Stuart I Hamilton
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1. Between 03 May 2011 and 07 September 2012 you:
i. Undertook eleven 12 Lead Electrocardiograms (ECG) on young female patients which were not necessary and/or clinically justified, namely:
Case 3 - 18 year old female patient
Case 4 - 23 year old female patient
Case 5 - 24 year old female patient
Case 7 - 16 year old female patient
Case 8 - 12 year old female patient
Case 9 - 21 year old female patient
Case 10 - 12 year old female patient
Case 12 - 14 year old female patient
Case 16 - 14 year old female patient
Case 17 - 16 year old female patient
Case 18 - 21 year old female patient
ii. Undertook a 12 lead ECG on a 24 year old female patient (case 5) in circumstances that were dangerous to her health, namely it would have led to delay in her being transported to a Hospital.
2. On unknown dates you performed ECG treatments on female patients and you:
a) asked them to remove their clothing from the waist upwards and/or removed their clothing from the waist upwards:
i. without the clinical need to do so; and/or
ii. without preserving their privacy and dignity;
iii. did not wear gloves during the procedure.
3. Whilst crewing with Colleague A you performed an ECG treatment on unidentified female patient A and placed an electrode on the nipple of this patient when this was not clinically justified.
4. Whilst crewing with colleague B you treated unidentified female Patient B and:-
i. You removed unidentified female Patient B's underwear without clinical justification
ii. You commented to colleague B that a '14 year old girl with a shaved pussy' or words to this effect.
5. You sent colleague C two picture messages to her mobile phone of your erect penis.
6. On three separate occasions you pushed a pair of gloves into female colleague D and E's crotch while they were driving an
7. Whilst crewing with colleague F you treated unidentified Patient C who was suffering from a PV bleed. In treating unidentified patient C you wiped the blood from between her legs.
8. Whilst crewing with Colleague G you treated unidentified female patient D, who was suffering with a PV bleed and you:
i. Removed the patient's clothing from the waist down when that was not necessary:
ii. Wiped the blood from between the patient's legs;
iii. Commented to Colleague G words to the effect of "she was alright wasn't she, she had a nice pussy".
9. After treating unidentified female Patient E you commented to Colleague H "she was more hairy than me".
10. After treating unidentified female Patient F you commented to Colleague E "did you see the hairs on her nipples".
11. Whilst crewing with Colleague I you treated unidentified female patient G, who expressed a need to go to the toilet. You removed unidentified female Patient G's clothing from the waist down when that was not necessary.
12. The matters alleged in particulars 1(i), (ii) and/or 2 and/or 3 and/or 4(i) and/or 5 and/or 6 and/or 7 and/or 8(i) and/or 8(ii) and/or 8(iii) and/or 9 and/or 10 and/or 11 were sexually motivated.
13. The matters set out in paragraphs 1 to 11 constitute misconduct.
14. By reason of your misconduct, your fitness to practise is impaired.
Service and Proceeding in Absence:
1) The Panel found that there had been good service of these proceedings, in accordance with rule 3 of the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 by notice dated 15 July 2015.
2) The Panel next considered whether to proceed with the hearing in the absence of the Registrant, in accordance with Rule 11 of the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003. The Panel was advised by the Legal Assessor to consider the guidance in the HCPC’s Practice Note entitled ‘Proceeding in the Absence of the Registrant’ and accepted that advice. An email dated 21 June 2015 from the Registrant states that he will be unable to attend the Final Hearing. The Panel decided to proceed in the absence of the Registrant, on the grounds that he has waived his right to attend the hearing and a fair hearing can take place in his absence for the following reasons:
• The Notice of Hearing had been sent to the Registrant’s registered address.
• In accordance with Rule 11 above all reasonable steps have been taken to secure his attendance at the hearing.
• The Panel is satisfied that the Registrant is aware of the proceedings and has voluntarily absented himself. His email of 21 June 2015 makes it clear that he had no intention of attending and gave his reasons.
• The Panel is satisfied that adjourning the hearing would serve no purpose as it is no more likely that he would attend any other hearing.
• It is in the public interest to hear cases expeditiously because of the passage of time and the potential effect of this on the memory of witnesses.
• There are 9 witnesses scheduled to give oral evidence, 2 of whom are in attendance. It would not be in the public interest to cause further disruption to the ambulance service to re-schedule the hearing and have the witnesses make fresh arrangements to attend.
• The Registrant has submitted his representations in relation to the particulars alleged and the Panel considers that this will assist in ensuring fairness and justice.
• The Registrant was sent a copy of the final bundle of documents on 3 August 2015.
Amendments to the Allegation:
4) The HCPC applied for leave to permit the particulars of the allegation to be amended. The Panel considers that there is no prejudice to the Registrant from these applications and he has not objected to the substantive applications notified to him by email dated 15 September 2015. The Panel granted the amendment applications in accordance with the above amended particulars, on the following grounds:
• The Registrant was notified on 15 September 2015 that an application to amend the allegation was going to be made.
• There was no response from the Registrant.
• An application was made by the HCPC to amend particulars: 1, 4 and 13.
• Particular 1i required amendment to particularise individual cases, accordingly the word “eleven” was removed.
• Particular 4 required amendment to improve its clarity.
• Particular 13 had a typographical error and was amended to make it clear that the ground of misconduct was being alleged in relation to all 12 factual particulars.
• The Panel was satisfied that the proposed amendments did not alter the nature or sense of the allegation.
• For all the above reasons there was no prejudice to the Registrant.
5) The Panel has considered sequentially whether:
• The facts are proved;
• If the proved facts amount to the statutory ground of misconduct and if so;
• Is the Registrant’s fitness to practise currently impaired?
6) The Panel accepted the advice of the Legal Assessor that the burden of proof is upon the HCPC on the civil ‘balance of probabilities’ in relation to findings of fact. Whether the proved facts amount to the statutory ground of misconduct and the issue of current impairment are not matters which need to be ‘proved’ but are matters of judgement for the Panel.
