Mr Anthony P Garrard

Profession: Paramedic

Registration Number: PA11238

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 18/01/2016 End: 17:00 20/01/2016

Location: Health and Care Professions Council, Park House, 184 Kennington Park Road, London, SE11 4BU

Panel: Conduct and Competence Committee
Outcome: Caution

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Allegation

Allegation (as amended at the hearing):
During the course of your employment as a Paramedic with South East
Coast Ambulance Service NHS Foundation Trust, you:
1. On 2 December 2013, attended an incident relating to Service User A and you:
a) did not complete a Patient Clinical Record;
b) did not complete a Non Conveyance Form;
c) did not make an onward referral to other health care professionals;
d) did not clear at the scene with control;
e) did not update the Intelligence Based Information System (IBIS) team;
f) did not obtain authorisation before driving back to the ambulance station.
2. On 29 June 2014, attended an incident relating to Service User B, and you:
a) did not ensure that clinical observations were documented;
b) did not make a full assessment of the patient's mental capacity;
c) did not make a full clinical assessment of the patient;
d) did not complete a Non Conveyance Form;
e) did not inform control that you were available;
f) did not inform control of your whereabouts.
g) tampered with the Mobile Data Terminal (MDT) following attendance at the incident.
3. On 10 July 2014, attended an incident relating to Service User C and you:
a) did not complete a Patient Clinical Record;
b) did not complete a Non Conveyance Form;
c) did not make an onward referral to the falls team or other health care professionals;
d) did not provide an appropriate standard of care to the patient in line with your employer's values, policies and procedures;
e) did not book clear with control;
f) did not update IBIS before leaving the patient's address.
g) tampered with the Mobile Data Terminal (MDT) following attendance at the
    incident and while returning to Guildford Ambulance Station.
4. On 31 March 2013, attended an incident, reference 21783940, and you:
a) No evidence offered by the HCPC – Discontinued.
b) tampered with the Mobile Data Terminal (MDT) following attendance at the incident.
5. On 21 December 2013, attended an incident, reference 22413317, and you:
a) did not complete the necessary documentation relating to patient care;
b) tampered with the Mobile Data Terminal (MDT) following attendance at the incident.
6. On 11 January 2014, attended an incident, reference 22468648, and you did not complete the necessary documentation relating to patient care.
7. On 14 January 2014, attended two incidents, and:
a) during incident, reference 22475954, you did not complete the necessary documentation relating to patient care and/or tampered with the Mobile Data Terminal (MDT) following attendance at the incident
b) during incident, reference 22475373, you did not complete the necessary documentation relating to patient care.
8. On 20 January 2014, attended incident, reference 22489423, and you tampered with the Mobile Data Terminal (MDT) following attendance at the incident.
9. On 22 January 2014, attended two incidents, and:
a) during incident, reference 22492485, you did not complete the necessary documentation relating to patient care;
b) during incident, reference 22492605, you tampered with the Mobile Data Terminal (MDT) following attendance at the incident.
10. On 15 February 2014, attended three incidents, and:
a) during incident, reference 22550625, you did not complete the necessary documentation relating to patient care;
b) during incident, reference 22550701, you did not complete the necessary
  documentation relating to patient care;
c) during incident, reference 22550806, you tampered with the Mobile Data
Terminal (MDT) following attendance at the incident.
11. On 9 March 2014, attended incident, reference 22605404, and you;
a) did not complete the necessary documentation relating to patient care;
b) tampered with the Mobile Data Terminal (MDT) following attendance at the
incident.
12. On 23 March 2014, attended incident, reference 22640822, and you did
  not complete the necessary documentation relating to patient care.
13. On 27 March 2014, attended incident, reference 22650931, and you tampered with the Mobile Data Terminal (MDT) following attendance at the incident.
14. On 8 May 2014, attended incident, reference 22753004, and you tampered with the Mobile Data Terminal (MDT) following attendance at the incident.
15. No evidence offered by the HCPC - Discontinued.
16. No evidence offered by the HCPC - Discontinued.
17. On 12 June 2014, attended an incident, reference 22838926, and you;
a) No evidence offered by the HCPC- Discontinued.
b) tampered with the Mobile Data Terminal (MDT) following attendance at the
incident.
18. No evidence offered by the HCPC.
19. On 18 June 2014, attended an incident, reference 22854104, and you;
a) No evidence offered by the HCPC.
b) tampered with the Mobile Data Terminal (MDT) following attendance at the
incident.
20. On 5 July 2014, attended an incident, reference 22894713, and you
tampered with the Mobile Data Terminal (MDT) following attendance at the incident.
21. On 6 July 2014, attended an incident, reference 22897846, and you
tampered with the Mobile Data Terminal (MDT) following attendance at the incident.
22. On 15 May 2014 attended an incident reference 22768509 and you tampered with the Mobile Data Terminal (MDT) following attendance at the incident.
23.   The matters at 2 (g), 3 (g), 4b, 5b, 7a, 7b, 8, 9b, 10c, 11b, 13, 14, 17b, 19b, 20, 21 and 22 were dishonest.
24. The matters set out in paragraphs 1 - 22 constitute misconduct.
25. By reason of your misconduct your fitness to practise is impaired.

