Carolyn L Gaff
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1. In attending to an 86 year old female patient suffering cardiac arrest you,
a. Ceased resuscitation attempts without completing an assessment of patient, in that you did not check:-
I. Her pulse; and/or
ii. Breathing sounds; and/or
iii. Pupil reactions
b. ignored clinical signs indicating that the resuscitation of the patient should continue;
c. Did not cannulate and administer drug therapy to the patient
2. The matters set out in paragraph 1 constitute misconduct and/or lack of competence.
3. By reason of your misconduct and/or lack of competence your fitness to practice is impaired.
1. Mrs Gaff was neither present nor represented at this hearing. The Hearings Officer took the Panel through the proof-of-posting documentation, which demonstrated that, by letter dated 28 October 2015, sent by post to her address as it appears in the Register, the Council notified Mrs Gaff of the correct date, time and venue for this hearing. The Panel had regard to the Council’s Practice Note of Service of Proceedings. The Panel was satisfied that notice had been duly served by post in accordance with Rule 3 of the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 (the Rules).
2. Accordingly, the Panel went on to consider whether to accede to Mr Dilaimi’s application to proceed with the hearing in Mrs Gaff’s absence in accordance with Rule 11 of the Rules. Mr Dilaimi made reference to Mrs Gaff’s submissions for this hearing, which indicated that she would not be attending.
3. The Panel has had regard to the submissions of Mr Dilaimi, the written submissions of Mrs Gaff, the advice of the legal assessor and the contents of the Practice Note “Proceeding in the Absence of the Registrant”, dated August 2012.
4. The Panel has had at the forefront of its consideration that the discretion to proceed in the absence of the Registrant is one that must be exercised with the utmost care and caution. The central consideration is whether Mrs Gaff can be said to have voluntarily absented herself from the hearing. The Panel has borne in mind the need to take account of both fairness to the Registrant as well as the wider public interest. The Panel has taken appropriate account of the list of considerations set out in the Practice Note, including the fact that the Council’s three witnesses are present and Mrs Gaff’s indication that she would not be attending. The Panel noted that it does have available some written submissions from Mrs Gaff to take into account. The Panel considered, in the absence of information to the contrary, that an adjournment would be unlikely to secure the Registrant’s attendance.
5. In all the circumstances, the Panel was satisfied that the Council had made all reasonable efforts to bring this hearing to the Registrant’s notice. The Panel concluded that the Registrant can be said to have voluntarily absented herself from this hearing. Thus, the Panel was satisfied that it was proper to proceed to hear this case in Mrs Gaff’s absence under rule 11 of the Rules.
6. At the relevant time, Mrs Gaff was employed by the South East Coast Ambulance Service (SECAmb) as a Paramedic. She qualified as a Paramedic in 1990, but retired on health grounds in early 2013.
7. On 8 December 2012, Mrs Gaff was working as part of a two-person crew, together with Witness 1, who was at the time an Emergency Care Support Worker (ECSW). They were dispatched to attend to an 86-year old lady in cardiac arrest. Witness 2 and another person, both Ambulance technicians were already present at the scene. Mrs Gaff was the most senior person present for the most part and, therefore, the lead clinician.
8. Attempts at resuscitation of the patient were started, but towards the end of the period of twenty minutes, Mrs Gaff is alleged to have indicated that resuscitation would be ceased and the police, as representative of HM Coroner, should be informed. Witness 1 and Witness 2 were concerned about this as they considered that there may be indications for it to continue. A Critical Care Paramedic (CCP) attended, but was mistaken by Mrs Gaff for a Clinical Team Leader and sent away. After twenty minutes of attempted resuscitation, Mrs Gaff ceased the procedure. However, it is alleged that the necessary checks in respect of pulse, breathing sound and pupil reaction were not performed prior to the machinery being switched off.
9. Shortly thereafter, Witness 1 and Witness 2 checked the patient’s carotid artery and found a pulse. The monitoring equipment was restarted, the CCP was recalled and the police were stood down. The equipment confirmed a Return of Spontaneous Circulation. In due course, the patient was stabilised and transferred to hospital.
