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During the course of your employment as a Paramedic at East Midlands Ambulance Service NHS Trust:
1. On 02 August 2014 you attended call number 6617501, and you:
a. Did not administer the recommended dose of adrenaline to Patient A, namely 0.15ml or 150 mcg;
b. did not administer the adrenaline dose, referred to in 1(a) above, over the recommended intervals of time.
2. Following the matter referred to in 1 above, you:
a. Did not report the error correctly via an IR1;
b. Did not report the error to a manager;
c. Asked Colleague A to alter and/or incorrectly complete the Patient Record Form;
d. Altered the carbon copy of the Patient Report Form namely:
i. Amending the original dosage administered from 500 mcg to 0.15 ml;
ii. Adding further dosages administered at 10:25hrs, 10:30 hrs and 10:35 hrs.
3. Your actions described in paragraph 2.c. and/or 2.d. were dishonest.
4. The matters described in paragraphs 1 - 3 constitute misconduct and/or lack of competence.
5. By reason of your misconduct and/or lack of competence, your fitness to practise is impaired.
Amendment to allegations:
1. At the outset of these proceedings the HCPC applied to amend a number of the Particulars. Those amendments were set out in a letter sent to the Registrant dated 21 April 2015. At the outset of the hearing Ms Lister also applied to make a further very minor amendment to particular 2d(i) which had not been notified to the Registrant in advance of today.
2. Ms. Lister submitted that the amendments would not prejudice the Registrant and that they serve to add clarity to the particulars of allegation. Mr Edwards did not object to the proposed amendments.
3. The Panel considered the application to amend each Particular separately and it had regard to the advice of the Legal Assessor. The Panel went on to consider whether there would be any prejudice to the Registrant if the amendments were permitted. The Panel considered that the proposed amendments were not significantly different in the nature and substance of the particulars that had been previously sent to the Registrant and did not prejudice him. In those circumstances the Panel determined to amend the allegations as set out in the letter dated 21 April 2015.
4. In respect of the proposed amendment to particular 2(d)(i) the Panel determined that the proposed amendment is not material and therefore there would be no unfairness to the Registrant to make that amendment.
5. The Registrant, Mr Edwards, began working at East Midlands Ambulance Service NHS Trust in October 2005 and commenced work as a Band 5 Paramedic on 3 February 2012.
6. On 7 August 2014, JC, Locality Manager at the Trust, was asked to investigate an allegation against the Registrant relating to an emergency call of 2 August 2014.
7. On 2 August 2014, the Registrant had been working as a single responder on a fast response vehicle. He was allocated an emergency call number 6617501 at 09:50am, to attend a patient who was vomiting. The Registrant arrived on scene at 10:08am and was met by the patient’s Father and Mother and the patient (“Patient A”); an 18-month old girl who was presenting with swollen lips and puffy eyes. It was thought that this was a severe allergic reaction (anaphylaxis), which had occurred after the patient had eaten a banana.
8. The Registrant called for back-up and a double-crewed ambulance, manned by Colleague A, Paramedic, and CH, Emergency Care Assistant were dispatched. They arrived on scene at 10:29am. The Registrant informed Colleague A on her arrival that he had administered a dose of Adrenaline to the Patient. Colleague A noticed that the dose was an adult dose, not the appropriate child dose. The Patient was transferred to Hospital. A patient Report Form (PRF) was completed by Colleague A detailing the overdose. Shortly thereafter CH, who was the Emergency Care Assistant on duty with Colleague A, received a text from the Registrant requesting him to ask Colleague A to alter the PRF to reflect the dose and the manner in which the adrenaline should have been given rather than how it was given. Colleague A declined to do this.
9. An internal investigation was undertaken by the Trust and the PRF form was examined. It was noted that the copy of the form left at the hospital by Colleague A did not match the carbon copy left at Oakham Ambulance Station. That copy at Oakham Ambulance station had been altered. The Registrant denied any wrongdoing at his investigatory interview. A disciplinary process was commenced and at his disciplinary hearing he admitted that he had administered the incorrect dose and that he had altered the PRF form. He was given a final written warning to remain on his record for a period of 12 months and demoted from his role as Paramedic to Emergency Care Assistant.