7) The Panel also received and accepted advice from the Legal Assessor that hearsay evidence is admissible in these proceedings under Rule 10 (1)(b) and (c) of the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003. However the Panel has approached the hearsay evidence with caution, because it has not been tested by cross-examination. The Panel has carefully considered what weight to afford to the hearsay evidence.
8) The Registrant is a qualified Paramedic, registered with the HCPC. He commenced employment with the Isle of Wight Ambulance Service (IOWAS) in September 2000, qualifying as an Ambulance Care Assistant in January 2001, an Ambulance Technician in 2002 and as a Paramedic in August 2006. At the time of the investigation giving rise to these proceedings he was a Band 6 Paramedic.
9) In August 2012, AT, an IOWAS Clinical Support Officer (CSO) carried out a routine audit of the use of 12 Lead electrocardiograms (ECGs).
Out of five cases reviewed only one of the patients had received an appropriate 12 Lead ECG from the Registrant. This was a cause for concern. A review of 12 Lead ECG practice across the whole of the service was then undertaken and trends began to emerge in the Registrant’s practice of using 12 Lead ECGs. In respect of female patients aged 10-30 he was undertaking significantly more 12 Lead ECGs than his colleagues. When the data collected was analysed for the period between 1 November 2010 and 18 September 2012 he had undertaken a number of ECGs which were not clinically justified.
10) His conduct was referred to the LADO (Local Agency Designated Officer) on 21 November 2012. This issue was considered at a LADO meeting on 26 November 2012 and the Police decided to keep a ‘watching brief’. The LADO advised IOWAS to undertake an internal investigation to cover both disciplinary and safeguarding issues.
The investigation was completed on 4 November 2013. The Registrant self-referred to the HCPC on 12 October 2012 and resigned from the IOWAS on 15 November 2013. A disciplinary hearing took place on 18 and 19 November 2013 in the Registrant’s absence. It was decided that had the Registrant not resigned with immediate effect, he would have been summarily dismissed. Following the disciplinary hearing the IOWAS provided information regarding the outcome of that hearing to the HCPC on 3 February 2014. The matter was referred to an HCPC Investigating Committee on 4 August 2014 and again, following further investigation on 8 May 2015.
Decision on Facts
11) The Panel heard evidence from the HCPC witnesses whose current roles are as follows: Dr RA, Emergency Medicine Consultant and Clinical Lead for the IOWAS, Mr NP, Assistant Head of Ambulance (clinical) IOWAS, Witness 5 (Paramedic), Witness 4 (Emergency Vehicle Operative), Witness 12 (Paramedic), Witness 6 (student Paramedic), Witness 7 (student Paramedic), Witness 8 (Emergency Vehicle Operative), Witness 10 (Emergency Vehicle Operative), witness 9 (Clinical Support Officer). The Panel considered the witness statements of Witness 3 (Head of Clinical Services) and Witness 11 (Emergency Vehicle Operative).
12) The Panel found all of the witnesses who gave oral evidence were consistent, credible and highly reliable. Dr A and NP provided corroborative evidence in respect of the clinical necessity for 12 Lead ECGs and other practices and procedures relevant to this case. Both of these witnesses demonstrated a clear understanding of their remit and particular cases. Their approach to the investigation had been focused and entirely credible. Both witnesses gave the Panel confidence that their evidence was objective and unbiased. Their responses and conclusions were consistent with one another. The Panel considered that the two witnesses were at pains to ensure fairness to the Registrant. The Panel found Witnesses 4 and 6 gave notably compelling and very strong evidence. Witnesses 7 and 8 gave balanced evidence and were clear with the Panel when they were unable to answer a question. Witness 5 was slightly inconsistent in his evidence on some of the wider issues. However he remained convincing on the substantive matters to which he gave evidence.
13) The representations of the Registrant contained in an email dated 21 June 2015 were read out by the Legal Assessor at the start of the hearing. The Panel also considered an extensive bundle of exhibits including, for example, the patient care records and the review undertaken by Dr A and NP.
Background to Allegation 1:
14) Dr A reviewed the clinical appropriateness of 15 random cases where the Registrant had performed 12 Lead ECGs. Out of these 15 cases, 12 were on female patients. Dr A found that 8 out of the 12 female ECGs were not clinically appropriate. These 8 cases constitute the 8 cases referred to in allegation 1ia to 1ih, namely cases 3, 4, 5, 7, 8, 9, 10 and 12. There were also seven cases reviewed as part of a police investigation. Three of these cases are referred to in allegation 1(i)I to 1(i)k, namely cases 16, 17 and 18.
15) The Registrant says in response to this allegation that he has never conducted any clinical procedure for sexual gratification or sexual motives, rather he says that these procedures have always been in the best interest of his patients.
16) In coming to its conclusions the Panel has relied on the evidence of Dr A and the corroborative evidence of NP. The quotations cited below are comments made by Dr A whilst giving his oral evidence to the Panel.
17) Allegation 1i a), Case 3 - 18 year old female patient.
The patient’s presenting condition was back pain and abdominal pain and she was under investigation for kidney stones. The Registrant suggested that he was exploring the possibility of an abdominal aortic aneurysm (AAA). The Panel accepted the evidence of Dr A that this did not stand up to scrutiny, but even if it did, it would not justify a 12 Lead ECG. There were therefore no obvious reasons for the 12 Lead ECG and the investigation via this method was “superfluous and gratuitous”.
This allegation was found proved.
18) Allegation 1i b), Case 4 - 23 year old female patient.
The patient’s presenting condition was abdominal pain. This was a vulnerable patient who had collapsed having ingested significant amounts of alcohol. The Registrant suggested that he was investigating the patient because she was tachycardic despite being on beta blockers. An ECG may have offered reassurance in these circumstances, but a 3 Lead ECG would have sufficed.
This allegation was found proved.
19) Allegation 1i c), Case 5 - 24 year old female patient.
The patient’s presenting condition was an acute, severe asthma attack and she was suffering from difficulty breathing. There was no clinical justification for the Registrant’s use of a 12 Lead ECG. The Panel accepted the evidence of Dr A that a 12 Lead ECG was “unnecessary and misguided”.
This allegation was found proved.