10. Witness 3 undertook an investigation of the incident on behalf of SECAmb. This led to a disciplinary hearing, the outcome of which did not result in any finding against Mrs Gaff. Although any sanction would have been unjustifiable, the disciplinary panel of SECAmb would have offered Mrs Gaff some “Learning and Development Interventions”.
11. On 24 February 2014, Mrs Gaff’s contract with SECAmb came to an end due to her ill health and she retired on that ground.
12. The panel heard oral evidence from three witnesses on behalf of the Council. They were:
(a) Witness 1, ECSW (at the time, now a registered Paramedic);
(b) Witness 2, Ambulance Technician; and
(c) Witness 3, registered Paramedic, Clinical Operations Manager for SECAmb and Mrs Gaff’s line manager, who undertook the internal investigation.
13. The panel read the statements and exhibits bundles. It also read the submissions sent in by Mrs Gaff in 2014 during the investigation and in 2015 for the purposes of this hearing.
14. Witness 1 confirmed the accuracy of his recollection of events on 8 December 2012. He was concerned that Mrs Gaff was ignoring vital signs that suggested resuscitation should continue and that she was not paying enough regard to the potential for it to be successful. He said that Mrs Gaff considered the monitoring equipment to be indicating Dying Heart Syndrome (DHS), whereas he was of the view that it may well be Pulseless Electrical Activity (PEA). Witness 2 agreed with Witness 1’s assessment of the monitoring equipment. Witness 1 accepted that the screen resolution of the monitoring equipment may not have been good enough to ascertain detailed measurements of electrical activity, but he was satisfied that it was sufficient to be able to distinguish between DHS and PEA. He did not see Mrs Gaff use a stethoscope or torch to check the patient’s breathing pattern or pupils. He explained that, in his subordinate role as ECSW, it would have been difficult to contradict Mrs Gaff, but that he and Witness 2 were pointing out matters that seemed to conflict with Mrs Gaff’s assessment of the situation. Asked about any pre-existing conflict or tension between himself and Mrs Gaff, as mentioned in general terms in her submissions, Witness 1 denied being aware of any tension with him or with any others present.
15. Witness 2 confirmed her witness statement. She expressed concern about what she considered to be Mrs Gaff’s “premature” conclusion that resuscitation would be attempted for twenty minutes and not longer. Witness 2’s interpretation of the monitoring equipment was that it showed PEA, rather than DHS, and she recalled alerting Mrs Gaff to this more than once. After the CCP had been sent away, Witness 2 considered that the monitoring equipment was showing increased signs of life and she announced that she wanted to recall the CCP. She confirmed that after the resuscitation had been ceased by Mrs Gaff, Witness 1 checked the patient’s carotid pulse and then asked Witness 2 to do the same. Both were satisfied that there was a pulse, but Mrs Gaff was not persuaded. Eventually, Witness 2 said that the monitoring equipment should be switched back on as this would provide evidence that the patient had a rhythm. Witness 2 did not see Mrs Gaff undertake any checks for a pulse, breathing sounds or pupil reaction. Witness 2 also denied any history of difficulty with or ill-feeling towards or from Mrs Gaff, whom she only knew in a limited professional way as they worked out of different stations.
16. Witness 3 adopted his statement and explained that he had known Mrs Gaff for some years as her line manager. He had conducted the internal investigation. He was unaware of any history of difficulty or tension between himself and Mrs Gaff as suggested in general terms in her submissions.
In her written submissions, Mrs Gaff stated:
“I can add nothing further to my original statement made in January 2013 … Although I do note that [Witness 1] has changed his original statement. I would follow this by saying that I am certain that regular circulation checks were made every 2 minutes throughout the duration of the episode, as we were using the [monitoring equipment] which prompted us to do so and was the whole point of remaining on that machine. I am also equally certain that the patient was in asystole at the point at which I decide [sic] to end the resuscitation attempt and that the patient had not presented any rhythm during the episode prior to ceasing. Furthermore I would also state that I did perform a pulse and pupil check at the time of ceasing, and consequently did not ignore clinical signs…”
17. Mrs Gaff also referred back to her earlier correspondence in which she expressed concerns about the way in which the witnesses were misrepresenting her for ulterior reasons.