Decision on Facts:
10. The Panel has taken into account all the documentation before it. In coming to its decision on facts the Panel had regard to all the evidence, both oral and documentary. It was reminded that it is for the HCPC to prove its case and that there was no burden on the Registrant to prove anything. The standard of proof applied when considering whether the allegations are made out is that of the balance of probabilities. i.e. whether it is more likely than not to have occurred.
11. The Panel took into account the submissions made on behalf of the HCPC and those of the Registrant and it had regard to the advice of the Legal Assessor.
12. At the outset of the proceedings the Registrant admitted all of the factual allegations. The Panel heard oral evidence from three witnesses (Colleague A, CH and JC) on behalf of the HCPC. The Panel found their evidence to be credible, balanced and consistent. The Registrant also gave oral evidence. He was open, honest and frank. His evidence was consistent with the evidence of the HCPC witnesses and it was also consistent with the account he gave during his internal disciplinary hearing.
‘On 02 August 2014 you attended call number 6617501, and you:
a. Did not administer the recommended dose of adrenaline to Patient A, namely 0.15ml or 150 mcg;
b. did not administer the adrenaline dose, referred to in 1(a) above, over the recommended intervals of time.’
13. The Registrant attended an emergency call out. Whilst waiting for back-up to arrive, he commenced treatment of Patient A who appeared to have suffered an allergic reaction from eating a banana. He administered an injection of adrenaline to treat the anaphylaxis.
14. JC told the Panel that the JRCALC Guidelines stipulate that in respect of an 18-month old patient suffering from anaphylaxis, 0.15 millilitres fluid volume (equivalent to 150 micrograms) of adrenaline should be given at intervals of 5 minutes, and this can be repeated as many times as needed. This would involve drawing up syringes of 1 millilitre of fluid and administering 0.15ml at a time.
15. Colleague A explained to the Panel that when she arrived on the scene, the Registrant handed her an “SBAR” pad, which prompts a Paramedic to write down any observations and drugs administered at the scene. Colleague A noted that the Registrant had recorded that he had administered a dose of 500 micrograms of adrenaline (equivalent to 0.5 millilitres fluid volume) to the patient at 10:20am.
16. Colleague A stated that the Registrant told her that he had administered 500mcg of 1:1000 adrenaline. She was concerned that an adult dose had been given to the 18 month old Patient and she consulted the JRCALC guidelines to confirm this. She told the Panel that she believed that the Registrant had already consulted the JRCALC booklet himself.
17. She explained that he had told her that he had read the Guidelines, but “read the dosage for Patient A as 0.5mls”. The Registrant asked her if he had overdosed the patient and Colleague A said that he had.
18. Patient A was taken to the ambulance and a pre-alert was made to Peterborough Hospital giving them notice of the anaphylaxis and overdose. During the trip to hospital there was no medical need for any further doses of adrenaline to be given. The crew arrived at 11:06am and were reassured there by staff that it was a positive sign that the patient’s symptoms had improved. Her heart rate was constantly monitored on route and remained within safe limits.
19. The Mother of Patient A was interviewed after the event and she confirmed that one injection was given, over the course of about a minute, which consisted of one or two pushes on the syringe.
20. When the Registrant was interviewed by JC, Locality Manager, about the incident he asserted that he had administered the adrenaline in accordance with the Guidelines. He only admitted that he had administered an incorrect adult dose when he attended the disciplinary hearing.
21. Particulars 1a and b were admitted by the Registrant at the outset of the hearing. He also told the Panel that he was stressed and felt under great pressure when he arrived at the scene alone. He said that he had read the JRCALC guidelines but for whatever reason he must have read the incorrect dose.