Finding

Introduction:

Mr Garrard is registered with the HCPC as a Paramedic and at the relevant times was employed by South East Coast Ambulance Service (SECAM). He attended the hearing and was represented as shown above.
The HCPC relied upon the evidence of two witnesses who were both employees of SECAM at the relevant times:
         Mr A. P – Paramedic Manager

         Ms S. M – Dispatch Team Leader.

In support of Mr Garrard’s case the Panel heard evidence from Mr Garrard, Ms R.S the partner of Mr Garrard, and Ms S.R, line manager of Mr Garrard in his current employment with Care UK NHS 111 London Service.

Preliminary issues:

At the commencement of the hearing Mr Dilaimi made two applications. First, to discontinue certain of the current particulars of the allegation and, secondly, for other particulars to be amended. There was no objection to either application by Ms Wilkes.
With regard to the first application the Panel took into account the HCPC Practice Note on Discontinuing Proceedings. The application related only to a small proportion of the total particulars.  The Panel accepted the account from the HCPC that there was either no or inadequate evidence to support the particulars in question or that the issues were adequately covered by the remaining particulars. The Panel approved the discontinuance application.
The application for amendment concerned a better particularisation of the underlying concerns relied upon by the HCPC. The detail had been provided in writing to Mr Garrard some two months before this hearing. Taking into account the lack of objection the Panel approved the application to amend.
The particulars of the allegation given above shows the particulars as they are after both the amendments and discontinuance.
Ms Wilkes put the Panel on notice that at parts of the hearing she would be asking the Panel to go into private session when she wished to examine material relating to the medical conditions of relevant individuals. The Panel determined that it would, in those circumstances, be appropriate to go into private session (as and when the relevant evidence arose) to protect the private life interests of those individuals.     

Background:

At the times in question Mr Garrard was a paramedic working on an ambulance. Each ambulance was fitted with a Mobile Data Terminal (MDT), which forms part of a tracking system. When operated properly, the MDT kept the SECAM Dispatch Centre advised of the position of each ambulance which, in turn, enabled the effective deployment of ambulances to calls. 
On 10 July 2014 it came to the notice of the SECAM Dispatch Centre that MDT information in respect of the ambulance for which Mr Garrard was responsible showed that the ambulance had remained present at the scene of a call for three hours. Enquiries were made of the relevant ambulance station which revealed that Mr Garrard and his colleague had, in fact, returned with the ambulance to the ambulance station and had left their shift.

SECAM started enquiries and managers concluded that Mr Garrard had tampered with the MDT with the effect that the MDT supplied inaccurate information to the Dispatch Centre as to the whereabouts of the ambulance and, therefore, the crew.  In the course of those enquiries it also appeared to SECAM managers, on the basis of records, that Mr Garrard had not, on all occasions, properly assessed and treated patients and maintained proper records.   

The HCPC has two main areas of concern as to the practice standards of Mr Garrard. Those are that on specific occasions Mr Garrard:
(i)   did not provide appropriate patient assessment and treatment and did not  complete appropriate documentation

(ii) actively tampered with MDTs

At the commencement of the hearing Mr Garrard admitted most of the particulars and denied the others. 
The particulars admitted were:
1, 2, 3, 4(b), 5, 7(a) (as to MDT tampering), 7(b), 8, 9, 10b, 10c, 11, 12, 13, 14, 17(b) and 19 (b).

The particulars denied were:
6, 7(a)(as to not completing documentation), 10a and 23.