20) Allegation 1i d), Case 7 - 16 year old female patient.
The patient’s presenting condition was that she had suffered a seizure which was witnessed by the Registrant. It was a “well described epileptic event” which meant that the 12 Lead ECG was “uncalled for, inappropriate and unnecessary”.
This allegation was found proved.
21) Allegation 1i e), Case 8 - 12 year old female patient.
The patient’s presenting condition was that she was under the influence of drugs and was found collapsed. She was vulnerable as she was unaccompanied and in a public place. There was nothing to suggest that the patient was suffering from a cardiac event, but if she had been, a 3 Lead ECG would have been adequate. The Registrant’s use of a 12 Lead ECG was therefore “gratuitous”.
This allegation was found proved.
22) Allegation 1i f), Case 9 - 21 year old female patient.
The patient’s presenting condition was an apparent assault. The patient was tachycardic and the Registrant suggested that the patient was suffering from a heart muscle injury. Even if this was the case, a 12 Lead ECG would not assist as a paramedic would not be expected to be able to recognise a heart muscle injury from a 12 Lead ECG. There were no obvious injuries and the patient was not conveyed to hospital which demonstrated that the patient was “not too poorly”.
This allegation was found proved.
23) Allegation 1i g), Case 10 - 12 year old female patient.
The patient’s presenting condition was that she had suffered a seizure for three minutes. The patient was known to suffer from cerebral palsy. She was a vulnerable patient under investigation for seizures, but was not fitting at the time of the arrival of the ambulance. The Registrant suggested that the patient needed investigation for hypoxia. She was quick to recover and her observations were normal. The Registrant’s use of a 12 Lead ECG was therefore “inappropriate”.
This allegation was found proved.
24) Allegation 1i h), Case 12 - 14 year old female patient.
The patient’s presenting condition was that another child weighing approximately 4 stone had landed on her chest and she was complaining of chest pain. The patient walked to the ambulance. The Registrant suggested to Witness 6 that the patient was suffering from cardiac tamponade. The Panel heard that this is a “very, very rare condition usually associated with high velocity trauma”. If this was the supposed diagnosis, a 12 Lead ECG would not have identified any such heart injury.
This allegation was found proved.
25) Allegation 1i i), Case 16 - 14 year old female patient.
The patient’s presenting condition was that she was complaining of right sided abdominal pain following vigorous exercise. The Registrant suggested that the patient was suffering from an AAA. The ECG would not give any useful information on this condition. The Registrant took the blood pressure in both arms which may have indicated that he was exploring a dissecting aneurysm. This is a very rare and unusual condition usually associated with 50 – 70 year olds. This was described as “over investigation” by Dr A.
This allegation was found proved.
26) Allegation 1i j), Case 17 - 16 year old female patient.
The patient’s presenting condition was that she was distressed and in drink in a public place. She was complaining of chest pain which resolved when she calmed down. She was a vulnerable patient and had a history of mental health problems. There was no reason to do a 12 Lead ECG “it was redundant as no observations pointed to a cardiac concern”.
This allegation was found proved.
27) Allegation 1i k), Case 18 - 21 year old female patient.
The patient’s initial presenting condition was described as chest pain which turned out to be abdominal pain with diarrhoea and vomiting. This affected a different system from the heart and there was therefore “no reason to do a 12 Lead ECG as it was clearly gastroenteritis”.
This allegation was found proved.
28) The Panel is satisfied that none of the cases 1ia – 1ik inclusive above necessitated a 12 Lead ECG nor was this clinically justified. The Panel has considered the Registrant’s stated reasons for undertaking a 12 Lead ECG, but having regard to the evidence of Dr A, it is satisfied that the Registrant’s justification totally lacks credibility.
The Panel therefore finds particulars 1ia to 1ik inclusive are proved to the required standard.
29) Allegation 1(ii) Undertook a 12 Lead ECG on a 24 year old patient (case 5) in circumstances that were dangerous to her health, namely it would have led to delay in her being transported to a Hospital.
On 6 July 2012, the Registrant attended upon a 24 year old female patient who was suffering from a severe asthma attack. In the patient care report (PCR) for this patient it is recorded “upon arrival p/t was self-nebulising following difficulty breathing for an hour and a half”. Dr A, upon reviewing this PCR, found the decision to undertake a 12 Lead ECG was not appropriate and that the ECG potentially led to delay in transport to definitive care. The Registrant says in response to this allegation that the ECG was conducted en route to hospital and there was therefore no delay in the transportation to hospital. Dr A and NP said that an effective ECG of sufficient quality to read would have required the ambulance to slow down or stop. The Panel heard no evidence on the quality of the ECG.
This allegation was not found proved.
30) The Panel accepted the evidence of Dr A and NP, but because there was no evidence on the quality of the ECG, it could not come to any conclusions on how effectively the ECG was undertaken.
31) In these circumstances the Panel was not satisfied that there was a delay in transporting the patient to hospital and so found the particular not proved.
32) Allegation 2 On unknown dates you performed ECG treatments on female patients and you asked them to remove their clothing from the waist upwards and/or removed their clothing from the waist upwards
12 Lead ECGs by their very nature require close physical contact with patients and access to the upper torso. It is therefore fundamental to treat patients with respect and dignity when performing this procedure. The Registrant had received training on the appropriate use of this procedure during the course of his training and working life.
32) In the course of the internal investigation a number of the Registrant’s colleagues observed that they had been crewing with the Registrant when he performed 12 Lead ECG’s on female patients without the clinical need so to do, without preserving their privacy and dignity and without wearing gloves.
33) The Registrant says in response to this allegation, that he never removed clothing unless it was absolutely necessary, that he always preserved dignity whenever possible. He also said that he stopped using gloves after the Infection Control Team told him he shouldn’t be wearing gloves unless there was a chance of bodily fluid transfer.
