HCPC marked “for the attention of the Director of Fitness to Practise”.
History of Hearings for Jeffrey D Hartopp
|Date||Panel||Hearing type||Outcomes / Status|
|14/06/2017||Conduct and Competence Committee||Review Hearing||No further action|
|14/07/2016||Conduct and Competence Committee||Review Hearing||Conditions of Practice|
|14/10/2015||Conduct and Competence Committee||Final Hearing||Conditions of Practice|