Decision on facts:

The HCPC has the burden of proving the facts on the balance of probabilities. Even where a Registrant admits a particular the Panel still has a separate responsibility to form its own view but in doing so may take into account any admissions by the Registrant.
In this case the Panel takes into account that Mr Garrard has been represented by Counsel. The Panel also takes into account all of the evidence and is satisfied that the admissions made by Mr Garrard are properly based.
On that basis the Panel finds the following particulars proved:
1, 2, 3, 4(b), 5, 7(a) (as to MDT tampering), 7(b), 8, 9, 10b, 10c, 11, 12, 13, 14, 17(b) and 19 (b).

In relation to particulars 1, 2 and 3 it is acknowledged that Mr Garrard admits his shortcomings in this regard. The Panel has reviewed the evidence supplied by the HCPC and whilst it concludes that Mr Garrard did not undertake the necessary assessments, documentation and onward referral on these occasions the patients were not harmed as a result. Nevertheless it is clear that service users were put at risk due to Mr Garrard’s failure to follow recommended procedures.
In relation to particulars 5(a), 7(b) and 12 the Panel has noted Mr Garrard’s position to the effect that in respect of the allegations that he failed to complete PCR forms, his practice was not to complete such forms in circumstances where, upon arriving at the scene, no patient was then present.

In that context the Panel has taken into account that a particular policy issued by SECAM may be read as requiring a PCR even in the type of circumstance referred to above. However, there has been other evidence which satisfies the Panel there was a clear accepted practice amongst a significant number of SECAM paramedics not to complete a PCR in those circumstances. The Panel has taken the view that although it was correct for Mr Garrard to admit some of the assertions relating to PCRs his failures in respect of particulars 5(a), 7(b) and 12, (in none of which was it proved that a patient was present), do not amount to misconduct.

The Panel has gone on to consider the particulars denied by Mr Garrard which are 6, 7(a) (as to documentation), 10a and 23 (dishonesty).
Particulars 6, 7(a) and 10(a) all assert that Mr Garrard failed to complete a PCR on occasions when patients were taken by him to hospital.  The accepted practice is that in such circumstances two copies of the PCR form would be created for each patient. The top copy would be retained in SECAM records and the carbon copy, in cases where the patient was admitted to hospital, would be passed to the hospital.

The HCPC case is based on evidence from Mr P to the effect that a PCR would be required in such cases but that, following enquiries, no PCR or carbon copy can be located. Mr Garrard’s case is that his invariable practice was to create a PCR where appropriate and that it would be extremely difficult for a patient to be admitted to hospital if a PCR was not accompanying the patient.
In the context of particular 10(a) the evidence from Mr Garrard has been that when SECAM was enquiring into the circumstances he made a visit to the relevant hospital and obtained a copy of the PCR form in question.  The Panel accepts the evidence of Mr Garrard that the copy PCR he has produced is in fact the one referred to in particular 10(a) and therefore finds this particular is not proved.

The Panel has considered particular 7(a) and takes into account that there is evidence showing that a PCR was at some stage attached to the incident report, although it could not subsequently be found. With regard to this and also particular 6 the Panel takes into account, and accepts, the evidence from Mr Garrard with regard to his usual practice and also takes into account the likelihood that there will be occasions when a PCR has been properly created but has been misfiled.  The Panel has concluded, on the balance of probabilities, that both particulars 6 and 7(a) are not proved.

The Panel has considered the particular asserting dishonesty and takes into account that the test in law is that the Panel should first determine whether on the balance of probabilities, the HCPC has shown that Mr Garrard acted dishonestly by the standards of reasonable and honest members of the public; and, if it finds that he did so, must go on to determine whether it is more likely than not that he realised that what he was doing was dishonest by those standards.
The Panel takes into account that in tampering with the MDT Mr Garrard was providing false information to the Dispatch Centre regarding the true whereabouts of his ambulance. The true whereabouts of an ambulance is a critical factor to be taken into account when the Dispatch Centre makes decisions on the effective and efficient allocation of ambulances. That, in turn, has a direct impact on patient safety.

The Panel has no difficulty in concluding that reasonable and honest members of the public (along with, for the avoidance of doubt, reasonable and honest paramedics) would regard the practice of tampering with the MDT as dishonest.

