Mr Andrew Davies
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During your employment as a Paramedic for West Midlands Ambulance Service NHS Trust:
1. On or around 23 June 2012, you did not take any action to provide care to a patient who had collapsed in the car park of Walsall Manor Hospital.
2. The matter described in paragraph 1 constitutes misconduct.
3. By reason of that misconduct your fitness to practise is impaired.
Notice of Hearing
1. The Panel had evidence that Notice of today’s hearing had been sent in the correct form; by the appropriate postal means; to the address shown for the Registrant on the HCPC’s Register; and in sufficient time in advance of the hearing. In addition the Panel had evidence of due posting of this Notice letter by way of a duly signed certificate. The Panel also noted that Notice had in addition been sent by email to the Registrant at the email address notified by the Registrant to the HCPC. The Panel therefore came to the conclusion that Notice had been served in accordance with the Rules and that in addition the HCPC had used all reasonable means to bring this hearing to the Registrant’s attention.
Proceeding in the Registrant’s absence
2. The HCPC made an application for this matter to proceed in the Registrant’s absence. The HCPC stated that it had given sufficient Notice; it had witnesses who were in attendance and ready and willing to give evidence; that there was public interest in this matter proceeding without delay, particularly as there had already been one adjournment.
3. The Panel had before it a letter from the Registrant dated 4 January 2016 in which he acknowledged that he was aware of today’s hearing. He states that, “I have chosen not to attend, and will not contest the finding of the allegations made against me, I believe they will be fair and impartial.” The Panel has also seen an email dated 21 November 2015, in which the Registrant stated his intention not to attend the proposed HCPC hearing.
4. The Panel has accepted this documentation as evidence that the Registrant has made an informed, settled and continuing decision not to attend and therefore he is considered to have voluntarily absented himself from this hearing. There is public interest in this matter proceeding without delay and in the absence of any indication from the Registrant that he is likely to attend at a future date, the Panel has decided that the hearing will proceed in his absence.
Hearing in private
5. There is reference within the representation sent to the HCPC by the Registrant to matters relating to his health. The Panel decided that consideration of this issue would either be by way of reference to documentation without mention of the detail contained, or within a private session of the hearing.
6. On 2 July 2012, the Registrant self-referred the fact of his suspension from duty as a Paramedic by his then employer West Midlands Ambulance Service (WMAS). He stated that the reason for his suspension involved an investigation into a failure to provide care to a patient on the 23 June 2012.
7. The matter being investigated related to a patient who had collapsed on two occasions in Walsall Manor Hospital car park whilst four members of clinical staff, including the Registrant, together with a student paramedic were present. The Registrant allegedly did not provide treatment to Patient A despite there being evidence of a clinical need for such treatment. Patient A later died in hospital.
8. The WMAS investigation resulted in a disciplinary hearing being held on 23 July 2012, the outcome of which was that the Registrant was dismissed on the basis of gross misconduct.
Decision on Facts
9. Before the Panel sets out its finding on fact the Panel confirms that it has had regard to the fact that the burden of proof is on the HCPC to prove the allegation to the requisite standard, namely the civil standard of balance of probabilities. There is no burden on the Registrant to disprove anything.
10. The Panel has before it a body of documentary evidence and a CD of video footage recorded by CCTV cameras sited at various vantage points around the car park and Accident and Emergency Department (A&E) of Walsall Manor Hospital on 23 June 2012.
11. The Panel heard live evidence from three HCPC witnesses:
• DD, who undertook the investigation on behalf of WMAS. A copy of that suitably redacted Investigatory Report is before the Panel. DD gave his evidence in a clear and concise manner. The Panel has accepted and placed weight on his testimony and supporting documentary evidence.