34) Allegation 2(i) Without the clinical need to do so
The Panel relied on the evidence of Dr A and NP which was supported by other witnesses. From the description of Witnesses 4, 6, 10 and 11, it was clear that if a 12 Lead ECG was appropriate, it could have been conducted without the clinical need to remove all the top clothing of the patients. NP said that there would never be an occasion when a bra would need to be removed completely. The Witnesses gave numerous examples of occasions when the Registrant requested that the young female patient concerned remove all of her clothing from the waist upwards to enable a 12 Lead ECG investigation to be conducted. Furthermore Witness 11 describes an occasion when the Registrant started to undo a patient’s top, in order to undertake a 12 Lead ECG investigation. In each example the Panel was satisfied that the patients removed their own clothes at the request of the Registrant.
The Panel finds this particular is proved in relation to the Registrant asking patients to remove their clothing, but no examples were given to the Panel of the Registrant himself removing all a patient’s clothing from the waist upwards.
35) Allegation 2(ii) Without preserving their privacy and dignity
Witness 4 stated that the Registrant was sitting with his eyes level with a female patient’s exposed breasts. She was completely naked from the waist up with her grandson present in the room. Witness 6 described how her 14 year old daughter was left exposed by the Registrant and she had to repeatedly cover her daughter with a blanket. It was clear that privacy and dignity was not maintained, the Registrant having left the patients exposed.
This allegation was found proved.
36) Allegation 2(iii) Did not wear gloves during the procedure
The Registrant admitted that he did not wear gloves and he explained in his representations that this was as a result of advice offered by the Infection Prevention Control Team who, he said, informed him that he should not be wearing gloves at all unless there was a risk of bodily fluid transfer. The evidence of many witnesses who gave oral evidence at the hearing was that it was custom and practice for paramedics and EVOs to wear gloves when undertaking a 12 Lead ECG.
This allegation was found proved.
37) Allegation 3 Whilst crewing with Colleague A you performed an ECG treatment on unidentified female patient A and placed an electrode on the nipple of this patient when this was not clinically justified.
Colleague A was interviewed by the Investigating Officer on 30 January 2013. She has refused to voluntarily attend this hearing, accordingly the HCPC rely upon her earlier statement as proof of this event. The Panel did not hear oral evidence from the witness who made this allegation and therefore exercised great caution when considering this particular and have attached less weight to the hearsay evidence of the witness. The Panel heard no evidence as to the specific anatomy of Patient A. NP said that it would be “outrageous” to place an electrode on a nipple, but Dr A said that there “ought to be an alternative”. The Panel noted the Registrant’s comments that he cannot recall ever placing an electrode on a patient’s nipple and that he would never deliberately place an electrode on a patient’s nipple. However he said he has known of occasions where he has not been able to avoid the areola due to the sheer size of them.
This allegation was found proved.
38) The Panel has concluded that the evidence for clinical justification of such an action, should it have occurred, is weak. Nevertheless, the evidence for the placing of the electrode on the nipple was just one sentence with no further detail in an untested hearsay statement.
For these reasons the Panel has not found this allegation proved.
39) Allegation 4 Whilst crewing with B you treated unidentified female patient B and:
Witness 8 stated she was crewing with the Registrant and they attended upon a 14 year old girl who was intoxicated, lying on the ground and (as it had been raining) was soaking wet. The patient’s mother did not want to travel in the ambulance with her daughter but the mother’s partner (who was not the patient’s father) accompanied them instead. Once the patient was in the ambulance all of the patient’s clothes were removed, including her underwear. The patient thrashed about and would not keep the blanket on her. After they had delivered the patient to the hospital the Registrant made a comment that: “I have never seen a 14 year old with a shaved pussy before”.
40) The Registrant says in response to this particular that he directed his crewmate to remove the patient’s articles of clothing that were wet and to cover the patient with two blankets. He said that his crewmate removed all of the patient’s clothing except for her bra which was not soaked. He said the patient kicked off the blanket which caused her to expose herself. Both the Registrant and Witness 8 said the Registrant tried to keep the patient covered with a blanket en route to the hospital. After transporting the patient to hospital the Registrant says that he commented on what an awful job it was, and then went on to say that he was in a state of disbelief that the child was shaved “down there” saying he never used the word “pussy”. He says he questioned his crew mate as to why someone of that age would shave unless they were sexually active and how it broke his heart that the youth of today were in such a hurry to rid themselves of their innocence. He said he never once referred to the patient in a sexual way or with sexual undertones.
41) Allegation 4(i) You removed unidentified female patient B’s underwear without clinical justification
Witness 8 (who was an EVO at the time) stated that at the Registrant’s request one or both of them (she cannot recall specifically) removed all the patient’s clothing. The Registrant said that the patient’s bra was kept on. Witness 8 said that all of the clothing was removed without clinical justification.
The Panel preferred Witness 8’s version of events and found this allegation proved.
42) Allegation 4(ii) You commented to Colleague B that you had never seen a ’14 year old girl with a shaved pussy’ or words to this effect.
Witness 8 in her oral evidence was sure that the Registrant used the phrase quoted in a jokey way. She was sure he was not expressing empathy or concern for the patient. The Registrant has denied using the word “pussy”, but stated that he did discuss the patients anatomical presentation ‘down there” in the context of concern.
This allegation was found proved.
43) The Panel preferred Witness 8’s version of events and found this particular proved. It noted that the Registrant, in his representations, accepted that any comment about the patient’s anatomical presentation was unprofessional.
44) Allegation 5 You Sent Colleague C two picture message to her mobile phone of your erect penis
Witness 9 (Colleague C) explained her initial friendship with the Registrant and the Panel accepted her evidence that the relationship had never been anything other than platonic.
Witness 9 described two episodes when the Registrant sent a picture message to her mobile phone, illustrating his erect penis. She said that the first event occurred after spring 2006 and the second occurred some months later. On both occasions she had expressed her disquiet and said she did not want it repeated. On the second occasion the Registrant said that he had sent it accidentally; he had intended to send it to his wife who had the same name. Witness 9 conceded that she shares the same first name as the Registrant’s wife, but she did not accept that the message had been sent accidentally. She believed he was “testing the waters again” after the earlier incident. The Registrant says that there had only been one occasion on which he had sent such a photograph and it had been in 2003. Witness 5 confirmed that he became aware of one of these events from Witness 9.