Decision on Facts
18. As regards the Council’s witnesses, the Panel found that all of the witnesses to be credible in that they came to give their evidence to the best of their ability. There were some minor discrepancies amongst particular parts of the documentary evidence, but these were not considered to be of any consequence. In broad terms, the panel found the evidence of the Council’s witnesses to be reliable and consistent. In addition, the Panel noted that the witnesses were quick to say where they no longer had a direct recollection of events, given the passage of time.
19. In reaching its decisions on the factual stage of the proceedings, the panel took account of all of the evidence, oral and documentary, the submissions of Mr Dilaimi, the written submissions of Mrs Gaff and the advice of the legal assessor. The panel also took account of the guidance contained in the Practice Note on ‘Finding that Fitness to Practise is Impaired’, dated July 2013. The panel drew no adverse inference from the absence of Mrs Gaff from the hearing, but it did take into account the various documents available to it that contain Mrs Gaff’s explanations for what happened.
Paragraph 1ai – proved
20. Having satisfied itself of the reliability of the evidence of Witness 1 and Witness 2, the panel found this paragraph proved. Neither witness could recall any checking of the patient’s pulse during or immediately prior to the cessation of resuscitation. Both would have been in a position to observe Mrs Gaff performing this action if she had done so and the panel was particularly aware of the evidence of both witnesses having checked the patient’s carotid pulse immediately after resuscitation was stopped.
Paragraph 1aii – proved
21. Again, the panel took account of the evidence from Witness 1 and Witness 2. Furthermore, it noted that Mrs Gaff acknowledged in her submissions that, “I did not check for breath sounds”.
Paragraph 1aiii - proved
22. For the same reasons given in relation to paragraph 1ai of the allegation (paragraph 21 above), the panel found this proved on the balance of probabilities.
Paragraph 1b – proved
23. The panel noted that Witness 1 and Witness 2 described a difference of clinical opinion between themselves and Mrs Gaff, with the former taking the view that the monitoring equipment indicated PEA and Mrs Gaff considering it to be DHS. Although the panel acknowledged that circumstances can arise when such a difference of opinion is reasonably held, it considered that in this case, the descriptions given by Witness 1 and Witness 2 clearly suggest a failure on the part of Mrs Gaff to consider that she might be wrong in her assessment and, therefore, a failure to undertake further exploration of the possibility that the patient was showing signs of PEA. Both witnesses felt a carotid pulse and, if this check had been performed by Mrs Gaff (which the panel has found she did not do) then she would have likely found it too. Mrs Gaff’s assertions about the checks that she performed during and before ceasing resuscitation are not supported by the other evidence available to the panel and, in the circumstances, the panel was satisfied on the balance of probabilities that Mrs Gaff ignored clinical signs that resuscitation should continue. This conclusion is, to some extent, also supported by the short time period before the monitoring equipment, once switched on again, registered the patient’s now Normal Sinus Rhythm.
Paragraph 1c – proved
24. The panel noted that Mrs Gaff acknowledges in her submissions that she did not cannulate or administer drug therapy to the patient. The absence of both these interventions is confirmed by Witness 1 and Witness 2. The panel therefore found this paragraph proved.
Decision on Grounds
25. The Council, through Mr Dilaimi, submitted that the facts in the allegation amounted to misconduct or lack of competence. Mr Dilaimi referred the panel to his detailed opening note and the definition of these two grounds as set out in the case of Calhaem. He also made reference to the definition in the case of Roylance and the need for any failing to be serious or grave before satisfying the statutory ground.
26. The Panel received advice from the legal assessor who addressed them on the point that misconduct, in line with the Practice Note requires a serious falling short of the standards expected of a registrant in the circumstances. However, he also made reference to the case of Calhaem, where the potential for a finding of lack of competence could arise in a particularly grave case, even though it may be an isolated incident. The legal assessor stressed the importance of considering Mrs Gaff’s 22-years of unblemished service in this regard.
27. Applying its professional judgment to the matters found proved, the Panel was satisfied that the failings detailed in the allegation amounted to conduct which fell far below the standards expected of a competent Paramedic. Mrs Gaff’s omissions in terms of checking vital signs are of the most basic kind when treating patients, especially those suffering cardiac arrest and it was a matter of significant concern to the panel that justifiable and legitimate alternative views raised with her by junior colleagues (with some relevant experience), however gently and perhaps even indirectly, were not accorded the respect that they ought to have been.