• SB, who at the time of the incident had been in training through Worcester University to become a paramedic. She had only undertaken about 12 shifts prior to her first and only time of working with the Registrant on 23 June 2012. Her placement with the Registrant had been arranged by the university. The Registrant had acted as her mentor that day and she gave evidence that despite observations which indicated that there was a need to give assistance to Patient A, the Registrant had instructed her on two occasions to remain in the ambulance as the patient was, in the Registrant’s words, ‘fine’. SB had been sufficiently concerned by the events of 23 June 2012 that on her arrival home she recorded her concerns in a note. A copy of the note is before the Panel. SB has since completed her studies and is now employed as a qualified paramedic by WMAS since February 2014. SB had stated her concerns arose out of Patient A being seen to ‘drop’ to the floor on the second occasion he had collapsed. This was at variance with the controlled falling to his knees and then lying down which he had done on the first occasion he had gone down to the ground. Her evidence was, in the Panel’s view, consistent with her statements made at the time of the event and subsequently. She provided her evidence in a confident manner and was in the Panel’s view a credible and reliable witness.
• Person A, at the time of the incident was an Emergency Care Assistant (ECA). She has worked for WMAS as an Ambulance Technician since February 2014. On 23 June 2012 Person A was a member of the ambulance crew working with the Registrant and had been an ECA at that time for only six weeks. This was the first occasion Person A had worked with the Registrant. On 5 July 2012, of her own volition Person A prepared a note of the events of 23 June 2012. A copy of that note is before the Panel. Person A confirmed the contents of her written evidence.
12. Within the Registrant’s letter, dated 4 January 2016, he admits and accepts the factual basis of the allegation, in that he took no action in relation to Patient A. The Panel noted that during the WMAS investigation the Registrant had made statements which were at variance with the evidence provided by his two crew members and were not supported by the findings of the investigatory report produced by DD. The Registrant had, in addition to stating that Patient A was nothing to do with him and not his patient, had maintained that he was unable to see Patient A on the ground as his view was obscured by concrete pillars that supported the canopy over the entrance to A&E.
Particular 1 - proven
13. The Panel had evidence that Patient A had been brought to A&E by another ambulance crew. Patient A had collapsed on two occasions, both times lying flat on the ground on the roadway access to the A&E Department. On the second occasion Colleague C, who had initially assessed and transported Patient A to the hospital, went to speak to him after his collapse. After being left in the road by Colleague C, visitors to the hospital, ambulance and hospital staff took no action to assist Patient A for around a cumulative period of nine minutes. In some instances cars and individuals took evasive action to avoid Patient A. He was then taken within the A&E department, on a trolley, in cardiac arrest.
14. The Panel viewed the CCTV footage of the incident. It read the statements which were gathered from colleagues after the incident by the Investigating Officer, DD. It heard and had the opportunity to question the HCPC witnesses. This evidence all indicates to the Panel that the Registrant had sight of Patient A whilst he was collapsed on the ground of the Walsall Manor Hospital car park and did not take ‘any action’, as identified in the particular, to provide care to this patient.
15. Whilst the Registrant initially stated he was unable to see Patient A, he also stated within another part of the investigatory interview that he was able to see Colleague C who was standing over and speaking to Patient A. The Panel therefore accept that for a period of between 6 and 9 minutes the Registrant had been able to see Patient A on the ground. During this time he was able to take action independent of Colleague C.
Decision on Grounds
16. The HCPC stated that whilst there was only one particular it related to a single, very serious matter which had a fatal outcome. Patient A was seen to collapse on the ground on two occasions over a period spanning six minutes.
17. The Registrant stated in his letter of the 4 January 2016, that “Working as a Paramedic was the most rewarding, satisfying and enjoyable career that I could ever envisaged, I was immensely proud to be a part of the Profession. I am know [sic] filled with regret and would like to apologise for my actions.” The Panel has interpreted this statement as indicating an acknowledgement and understanding that, on reflection, the Registrant’s failure to act on that day had been conduct that had fallen below that required of a member of his profession.
18. The Registrant added that, “I believe that on the day in question I was not endangering anyone when I left the scene of the incident at Walsall Manor Hospital. I should not have trusted in the opinions of others and made my own judgements based on my own findings, I was wrong to let someone else lead me.” The Registrant has, in the Panel’s view, acknowledged that he had some personal responsibility, as an autonomous practitioner, for his acts and omissions and that, on this occasion he has failed to act appropriately.
19. The Panel took into account the representations of the parties and referred to the relevant guidance issued by the HCPC and in particular the Standards of Performance, Conduct, and Ethics.