The Panel has gone on to consider whether it it is more likely than not that Mr Garrard realised at the time that what he was doing was dishonest by those standards.
During cross examination Mr Garrard accepted that his reason for tampering with the MDT was to prevent the Dispatch Centre from seeing the location of his ambulance and to avoid being given another job. He accepted that this amounted to providing inaccurate and misleading information but that this was “not a lie, we just haven’t provided them with the more current detail”. Mr Garrard stated that, at the time, he considered this to be a “minor misdemeanour”. He said that he realised he was not being “fully honest” but he was not being “dishonest”.

Mr Garrard also gave evidence that there was another practice operated by some paramedics in the area which was applied in circumstances where a patient was being delivered to hospital close to the end of a paramedic’s shift.  A paramedic in such circumstances might simply delay sending a signal over the MDT to the effect that they were now clear to take further calls. They would not send such a signal until the shift had virtually ended with the consequence that their time taken to return to the ambulance station would be paid at overtime rate or recompensed by time off in lieu. In giving his evidence Mr Garrard accepted that although he knew his tampering with the MDT was wrong he thought the above practice was more reprehensible because it involved improperly gaining overtime.
The Panel has taken into account the evidence from Mr Garrard and his partner, Ms S, regarding the medical condition experienced at the relevant times by Ms S.  The Panel accepts all of the evidence concerning that medical condition. Mr Garrard’s position is that he felt under tremendous pressure to tamper with the MDT system so as to ensure that, towards the end of a shift, he would not be allocated callouts by the Dispatch Centre which may have the effect of extending his shift and thus delaying his return from work so that he could care for Ms S.
However, the Panel also takes into account that there are 16 accepted occasions of tampering with the MDT equipment.  The practice of tampering required a continuous action by the paramedic crew throughout the period during which the MDT was disabled by repeatedly resetting it every 15 to 45 seconds. The events were not isolated occasions. They were committed over a protracted period of time.
The Panel also takes into account that on one occasion when Mr Garrard was tampering with the MDT he was told by a colleague it was wrong to do so.
In all the circumstances the Panel has concluded that at the times in question Mr Garrett did in fact himself appreciate and realise that what he was doing in tampering with the MDT would be regarded as dishonest by both honest and reasonable members of the public and honest and reasonable paramedics.   The Panel finds that in these respects he acted dishonestly.
Decision on grounds:

The Panel went on to consider whether the actions and failures of Mr Garrard amount to misconduct. As indicated above the Panel does not accept that particulars 5(a), 7(b) and 12 (where PCRs were not completed because a patient was not present) amount to misconduct.

However, the Panel finds that the other failings were serious and involved breaches of the following standards as set out in the HCPC Standards of Conduct, Performance and Ethics: 
1       You must act in the best interests of service users.

10     You must keep accurate records.

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.

The Panel finds that these failings do constitute misconduct.

Decision on impairment:

The Panel then considered the question of whether Mr Garrard’s fitness to practise is currently impaired.  In doing so the Panel took into account the HCPC Practice Note on Finding that Fitness to Practise is Impaired.   That document refers to the personal and public components that should be considered.  The personal component considers the current competence and behaviour of Mr Garrard. The public component considers the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession.
The Panel accepts that Mr Garrard has now gained sufficient insight into the gravity of his failings to preclude any real likelihood of further dishonest behaviour. The evidence of Mr Garrard has been that if in future he were to face similar circumstances he would act differently. The Panel accepts that evidence and has concluded that the risk of repetition of any failings found proved above is low.  Mr Garrard’s remediation on the matters which relate to shortcomings in his practice delivery is substantial. He has provided two reflective pieces where he has analysed his failings and he has produced evidence of further training which has reassured the Panel that any repetition is unlikely. The Panel has also taken into account the evidence of Ms R, who has attested to his integrity, his competence, and his management of conflicts between his professional obligations and his responsibilities as a carer. Accordingly, in all the circumstances, the Panel does not consider that Mr Garrard presents any future risk to public safety or to the reputation of the profession.    
However, in the context of the wider public interest the Panel again takes into account there were 16 occasions of dishonesty committed over an extended period of about 18 months.  On behalf of Mr Garrard the Panel has been asked to assess the circumstances from the perspective of a member of the public with full knowledge of all the circumstances in the case including the mitigating factors relating to Ms S.  The Panel has followed that approach but has concluded that even taking into account all of the surrounding circumstances the dishonest actions of Mr Garrard would be seen as serious breaches of proper standards of behaviour.  The Panel is dealing with repeated dishonest acts committed over an extended period of time. In the Panel’s view not to find current impairment would fail to declare and uphold proper professional standards and fail to maintain confidence in the profession and in the regulatory process. Accordingly the Panel finds that Mr Garrard’s fitness to practice is currently impaired. 