45) The Panel preferred the evidence of Witness 9 to that of the Registrant and considers that the Registrant’s explanation, given after the event, is in his self-interest rather than being reflective of his true intentions at the time. For these reasons the Panel found this allegation proved.
46) Allegation 6 On three separate occasions you pushed a pair of gloves into female colleague D and E’s crotch while they were driving an ambulance
Witness 4 (Colleague E) described two separate occasions when the Registrant pushed a pair of gloves into her crotch. She said that his hands were close to her private parts, between the gloves and her trousers. She was shocked and stunned. Witness 10 (Colleague D) described a virtually identical incident when she was working with the Registrant. The Registrant says that he was placing the gloves close to their knees. Both witnesses explained that there was no need for gloves to be passed to them at all, let alone when they were driving. The Panel accepted the evidence of both witnesses and that subsequent to these incidents they took measures to ensure that they were not exposed to this behaviour again. In the case of Witness 4 she ensured she changed shifts in order to avoid working with the Registrant. In the case of Witness 10 she learned to pre-empt his behaviour by having gloves ready when she crewed with him.
For these reasons the Panel preferred the evidence of Witnesses 4 and 10 and found this allegation proved.
47) Allegation 7 Whilst crewing with Colleague F you treated unidentified female patient C who was suffering with a PV bleed. In treating unidentified patient C you wiped the blood from between her legs.
Witness 11 (Colleague F) states that when he crewed with the Registrant, they attended a female patient with a PV bleed. They got the patient into the ambulance and onto the stretcher and stated that he saw the Registrant wiping between the patient’s legs with wipes. He asked the Registrant whether this was something that he would have to do in future and the Registrant replied “No it’s a Paramedic’s job”. On another occasion in similar circumstances, a different Paramedic did not wipe between the patient’s legs and said to Witness 11, in response to a question, that wiping between the legs would be totally unacceptable. The Panel did not hear oral evidence from Witness 11 and relied on his statement. The Panel reminded itself that such evidence needed to be approached with caution and weight to be placed on this.
48) The Registrant said that he “scooped tennis ball sized clots of blood from between the patient’s legs into a clinical waste bag to give to the treating physician”. He also said that he gave the patient some wet wipes so that she could clean herself in that area. According to NP, Dr A and the clinical guidelines on PV bleeds, the need to visibly assess the blood loss was unnecessary in this context, as it is possible to assess blood loss in other ways without the need to expose the patient.
49) The Panel accepted NPs evidence that the appropriate way to manage these circumstances was to ask the patient to deal with the bleeding themselves with padding. The Panel has found this particular proved on the basis of the evidence of the witnesses and the Registrant’s description of what he did.
50) Allegation 8 Whilst crewing with Colleague G you treated unidentified female patient D, who was suffering with a PV bleed and you:
Witness 7 (Colleague G) said that he was crewing with the Registrant when they attended a female patient with a PV bleed and that after they placed her on to a stretcher the Registrant asked the patient to take her jogging bottoms and underwear off. When Witness 7 turned towards the patient, he saw she was naked from the waist down and he passed a blanket to the Registrant so that the patient could be covered up.
Whilst Witness 7 was driving the ambulance he could hear a paper tissue dispenser being used by the Registrant, he thought, to wipe the patient between her legs. After they had transported the patient to the Hospital the Registrant commented: “She was all right wasn’t she, she had a nice pussy” or words to that effect. Witness 7 felt shocked by that comment.
51) Allegation 8(i) Removed the patient’s clothing from the waist down when that was not necessary
Witness 7 said that the Registrant asked the patient to remove her jogging bottoms and pants. She obliged by removing them.
The Panel does not find this particular proved because it was not the Registrant who removed the clothing.
This allegation was not found proved.
52) Allegation 8(ii) Wiped the blood from between the patient’s legs
The Panel noted that Witness 7 stated that when he heard the paper towel dispenser being activated he looked in his rear mirror and saw the Registrant kneeling at the far end of the stretcher with the patient’s knees raised. Witness 7 was not 100% sure that the Registrant was wiping the patient, but this is what he appeared to be doing.
53) Given the Registrant’s response that he was assessing the patient’s blood loss, the Panel is satisfied on the balance of probabilities that he was wiping blood from between the patient’s legs and thus finds this allegation proved.
54) Allegation 8iii Commented to Colleague G words to the effect of “She was all right wasn’t she, she had a nice pussy”
Witness 7 was sure that this comment was made and stated that he was shocked to hear it. The Registrant denied that he made the comment.
The Panel preferred the evidence of Witness 7 and found this allegation proved.
55) Allegation 9 After treating unidentified female patient E you commented to Colleague H “she was more hairy than me”
Witness 5 (Colleague H) stated he was crewing with the Registrant when they attended upon a female patient and the Registrant performed a 12 Lead ECG upon her.
After they had finished dealing with the patient the Registrant commented “she was more hairy than me” or words to that effect. Witness 5 felt that this comment was rude and unprofessional.
56) The panel found that Witness 5 was convincing when he asserted that this comment was made and that it was said in a rude, unprofessional and distasteful tone. The Registrant admits in his Representations that he did make comments about one patient who he noted to be rather “hirsute” and that his comment was not the most professional thing to say.
The Panel finds this allegation proved as it preferred the evidence of Witness 5 and noted the Registrant’s partial admission.
57) Allegation 10 After treating unidentified female patient F you commented to Colleague E “did you see the hairs on her nipples”
Witness 4 (Colleague E) states that an aspect of the Registrant’s conduct that concerned her on the occasion when he performed a 12 Lead ECG on a female patient in the presence of her grandson, was a comment that he made after that event, upon returning to the ambulance, namely: “did you see the hairs on her nipples”.
58) Witness 4 was clear that the alleged comment was made in such a way that it made her feel sick. As noted in particular 9 above, the Registrant states that he only remembers one incident when he commented on a patient being “hirsute”.
The Panel preferred the evidence of Witness 4. It therefore found this allegation proved.