28. In the panel’s determination, the acts and omissions of Mrs Gaff on the 8 December 2012 fall squarely within the definition of misconduct. In reaching this conclusion, the panel was mindful of Mrs Gaff’s lengthy and previously unblemished career, such that a finding of lack of competence would not be appropriate.
Decision on Impairment
29. The panel heard submissions from Mr Dilaimi on the question of current impairment and took account of the relevant parts of Mrs Gaff’s written submissions.
30. As to impairment, the legal assessor again invited the panel’s attention to the Practice Note, highlighting the need to consider the extent to which the matters found proved are capable of and have been remedied. He also reminded the panel of the public interest grounds on which impairment can also be found.
31. The panel has concluded that Mrs Gaff’s fitness to practise is currently impaired.
32. As regards the personal element of assessing impairment, the panel took account of the context in which those failings occurred, being a single event within a 22-year career. The panel took the view that the failings identified were likely to be remediable. However, whilst appreciating that Mrs Gaff has retired on medical grounds and, therefore, did not take up offers of relevant learning to address the failings identified, the panel was concerned about the limited nature of Mrs Gaff’s insight into those failings. Her assertion of some ulterior motive on the part of one or more of the witnesses or others involved in the internal investigation was not borne out by the oral evidence, which the panel accepted. In particular, the panel relied on Witness 3’s knowledge of Mrs Gaff as her line manager for a number of years in this regard. In the absence of full insight and some demonstrable remediation, the panel cannot be satisfied that there will not be any repetition of the failings in the future. The panel has to concern itself with protection of the public and Mrs Gaff’s current position may change and, in the future, she may wish to return to practice even in a non-clinical role. Therefore, a finding of current impairment on the personal component is proper in all the circumstances.
33. As to the public component, the panel had to take account again of the context within which it has found that Mrs Gaff’s failings occurred. She was attending a patient suffering a cardiac arrest and, as with many other aspects of the role of Paramedic, there are protocols in place to guide clinical practice and actions in the best interests of patients. A Paramedic’s failing to ensure adherence to protocols, particularly at serious events such as with the patient in this case, gives rise to concern in the public consciousness as to the degree of confidence that can legitimately be placed in the profession as a whole. When coupled with a failure to heed the concerns of colleagues, especially those who are experienced even though they may not be registered professionals, the public’s concern about confidence in the profession is heightened. The need to remind Paramedics of the importance of conforming to practice established in the accepted protocols and of working effectively and positively within a team are also active aspects of this case that favour a finding of current impairment.
34. In all the circumstances, the panel determined that Mrs Gaff’s fitness to practise is also impaired on the basis of the public component.
Decision on Sanction:
35. Mr Dilaimi submitted that the question of sanction is a matter for the panel and reminded the panel of the Indicative Sanctions Policy. He also submitted that the panel has the full range of sanctions available in this case, identifying the aggravating and mitigating factors as submitted by the Council.
36. The panel received advice from the legal assessor, who made reference to the Council’s Indicative Sanctions Policy and, specifically, the question of proportionality. The panel accepted this advice.
37. In reaching its determination on sanction, the Panel has again given careful consideration to all of the evidence and to the submissions of Mr Dilaimi, the written submissions of Mrs Gaff, as well as its findings at the earlier stages of the proceedings.
38. The panel reminded itself that although the primary purpose of sanction is to address public safety, nevertheless the wider public interest considerations of the reputation of the Paramedic profession, public confidence in the profession and the regulatory process and the deterrent effect on other registrants are all key considerations in this case.
39. The panel had regard to the Council’s Indicative Sanctions Policy and the need to ensure that any sanction imposed is both reasonable and proportionate, properly balancing the interests of the public with Mrs Gaff’s own interests. The panel accepted the legal assessor’s advice that proportionality would mean imposing no greater restriction on Mrs Gaff’s ability to work as a Paramedic than is absolutely necessary to protect patients and/or satisfy the public interest engaged in this case.