Decision on sanction:

The Panel has taken into account the HCPC Indicative Sanctions Policy. It is not mandatory to impose a sanction. If a sanction is to be imposed it must relate only to the facts proved or admitted. The primary function of a sanction is to address public safety issues although there will also be secondary considerations in the form of a deterrent effect on other professionals, maintaining the reputation of the profession and public confidence in the regulatory process. Any sanction must be proportionate and a key factor to be considered is the extent of insight demonstrated by a registrant.
The Panel has fully considered the submissions made by Mr Dilaimi and Ms Wilkes together with the references and testimonials provided. The Panel has also accepted the advice of the Legal Assessor.

The aggravating features of the case are that:
(i)the misconduct amounted to repeated acts of dishonesty over an extended period and

(ii)the failings on the part of Mr Garrard created potential harm to service users including the risk that service would be delayed by the inability of the Dispatch Centre to allocate the closest ambulance to a nearby emergency.

 The mitigating features are:
(i) although any dishonest behaviour is a serious breach of professional standards the dishonesty in this case was not at the higher end of the spectrum of culpability in that there was no apparent motivation beyond the desire to avoid work which would take him into overtime.

 (i)      the presence of substantial personal mitigation which the Panel accepts substantially contributed to his motivation to act dishonestly. This mitigation applied for the entire period over which the dishonesty occurred.

 (ii)    there is no evidence of actual patient harm.

 (iii)   comprehensive admissions at an early stage in the Trust proceedings and, except regarding dishonesty, in these regulatory proceedings.

Bearing those factors in mind the Panel has considered the available sanctions in ascending order. The Panel has determined that taking no action would fail to meet the public interest in declaring and upholding proper professional standards and maintaining confidence in the profession and the regulatory process.

The Panel next considered a caution order and noted that the Indicative Sanctions Policy states that such an order may be an appropriate sanction for cases where the lapse is limited, there is a low risk of recurrence, the Registrant has shown insight and taken appropriate remedial action. It notes that it “may also be considered in cases where the nature of the allegation means that meaningful practice restrictions cannot be imposed but where the Registrant has shown insight, the conduct concerned is out of character, the risk of repetition is low, and thus suspension from practice would be disproportionate”. This is just such a case.
The failings in this case in relation to dishonesty are limited in that they all arose from the same underlying issue of Mr Garrard’s desire to avoid finishing late so that he could provide care for his partner. The Panel also considers from the evidence it has heard that his misconduct is out of character. Mr Garrard has shown sufficient insight for there to be a low risk of recurrence. It is the view of the Panel that a fair minded member of the public apprised of all the circumstances of this case would consider that a lengthy caution order would be sufficient to demonstrate enough disapproval of Mr Garrard’s conduct to declare and uphold proper standards and maintain public confidence in the profession and the regulator. The Panel is of the view that the same fair minded member of the public would consider that, in the light of the substantial mitigation in this case, a sanction such as a suspension order, which would effectively deprive Mr Garrard of his current ability to earn a living, would be disproportionately punitive.

Accordingly the decision of the Panel is to impose a Caution order for a period of 5 years. The reason the period of 5 years has been selected is to emphasise the unacceptability of misconduct of this nature. It should also indicate that, even in the light of the very substantial mitigation, this misconduct is at the top of the range of behaviour which can be dealt with other than by a Suspension Order or Striking-off.

In order to test the soundness of the Panel’s judgment in imposing a Caution Order the Panel then considered the appropriateness of the next sanction in ascending order. Because a Conditions of Practice Order would not be appropriate, given the finding of dishonesty, the Panel considered whether a Suspension Order might be a more appropriate sanction. Having done so, the Panel determined that a Suspension Order was unnecessary to address the wider public interest as earlier identified as this is adequately achieved by a lengthy Caution Order. In the circumstances of this case, particularly in the light of all the mitigation, the Panel also considered that a Suspension Order would be disproportionate.

Order

"ORDER: That the Registrar is directed to annotate the register entry of Mr Anthony P Garrard with a caution which is to remain on the register for a period of five years from the date this order comes into effect."

Notes

No notes available

Hearing History

History of Hearings for Mr Anthony P Garrard

Date Panel Hearing type Outcomes / Status
18/01/2016 Conduct and Competence Committee Final Hearing Caution