20. In considering the issue of misconduct the Panel took into account the following:
• The Registrant had seen Patient A fall to the ground on two occasions.
• Patient A was on the ground in the roadway leading to the A&E Department for a cumulative period of around nine minutes at which time he was not receiving appropriate care but was, in addition, at risk of sustaining injury from cars approaching the hospital.
• The Registrant had failed to acknowledge or act on the concerns that were expressed by his student crew member.
• There is no evidence the Registrant had challenged the action taken by Colleague C, or given any consideration to whether Colleague C’s actions were appropriate or sufficient in the circumstances.
21. In the Panel’s view the Registrant’s actions on 23 June 2012, had fallen short of that required and expected of a registered paramedic, in particular the terms of the following sections of the HCPC’s Standards of Proficiency and Standards of Conduct, Performance and Ethics:
1a.1, be able to practise within the legal and ethical boundaries of their profession, in particular, to understand the need to act in the best interests of service users at all times.
1a.5, be able to exercise a professional duty of care.
1a.6, be able to practise as an autonomous professional, exercising their own professional judgment.
1. You must act in the best interests of service users.
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.
22. The Registrant’s failure to act placed Patient A at increased risk of harm and was conduct falling far below that expected by the public, his profession, and fellow practitioners. The Panel therefore find that this omission amounts to serious misconduct.
Decision on Impairment
23. In reaching its decision the Panel took into account the following:
• In relation to impairment, the Panel reminded itself that the test of impairment is expressed in the present tense, that fitness to practise ‘is impaired’.
• Whether the Registrant’s fitness to practise is impaired is a matter of judgment for the Panel.
• Rule 9 of the Health Professions HCPC (Conduct and Competence Committee) (Procedure) Rules 20003 (as amended) provides ‘where the Committee has found that the health professional has failed to comply with the standards of conduct, performance and ethics established by the HCPC under Article 21(1)(a) of the Order, the Committee may take that failure into account, but such failure will not be taken of itself to establish that the fitness to practise of the health professional is impaired.
• The practice note issued by the HCPC titled ‘Finding that fitness to practise is impaired.’
24. The HCPC submitted that there was little, or no insight demonstrated or expressed by the Registrant since the time of the incident.
25. In the Registrant’s letter of 4 January 2016, he states that he considers he has no future role within the Ambulance Service. The Registrant also makes reference to his personal situation since the event on 23 June 2012 which has prohibited him from working. There may, therefore, have been administrative and personal reasons why the Registrant has been unable to demonstrate that he is capable of working without cause for concern since June 2012.
26. In his letter of 4 January 2012 the Registrant states that in his view the actions of the police and his employer were unwarranted. He considered his employer had treated him unfairly and that he was victimised due to the fact he was a paramedic. He stated that media pressure played an important part in his dismissal and he believes his employer’s swift conclusion of the investigation within a period of four weeks was driven by a desire to avoid any embarrassment and further media coverage. The police investigation took over 10 months and concluded in no prosecution, however despite this, the police “deem me to be a threat to vulnerable adults and children, an opinion based entirely on the fact that I was dismissed from my position with West Midlands Ambulance Service”. The terms in which the Registrant expresses his reflection on the event demonstrates that he does not completely accept responsibility for his actions, nor has he gained a balanced or informed view of the public interest issues which his failure to act raises. At no time does the Registrant make reference to Patient A, or the impact of his death on his family and friends. Therefore, in relation to the personal component of the Panel’s decision on current fitness to practise, there is, in the Panel’s view, insufficient evidence that the Registrant has gained meaningful insight into his failings.
27. In the absence of such insight there remains a likelihood of repetition of the misconduct. The Panel has therefore concluded that there is insufficient evidence that the Registrant has identified his failings, taken appropriate action to remedy those failing nor has he been able to demonstrate that there will be no repetition of his failings.
28. In relation to the public component of the decision the Panel is of the view that the matters found are so serious and so harmful to the reputation of the profession, that a finding of current impairment is also required in the public interest.
Decision on Sanction
29. The Panel has taken into account the terms of the current edition of the Indicative Sanctions Policy which was published in September 2015. It has noted the HCPC’s representations which included reference to matters that could be considered as aggravating and mitigating factors, namely:
• The Registrant has stated that he has already suffered physically and emotionally.