59) Allegation 11 Whilst crewing with Colleague I you treated unidentified female patient G, who expressed a need to go to the toilet. You removed unidentified female patient’s G’s clothing from the waist down when that was not necessary.
Witness 12 (Colleague I) states that when he was a student Paramedic he crewed with the Registrant and on one occasion they were called to a road traffic collision. He says the patient was a young female who was complaining of neck pain. As a consequence the patient was stabilised on a spinal board. Once in the ambulance the Registrant attended to the patient. The patient began complaining that she needed to urinate. In response the Registrant removed the patient’s lower clothing and underwear and placed a bedpan beneath her. When she did not use the bedpan he removed it and replaced it with incontinence pads that he placed between her legs.
60) Witness 12 said that the Registrant removed the patient’s lower clothing and the Registrant admits this in his representations. The Registrant contended that the patient was insistent on getting up from the board to urinate despite having had the risks of so doing explained by him. Witness 12 does not remember any such conversation despite being in close proximity to the patient. He also asserted that the patient was not angry, difficult or threatening and he did not agree with the Registrant’s actions. The Registrant further contended that he placed a flattened bed pan underneath the patient as he felt that this was preferable to the patient getting off the board.
61) NP said that the appropriate and safe course of action would have been to explain the risks and encourage her to urinate on the spinal board if she could not wait.
62) The Panel preferred the evidence of Witness 12 and particularly his description of the patient’s “easy to placate” demeanour and therefore concluded that removing the patient’s clothing was not necessary.
Accordingly this allegation is proved to the required standard.
63) Allegation 12 The matters alleged in particulars 1 (i) (ii) and/or 2 and/or 3 and/or 4(i) and/or 5 and/or 6 and/or 7 and/or 8(i) and or 8(ii) and/or 8(iii) and/or 9 and/or 10 and/or 11 were sexually motivated
The Panel bore in mind the advice of the Legal Assessor that this is a question of fact which must be proved to the required standard in each particular case.
64) For an act to be sexually motivated it is not sufficient merely to prove that the subject of the act complained of perceived it as a sexual act. Sexual motivation may be proved to the required standard if the act complained of was overtly sexual or could reasonably be perceived as such. Alternatively, if the act complained of, whilst not inherently sexual, was carried out for the Registrant’s own sexual gratification.
65) As a result of a routine audit of the use of ECG, it became apparent that some of the Registrant’s patients had had ECGs in circumstances that did not seem to necessitate such an investigation. Dr A explored the use of ECGs across the Trust and found that the Registrant was an extreme outlier. The profile of the Registrant’s typical patient on whom he undertook a 12 Lead ECG was a young female with little or no presenting clinical symptoms which necessitated such an investigation. The IOWAS Investigation Report of 4 November 2013 states that:
“Stuart Hamilton’s contribution of 27 of the 128 equates to 21%. Given that the Ambulance Service employs around 60 Paramedics (this volume has fluctuated during the period) it could be assumed that a Paramedic should undertake approximately 1:60 of the ECG’s – this is borne out by the volumes recorded against the other ‘high users’. Stuart Hamilton is at a rate of 1:5 of the total number of ECGs performed by the service for this age group for the time period.”
66) Dr A and NP both said that the Registrant had an almost textbook answer when his technical knowledge of the necessity of performing an ECG was put to him. His inappropriate use of 12 Lead ECGs cannot thus be explained by any lack of knowledge. Dr A commented that if there was any hole in the Registrant’s knowledge, it only applied to young females. Dr A went on to say that the Registrant was only an outlier in respect of females. The Registrant’s explanation for doing some of the 12 Lead ECGs did not stand up to scrutiny and was clearly not clinically justified as found proved in particular 1(i). In a few cases he went on and did further unnecessary investigations justifying them by the possibility of that patient suffering from an incredibly rare event for a patient with a presenting profile which would normally exclude them, such as an AAA. Dr A described some examples as ‘unnecessary’ and ‘intimate over-investigation’ when there were viable alternatives.
67) In usual working circumstances Paramedics and other professionals do what they can to preserve the privacy and dignity of patients by keeping them covered up. The Panel has already found proved that the Registrant did not do this. In one case, a patient’s underwear was removed and she was left naked. NP told the Panel that the removal of clothing including bras was “outrageous”. He went on to describe how the use of clothing or blankets could be facilitated to protect a patient’s dignity.
68) In other circumstances, the decision by the Registrant to not wear gloves when conducting a 12 Lead ECG could be justified by saying that there was no risk of cross infection, when conducting that investigation. However, the cases which were the subject of the allegation all involved unnecessary 12 Lead ECGs and this, combined with the lack of use of gloves, was inappropriate in an organisation where the custom and practice of his colleagues was to wear gloves for such investigations. In effect, the Panel considers that the Registrant’s explanation was a smokescreen and that his real motivation was to be able to touch patients directly skin to skin.
69) The Panel has found proved that the Registrant sent two photographs to a colleague of his erect penis. He put gloves into the crotches of female colleagues when there was no need to even pass them the gloves. The Registrant wiped blood from between the legs in two cases when patients had been suffering from vaginal bleeding.
70) In addition to the specific allegations cited above, the Panel heard from a number of witnesses about the perception of several colleagues that the Registrant could be expected to perform totally unnecessary investigations, necessitating young females removing their clothes from the waist upwards. Two colleagues explained how they did their best to avoid ever working with the Registrant because of his approach to patients and his over familiarity towards them. Of particular concern to the Panel, was the evidence of one witness who described how the Registrant had been a family friend. Subsequent to treating a member of that colleague’s family (charge 1(i)h) the witness went on to explain how on one occasion the Registrant had been to her home, visited a bedroom and sprayed his cologne over the pillow of the young female who had been previously treated by him. He explained to her that he had sprayed the cologne on the pillow because he knew that the young female liked the smell of it. The witness was left feeling very unnerved by this. The Panel was also told about a conversation the Registrant had, with a young female patient about her physical appearance whilst she was naked from the waist upwards. In particular his advice to her was that “she should show off what she’s got”.