22. In all the circumstances the Panel found particulars 1a and 1b proved.
Particulars 2a and 2b:
‘Following the matter referred to in 1 above, you:
a. Did not report the error correctly via an IR1;
b. Did not report the error to a manager;’
23. There was no evidence to suggest that the error was reported in accordance with policy via the IR1 Form.
24. JC told the Panel that the Registrant should have completed an IR1 form further to the incident. An IR1 details any adverse incident during a shift and its completion allows the details to be assessed by a manager, and a decision made as to whether an investigation is necessary. JC also stated that Registrant should have telephoned a manager on duty regarding the error.
25. The Reporting and Investigation of Serious Incidents Procedure (p.83) states at section 7.2 (p.93) as follows:
“Staff involved in a potential SI must either report the incident using the telephone incident reporting line which is available 24 hours a day…or complete an IR1 form as soon as possible but at least before the end of their shift and pass this to an appropriate manager”.
26. At the outset of the hearing the Registrant accepted that he did not report the incident on the IR1 Form. The Registrant also accepted that the error should have been reported to his Manager that he had not done so.
27. Particulars 2a and 2b are found proved.
‘Asked Colleague A to alter and/or incorrectly complete the Patient Report Form;’
28. Colleague A explained that she completed the Patient Report Form and detailed the exact dose of adrenaline administered to Patient A as 500mcg in the “Drugs Administered” section. The top copy of the PRF was left by Colleague A at Peterborough Hospital. Both CH and Colleague A confirmed that on leaving the hospital together, CH received a text message from the Registrant, asking CH to ask Colleague A to amend the PRF to show a different dose of adrenaline to that which he had administered.
29. The text reads as follows:
“Hi Chris I’ve messaged u on Facebook can u get ur crew mate to put my adrenaline over 5 min intervals on paperwork as I wasn’t clear about it on scene cheers maty…It’s rich by the way”
30. Colleague A did not amend the PRF in the way requested. The Registrant admitted this allegation at the outset of the hearing and in evidence he accepted that it was entirely wrong of him to ask his colleague to alter the form.
31. This particular is found proved.
‘Altered the carbon copy of the Patient Report Form namely:
i. Amending the original dosage administered from 500 mcg to 0.15 mls;
ii. Adding further dosages administered at 10:25hrs, 10:30 hrs and 10:35 hrs.‘
32. Colleague A reported her concerns to her manager and made a formal statement. During her evidence she was shown the contents of the carbon copy of the PRF which was left at Oakham Ambulance Station by the Registrant. Colleague A identified for the Panel the changes that had been made to that Form. The Registrant accepted that he had made those alterations to the carbon copy of the PRF.
33. Particulars 2di and 2dii are found proved.
‘Your actions described in paragraphs 2.c and/or 2.d were dishonest’
34. At the outset of the hearing the Registrant admitted this allegation. In evidence he accepted that after the event that he realised he had made a mistake in terms of the amount of adrenaline administered, and by not administering it in 5-minute intervals. He panicked and was concerned that he might lose his job as a Paramedic. He accepted that he was acting dishonestly when he asked Colleague A to record that adrenaline had been given in 5-minute intervals; which was not the true position.
35. Further, by altering the PRF by adding further dosages administered at 10:25hrs, 10:30hrs and 10:35hrs, he was attempting to conceal this by altering the PRF to suggest that he gave 4 separate doses when this was not true.
36. The Registrant’s actions in asking a colleague to alter the PRF and in altering a carbon copy of that form would be regarded as dishonest by a reasonable and honest person and the same conclusion would apply by the standards of reasonable and honest Paramedics. Applying those standards, the Panel is satisfied that the Registrant realised that his actions were dishonest, as he has admitted at this hearing.
37. Particular 3 is therefore found proved.
Decision on Grounds:
38. On the basis of the facts found proved the Panel went on to consider whether those facts amounted to misconduct and/or lack of competence. It took into account the submissions made by Ms Lister on behalf of the HCPC, the Registrant’s submissions and it had regard to the advice of the Legal Assessor.
39. The Panel first considered whether the facts found proved amounted to misconduct as distinct from a lack of competence. In particular the Panel had regard to the distinction between misconduct and lack of competence as identified in the case of Calhaem v GMC  EWHC 2606 Admin.