• He has recently expressed regret and apologised for his actions.
• There has been a breach of the Registrant’s professional responsibility to fulfil his duty of care to Patient A.
• There is only very limited evidence of insight into his role in this event.
• There is no evidence of remediation.
30. The Panel has taken into account the evidence that the Registrant had initially provided his employer with reasons for his inaction which were at variance with other evidence amassed during the WMAS investigation and the oral evidence at the hearing.
31. The Panel has noted the terms and tone of the two communications from the Registrant to the HCPC in November 2015 and January 2016, in which he attributes blame to his employer, the police and the media for his current situation.
32. The Panel has also taken into account the fact that action taken by the Registrant’s former employer, or any action taken by the police in the wider public interest, are not a measure of the sanction to be imposed within this regulatory environment. The Panel is making its determination on an individual case-by-case basis with facts and factors relevant only to the matter before it. In other words the Panel is not attributing blame or responsibility to any other person who may have been involved in the incident on the 23 June 2012.
33. The Panel is aware that its primary function is to balance service user protection, the public interest in the maintenance of standards and the reputation of the profession, with the interests of the Registrant. Sanctions are not to be a form of punishment however they may have a punitive impact on the Registrant. Sanctions should also be a deterrent to other professionals from acting in the same manner as the Registrant.
34. As advised, the Panel started its consideration of the appropriate and proportionate sanction to apply in ascending order.
35. The Panel has come to the view that the matters raised are too serious for it to take no further action. Mediation is not appropriate in this case.
36. In relation to the imposition of a Caution Order, the Panel came to the conclusion that it was not a proportionate measure in this instance where Patient A was put at an increased risk of harm and there had, even at this distance from events, been so little evidence of insight, remorse or remediation.
37. The Panel gave careful consideration to the use of Conditions of Practice to address the Registrant’s failings, however, given that there are no identifiable issues relating to competence, and the evidence that the Registrant continues to place blame on others, the Panel has come to the conclusion that this is not a workable means to address the Registrant’s behavioural or attitudinal deficiencies and lack of insight.
38. The Panel therefore moved on to consider whether the Registrant’s omission to act was fundamentally inconsistent with him remaining on the Register. The Indicative Sanctions Policy indicates that a period of suspension is appropriate when there is evidence which suggests there is a possibility of the Registrant resolving or remedying their previous behaviour. The Panel has noted that the Registrant has stated that he has no interest in remaining on the HCPC Register. He has also, however, stated that “working as a Paramedic was the most rewarding, satisfying and enjoyable career that I could ever envisage.”
39. In reaching its decision to strike the Registrant from the Register the Panel has taken into account the following:
• There is no historic evidence before the Panel as to whether there had been any previous matters of concern arising from the Registrant’s previous conduct. There are no references which attest to the Registrant’s work as a paramedic before the events that led to these proceedings. There is nothing which supports the Registrant’s statement about his love of his career or his conduct since the incident.
• There is no evidence from the Registrant as to whether he has maintained his professional knowledge since leaving WMAS.
• The Registrant has stated his regret but there is nothing before the Panel which denotes or expresses true remorse. There has been no demonstration of insight into the seriousness of the Registrant’s omission to act.
• The Registrant has not provided any personal or professional references that would attest to his ability to work as a paramedic without concern in the future.
• There is no evidence of any steps the Registrant has identified which would address the possibility of repetition of the misconduct found.
40. The Panel has therefore come to the conclusion that the appropriate and proportionate sanction in this instance is to remove the Registrant’s name from the Register on a permanent basis. The Order is made on the grounds of service user protection and in the wider public interest.
The Order takes effect from 15 March 2016 following the appeal period. The Panel imposed an Interim Suspension Order to cover the appeal period.
This was a Conduct and Competence Committee hearing that took place at the HCPC on the 15 and 16 February 2016.
History of Hearings for Mr Andrew Davies
|Date||Panel||Hearing type||Outcomes / Status|
|15/02/2016||Conduct and Competence Committee||Final Hearing||Struck off|
|05/10/2015||Conduct and Competence Committee||Final Hearing||Adjourned|