71) The Panel has concluded that the objective statistical evidence, coupled with the description of the Registrant as a person and how he conducted some of his examinations, leaves it in no doubt that the Registrant’s actions were sexually motivated, because of the overt sexual nature of some of his actions and the fact that all of his actions can reasonably be perceived as such. The Panel is of the view that there is no other explanation for the Registrant’s behaviour other than that it was carried out for his own sexual gratification.
For all of the above reasons the Panel finds the following allegations were sexually motivated:
Allegation 1(i); Allegation 2; Allegation 4(i); Allegation 5; Allegation 6; Allegation 7; Allegation 8(ii); Allegation 8(iii); Allegation 9; Allegation 10; Allegation 11.
Decision on Grounds
72) Article 22(1) of the Health and Social Work Professions Order 2001 states:
This article applies where any allegation is made against a Registrant to the effect that—
(a) his fitness to practise is impaired by reason of—
73) The Panel accepted the advice of the Legal Assessor that misconduct is 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.
74) It also noted the case of: R v Meadow 2006 EWCA Civ 1390, in which Sir Anthony Clarke MR stated that misconduct is incapable of definition but has to be serious and “…it will be a rare case in which a person should be held to be guilty of serious professional misconduct in the absence of bad faith.” Seriousness needed to be given proper weight and was referred to as: “conduct which would be regarded as deplorable by fellow practitioners.”
Under the HCPC Standards of Conduct, Performance and Ethics, Registrants are required to comply, amongst others, with the following standards:
1 You must act in the best interests of service users.
3 You must keep high standards of personal conduct.
7 You must communicate properly and effectively with service users and other practitioners
13 You must behave with honesty and integrity and make sure that your behaviour does not damage the public’s confidence in you or your profession.
75) The Panel had regard to the above standards and concluded that Standards 1, 3, 7 and 13 have been breached on the basis of the facts proved. The Panel has found that the Registrant undertook unnecessary investigations at the same time as compromising patients’ dignity which was clearly not in the best interests of service users. The sending of a photograph of his erect penis on two occasions was clearly in breach of the maintenance of high standards of personal conduct. The Registrant communicated inappropriately with service users and their relatives by raising unfounded clinical concerns and by making totally unnecessary personal comments about patients’ anatomy. All of the cases cited demonstrated a clear lack of integrity, particularly those where sexual motivation was found. These have the potential to severely damage the public’s confidence in the Registrant, the Paramedic profession and the regulatory process.
76) The Panel reminded itself that breaches of the HCPC Standards do not automatically constitute misconduct. However, the Panel is in no doubt that the nature of the Registrant’s behaviour does constitute misconduct and that it was serious.
77) The Panel determined that the allegation of misconduct is well founded because the Registrant, through his gross breach of trust, has fallen significantly short of the standards expected in his chosen profession over a significant period in respect of a large number of vulnerable patients. He has conducted 12 Lead ECGs that were not appropriate given the patients’ clinical presentation, he failed to respect the dignity and privacy of young female patients, engaged in highly inappropriate conduct towards female crewmates and has made unprofessional and offensive comments about his patients. Furthermore, the vast majority of his conduct has been sexually motivated. In these circumstances the Panel has determined that the particulars found proved, individually and collectively, amount to misconduct.
78) The Panel concluded that the Registrant’s behaviour could be described as “deplorable” by fellow practitioners.
Decision on Impairment
79) The Panel has considered the HCPC Practice Note entitled Finding that Fitness to Practise is “Impaired”. In determining whether fitness to practise is impaired, Panels must take account of a range of issues which, in essence, comprise two components:
1. The ‘personal’ component: the current competence, behaviour etc. of the individual Registrant; and
2. The ‘public’ component: the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession.
80) The Panel has taken account of further guidance including:
Dame Janet Smith’s identification of the circumstances where impairment might arise including: (a) where a Registrant presents a risk to service users (b) has brought the profession into disrepute (c) has breached one of the fundamental tenets of the profession.
81) In respect of the public interest Panels were given guidance by Mrs Justice Cox at para 74 of her Judgement in Grant: “..... In determining whether a practitioner’s fitness to practise is impaired by reason of misconduct, the relevant panel should generally consider not only whether the practitioner continues to present a risk to members of the public in his or her current role, but also whether the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular circumstances.”
82) In respect of the personal component, the Panel has considered the Registrant’s representations which do not demonstrate any insight, or remorse. He denies the allegation. His behaviour had an adverse impact on patients and colleagues. The Panel has received no evidence on what the Registrant has done since he resigned from the Trust. Similarly, it has not received any evidence that the Registrant has remedied his behaviour in any way.
83) In respect of the public component the Panel finds that there is current impairment because of the need to protect the public. Having concluded that the Registrant has not demonstrated remorse, insight or remediation, the Panel has determined that the risk of harm to the public remains both for patients and colleagues. This Registrant’s behaviour is entirely contrary to a fundamental tenet of the health and care professions which is to act in the best interests of service users. Such behaviour is highly likely to bring the profession into disrepute as this is not an isolated event and the Panel has concluded that there is a significant risk of repetition. The potential to breach a fundamental tenet and bring the profession into disrepute remains. Given the serious nature of the misconduct that is proven and given the Registrant’s lack of insight and failure to accept or address his misconduct, a finding of current impairment is necessary to afford the appropriate degree of public protection.
84) A finding of impairment is also necessary to maintain confidence in the reputation of the profession and the regulatory process. The nature of the facts found proved included the compromising of patients’ dignity and inappropriate and unnecessary touching which was sexually motivated. This put patients and those caring for them at risk of harm. The sending of explicit personal photographs to a colleague and his over-familiarity with female work associates put those colleagues at risk of harm and caused them to take preventative steps to avoid contact with the Registrant.
85) The Panel considers that confidence in the profession is of great importance when decision making in life-threatening situations needs to be relied upon. The circumstances of this case demonstrate cases where the Registrant’s decision making was influenced by sexual motives. The Panel is in no doubt that this case has the potential to damage confidence in the profession.
86) The Panel considers that it is essential to uphold proper professional standards, in order to maintain public confidence in the profession and confidence between professionals within the profession itself. The Registrant’s behaviour was way below, and entirely contrary to, what would be expected of a Paramedic.