40. The Panel considered that the Registrant had the requisite knowledge, training and experience and he should have had the skill to carry out the tasks that were expected of him. The Panel considered that the matter before them could not be characterized as a case evidencing a lack of competence. There is neither sufficient evidence, nor a fair sample of the Registrant’s work to substantiate a ground of ‘lack of competence’. In any event there is detailed evidence in the bundle which supports the case that the Registrant was a competent and capable Paramedic.
41. The Registrant’s actions in administering an incorrect dose of adrenaline and failing to administer it at the recommended intervals of time fell short of what was proper in the circumstances. Moreover, his failure to report his error and in asking Colleague A to alter the PRF, and in altering the carbon copy himself also fell short. The Panel finds that the following HCPC Standards of conduct, performance and ethics have been breached:
• 1 – You must act in the best interests of service users
• 3 – You must keep high standards of personal conduct
• 10 – You must keep accurate records
• 13 – You must behave with honesty and make sure that your behaviour does not damage the public’s confidence in you or your profession.
42. The failings identified in this case amount to a serious departure from the standards expected and in particular the Registrant’s dishonest conduct would be regarded as deplorable by fellow practitioners.
43. The Panel therefore considered that the Registrant’s failings were serious and amount to misconduct.
Decision on Impairment:
44. The Panel next considered whether the Registrant’s misconduct impairs his fitness to practise. In approaching this task the Panel applied its own professional judgment. The Panel had regard to the practice note issued by the HCPC. The Panel took account of the case of the CHRE v Grant  which reminds panels of the need to consider the public interest when considering whether a registrant’s fitness to practise is currently impaired. Further the Panel had regard to the factors identified by Dame Janet Smith in her Fifth Shipman Report, at paragraph 25.67 which were also cited in Cheatle v GMC  EWHC 645(Admin).
45. The Panel considered whether the Registrant’s fitness to practise is currently impaired. The Panel were particularly concerned with the Registrant’s dishonest behaviour which has serious implications for maintaining the reputation of his profession. The fact that, for a period of two months after the incident on 2 August 2014, the Registrant maintained a position that he subsequently declared to have been false exacerbates the seriousness of his actions. However, the Panel finds that the Registrant has developed full insight into his behaviour. Throughout the hearing he has convincingly displayed an in-depth understanding of the seriousness, both of his initial actions and of his subsequent dishonesty.
46. His actions in incorrectly administering the wrong dose of adrenaline to Patient A raise issues of public safety. The Registrant had available to him, at the time, the JRCALC, showing the correct dose and the procedure for its administration. However, he failed properly to interpret and apply the Guidelines. The Registrant consulted the JRCALC, but for reasons for which he could not explain, he misread the dose. The Public has a right to expect a high standard of practice from Paramedics even in the most stressful of situations. In this case there is no evidence to suggest that harm was caused to Patient A, but the potential for serious harm existed.
47. The Panel first considered the risk of the Registrant repeating his error in the administration of medication. It is evident that the process of being brought before his regulator and his own admissions and associated reflections has had a significant impact on the Registrant. He has reflected extensively on his error, undertaken further study and sought advice from colleagues. Accordingly, the Panel considers that the risk of repetition is low.
48. Turning to the Registrant’s dishonest behaviour; he has provided convincing evidence that he has, since the incident, adopted a commendably open and honest approach to dealing with any issues arising in his practice. He cited an example of self-reporting a recent minor incident, using the proper procedure and in circumstances in which a less diligent practitioner might have taken no action.
49. In the Panel’s opinion, he shows a high level of insight and the risk of repetition is again low. This conclusion is reinforced by the Registrant’s clearly expressed understanding of the consequences of his actions not only for Patient A, but also for all who were touched by the incident. He accepted completely that to act dishonestly has brought his profession into disrepute and fails to uphold proper standards of conduct and behaviour, convincingly expressing shame and remorse.