40. As a preliminary point, the panel considered the aggravating and mitigating features. In relation to aggravating factors the panel considered that the identified failings in Mrs Gaff’s practice, which were fundamental in nature, occurred without any obvious cause, and the panel has rejected the limited explanation provided in her written submissions. The attendant limited insight and complete lack of any expressed remorse for the incident only exacerbated the findings made by the panel in the earlier stages. Mrs Gaff did not appear, in the panel’s view, to appreciate the seriousness of her failings, their potential for harm to patients or their effect on the team work that is so vital within the profession.
41. In respect of mitigating factors, Mr Dilaimi properly raised Mrs Gaff’s long and previously unblemished career as well as her recognition that if she had been able to continue in the profession, she would have undertaken some relevant training to avoid any repeat. Mrs Gaff did acknowledge that she had not dealt with the incident in an ideal manner.
42. When characterising the findings of fact, it seemed to the panel that they should properly be seen as a series of failings demonstrated during the course of a single event. In reaching its decision in this case, the panel is anxious to emphasise that it has been influenced only by the potential serious harm that might have been caused by Mrs Gaff’s failings on 8 December 2012 (or if they were to be repeated in the future) and in no way by the actual outcome for the patient in question.
43. The panel first considered taking no further action, but decided that the public would not be protected and the public interest considerations in this case would not be addressed at all by such an outcome. The identified, and as yet unremediated, failings were too serious for the case to conclude without action being taken by the regulator.
44. The panel took the view that mediation would be an inadequate sanction in the circumstances of this case to address the significant public protection and public interest aspects of it.
45. The panel next considered a Caution Order, but it determined that the impairment overall could not be said to involve an isolated lapse of a minor nature. The panel concluded that the public protection and public interest considerations could not be met by the imposition of such an order, particularly as it had expressed no confidence that the risk of repetition could be said to be low. Further, Mrs Gaff’s limited insight and the absence of evidence of remediation added to the reasons why a Caution Order would be inadequate in this case.
46. The panel then considered imposing a Conditions of Practice Order. Such a sanction must be formulated with workable, practical and measurable conditions. Whilst the absence of an employer does not prevent such an Order being appropriate, the absence of an intention to practise, as espoused by Mrs Gaff currently, makes a Conditions of Practice Order impractical and unworkable. In the panel’s view, it would also be insufficient to mark the unacceptability of the failings found proved in order to maintain public confidence in the Paramedic profession and the regulatory system as a whole.
47. The panel then considered a Suspension Order, recognising that this would represent a serious and significant restriction on Mrs Gaff’s ability to practise as a Paramedic. The panel took account of all of the evidence and was mindful of the relevant paragraphs of the Indicative Sanctions Policy. In particular, the panel noted the provisions of paragraph 32 of the Indicative Sanctions Policy:
'32. Suspension should be considered where the Panel considers that a caution or conditions of practice would provide insufficient public protection or where the allegation is of a serious nature but unlikely to be repeated and, thus, striking off is not merited.'
48. The panel has already concluded in its impairment determination that Mrs Gaff has limited demonstrated limited insight and there is no tangible evidence of remediation. It is undoubtedly the case, in the panel’s estimation, that the identified failings were very serious and they could have had very serious consequences indeed. Furthermore, the panel determined that public confidence in the Paramedic profession and its regulation would not be maintained by the imposition of a Suspension Order in the specific circumstances of this case.
49. The panel noted paragraph 42 of the Indicative Sanctions Policy, which states:
'42. 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...'
50. The Paramedic profession is one that is high in the public consciousness, because of its role in emergencies, particularly those where a person’s life may be at risk. The very highest degree of compliance with accepted protocols and practice is justifiably expected by the public in such circumstances. Any deviation or failure of the kind found in this case has significant potential to undermine public confidence, such that only a Striking off order will be sufficient and proportionate to redress this.
51. In all the circumstances of this case, the panel has determined that only a Striking off order will be sufficient to meet all of the purposes for which sanction is imposed.
History of Hearings for Carolyn L Gaff
|Date||Panel||Hearing type||Outcomes / Status|
|04/01/2016||Conduct and Competence Committee||Final Hearing||Struck off|