87) In all the circumstances of this case, the Panel has determined that the Registrant is currently impaired and it has concluded that any other decision would, not only be perverse, but would severely compromise the public’s confidence in the profession and its regulation.
Decision on Sanction
88) Ms Berridge submitted that the decision on sanction is a matter for the Panel exercising the principle of proportionality and reflecting the principles within the HCPC’s Indicative Sanctions Policy (ISP).
89) In coming to its decision on sanction the Panel has given careful consideration to all the evidence which contributed to its findings on the facts found proven, the statutory ground and current impairment. It has considered the submissions made by Ms Berridge on behalf of the HCPC and has heard and accepted the advice of the Legal Assessor. In accordance with that advice the Panel has had due regard to the ISP. The Panel has noted that any sanction must be proportionate to the misconduct established, that it is not intended to be punitive although it may have a punitive effect. The Panel has also noted that any sanction should be no more than is necessary to meet the legitimate purposes of providing adequate protection to the public and otherwise meeting the wider public interest, in protecting the reputation of the Paramedic profession, maintaining confidence in the regulatory system, and declaring and upholding proper professional standards and the tenets of the profession.
90) The Panel identified the following aggravating and mitigating factors that it took into account.
The aggravating factors are:
• The impact on the patients and colleagues involved who suffered actual and potential harm, due to the Registrant’s misconduct.
• The misconduct amounted to a gross abuse of trust, including sexual motivation which places his misconduct at a very high level of seriousness.
• There was only the merest hint of insight in that the Registrant recognised that making personal comments about a patient’s anatomy was unprofessional; other than that the Panel could find no evidence of insight. The Panel has rejected the Registrant’s Representations that his actions were appropriate and that he was the victim of a witch hunt by IOWAS.
• The Panel has not received any evidence to demonstrate remorse.
• The Panel has not received any evidence to demonstrate that the Registrant has taken steps to remedy his misconduct.
• Due to the volume of cases considered, and the duration over which the Registrant’s misconduct continued, the Panel has inferred that his misconduct was premeditated. The Panel considers that the Registrant had sought out and orchestrated opportunities to abuse his position of trust. This resulted in colleagues changing their patterns and practice.
• This was a course of misconduct as opposed to an isolated incident.
• The Panel has concluded, because of the lack of insight and the scale and scope of the Registrant’s misconduct, that the nature of his failings were attitudinal in character.
• The only mitigating feature in this case is that some colleagues made positive comments about some of the Registrant’s practice.
91) With those factors in mind the Panel then considered the available sanctions in ascending order of severity.
92) No Further Action: The Panel concluded that to take no action would be wholly inappropriate given the seriousness of the case because it would not protect the public or be in the wider public interest.
93) Mediation: The ISP states that “mediation may only be used if the Panel is satisfied that the only other appropriate course would be to take no further action. Thus, a case may only be referred to mediation if the Panel considers that no further sanction is required. Generally this will only be where impairment is minor, isolated in nature and unlikely to recur, where the registrant fully understands the nature and effect of that impairment and has taken appropriate corrective action”.
The Registrant’s misconduct was neither minor nor isolated therefore mediation is wholly inappropriate in this case and would not protect the public or the wider public interest.
94) Caution: To impose a caution is also wholly inappropriate because there would be no effective restriction on the right of the Registrant to practise, and the Panel has already found that there is a risk of repetition of the misconduct demonstrated in this case. To impose a caution would not protect the public, or maintain the wider public interest.
95) Conditions of Practice: The ISP states: “Conditions of practice will be most appropriate where a failure or deficiency is capable of being remedied and where the Panel is satisfied that allowing the registrant to remain in practice, albeit subject to conditions, poses no risk of harm or future harm. Panels need to recognise that, beyond the specific restrictions imposed by a Conditions of Practice Order, the registrant concerned is being permitted to remain in practice. Consequently, the Panel’s decision will be regarded as confirmation that the registrant is capable of practising safely and effectively”.
In this case there are attitudinal failures which are potentially not capable of being remedied and so the Panel is unable to formulate conditions which could protect the public, the wider public interest and adequately reflect the serious nature of the Registrant’s misconduct.
96) Suspension: The Panel next considered a suspension order. The ISP states: “Suspension should be considered where the Panel considers that a caution or conditions of practice are insufficient or inappropriate to protect the public or where the allegation is of a serious nature but there is a realistic prospect that repetition will not occur and, thus, that striking off is not merited”.
In this case a suspension would not be sufficient because there is a realistic prospect of repetition. The seriousness of the particulars proved, which included sexual motivation, is such that a suspension order would not be sufficient to protect the public and would not be in the public interest.
97) Striking Off: The ISP states: “Striking off may also be appropriate where the nature and gravity of the allegation are such that any lesser sanction would lack deterrent effect or undermine confidence in the profession concerned or the regulatory process. Where striking off is used to address these wider public protection issues, Panels should provide clear reasons for doing so. Those reasons must explain why striking off is appropriate and not merely repeat that it is being done to deter others or maintain public confidence”.
In this case the Registrant’s misconduct is so serious that the Panel finds there is a public interest in permanently preventing his return to Paramedic practice. Therefore a suspension order is insufficient. The Panel has concluded that it is necessary for the Registrant to be prevented from practising, in order for the public to be fully protected, and for public confidence in the profession and the regulatory process to be maintained. In this case there was a serious abuse of trust over a sustained period of time which was largely sexually motivated. There is an absence of insight and the Registrant denies the allegation.
98) The Panel has determined that the Registrant’s behaviour is incompatible with continued registration. In coming to this conclusion the Panel has borne in mind the Registrant’s interests but has concluded that there is an overwhelming necessity to protect the public.
In these circumstances the Panel considers that a striking off order is proportionate, as the requirements of public protection and the wider public interest cannot be adequately served by any other sanction
History of Hearings for Stuart I Hamilton
|Date||Panel||Hearing type||Outcomes / Status|
|21/09/2015||Conduct and Competence Committee||Final Hearing||Struck off|