50. The Registrant’s subsequent action in choosing of his own volition to reveal candidly his drug administration error and dishonest behaviour as a case study to a course of trainee paramedics is to his credit and underlines both his insight and his understanding of the unacceptability of his actions.
51. The Panel took into account the public interest which includes protection of patients, maintenance of public confidence in the profession and the declaring and upholding of proper standards of conduct and behaviour.
52. The Panel concluded that the risk to the public through a repetition of the drugs administration errors is low. However, the Registrant’s fitness to practise is currently impaired by reason of the need to uphold proper standards of conduct and behaviour and to maintain public confidence in the reputation of the profession and the regulatory process.
Decision on Sanction:
53. In considering what, if any, sanction to impose the Panel had regard to the HCPC Indicative Sanctions Policy and the advice of the Legal Assessor. It also took into account Ms Lister’s submissions and those of the Registrant. The Panel notes that these proceedings are not intended to punish the practitioner for past misdoings but to protect the public against the acts and omissions of those who are not currently fit to practise.
54. The Panel considered the mitigating and aggravating factors relevant to this case.
55. It identified the following mitigating factors:
• The exceptionally high degree of insight achieved by the Registrant
• The genuine remorse and contrition shown by the Registrant throughout the course of this hearing has also been exceptional.
• The Registrant’s effective attempts at remediation during the year since the incident, including his extensive and relevant Continuing Professional Development (CPD) and his work as an Emergency Care Assistant in partnership with a Registered Paramedic. He has been proactive in using this work as an opportunity to improve and reflect upon his practice, as confirmed by the Electronic Patient Report Forms (EPRFs) that he submitted in evidence.
• His admissions and his full and frank engagement with the regulatory process
• His openness and unconditional acceptance of responsibility for his actions
• The positive testimonials submitted by persons of standing
• His previously unblemished record, which helped to persuade the Panel that his actions were isolated and out of character
• His voluntary actions in participating in a paramedic training course allowing others to learn from his mistakes.
56. The Panel considered that the principal aggravating factors are the seriousness of the allegations found proved and that they involve dishonesty.
57. The Panel next considered what, if any, sanction was appropriate in this case. It considered that it would be neither appropriate nor proportionate to conclude the matter with no further action. This would not mark the seriousness of the allegations and would not be sufficient to address the wider public interest in maintaining public confidence in the profession and the regulatory process.
58. In the circumstances of this case, Mediation is not appropriate.
59. The Indicative Sanctions Policy suggests that a Caution Order is an appropriate sanction in cases where there is a low risk of recurrence and the Registrant has shown insight and taken remedial action, even where dishonesty is involved. As these factors are present in this case to an exceptional degree the Panel considers that a Caution Order would be both proportionate and appropriate as well as being sufficient to safeguard the wider public interest, by marking the unacceptability of the Registrant’s conduct. It is also in the wider public interest not to deny patients the services of a trained and otherwise competent paramedic.
60. Nonetheless, the Panel went on to consider the sanction of a Conditions of Practice Order. It concluded that it would not be possible to formulate workable conditions in the circumstances of this case and that a Conditions of Practice Order would in any event be disproportionate. The Panel also considered making a Suspension Order. However, having already identified that a Caution Order was sufficient to protect the wider public interest, it concluded that a Suspension Order would also be a disproportionate sanction. For the same reasons the Panel dismissed the option of a Striking Off Order.
61. The Panel then considered the appropriate period for a Caution Order. Given the seriousness of the allegations and the need to deter other members of the profession from behaving in a similar manner, the Panel has determined that only a period of the maximum of five years will be sufficient in the circumstances.
62. Accordingly, a Caution Order is imposed for a period of five years.
That the Registrar is directed to annotate the register entry of Mr Richard Edwards with a Caution which is to remain on the register for a period of 5 years from the date this order comes into effect.
The order imposed today will apply from 07 October 2015 (the operative date).
History of Hearings for Richard Edwards
|Date||Panel||Hearing type||Outcomes / Status|
|07/09/2015||Conduct and Competence Committee||Final Hearing||Caution|