Mr Stephen E Meyern

Profession: Paramedic

Registration Number: PA02239

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 09/03/2016 End: 17:00 11/03/2016

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

Panel: Conduct and Competence Committee
Outcome: Conditions of Practice

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Allegation

Allegations (as amended):

During the course of your employment as a Paramedic with East of
England Ambulance Service NHS Trust,

1. On 8 September 2013, you were sent to attend an emergency call for a patient who was described as 'fitting', and:-

a. You did not take a defibrillator into the emergency scene to assist you in your treatment of the patient.

b. You did not take a bag valve mask (BVM) into the emergency scene which caused a delay in providing assisted ventilation to the patient.

c. You instructed an Emergency Care Assistant (ECA) to act outside of the Trust's protocol and/or gave incorrect instructions in that:

i. You directed an ECA to draw up diazepam which is a controlled drug.
ii. You directed an ECA to draw up diazepam with a saline solution.
iii. You directed an ECA to administer diazepam intravenously.
iv. You directed an ECA to prepare adrenaline.
v. You directed an ECA to administer adrenaline intravenously.

d. In using a carry sheet to move the patient from the scene you did not ensure that the patient’s airway was correctly maintained.

e. You did not provide an appropriate Patient Care record in that you recorded inadequate details of the drugs given.

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 practise is impaired.

 

Finding

Preliminary matters


There were no preliminary matters. 

Proceeding in Private

1. However, during the Registrant’s evidence, the Panel considered an application from Ms Spencer on behalf of the Registrant for parts of the hearing to proceed in private during the times that evidence about his health was being considered.  There was no objection to this application by Mr Chalmers.

2. The Panel reminded itself of the provisions of Rule 10(1)(a) of the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 (the Rules), which states:

“At any hearing—
(a) the proceedings shall be held in public unless the Committee is satisfied that, in the interests of justice or for the protection of the private life of the Registrant, the complainant, any person giving evidence or of any patient or client, the public should be excluded from all or part of the hearing;”

3. The Panel also noted the Practice Note entitled “Conducting Hearings in Private”.

4. The Panel was mindful that, under Rule 10(1)(a), it must be satisfied that it is in the interests of justice or for the protection of the private life of a Registrant before a decision can be made to exclude the public from any proceedings. Moreover, its decision must be consistent with Article 6(1) of the European Convention on Human Rights (ECHR), which provides limited exceptions to the need for hearings to be held in public, namely that it is “in the interests of justice or for the protection of the private life of the health professional, the complainant, any person giving evidence or of any patient or client”.

5. The Panel decided to grant the application so as to protect the private life of the Registrant insofar as to hold the hearing in private whenever matters of the Registrant’s health were being discussed. Accordingly, at various times during the hearing the Panel went into private session.


Amendment to the particulars


6. In addition, at the conclusion of the evidence from both parties, and prior to the Panel making any decision on facts, a joint application was made by the parties to amend particulars 1 (e) and 1 (f) on the basis that such amendments more properly reflected the evidence heard by the Panel.

7. It was proposed that particular 1 (e) be amended so as to read: “You did not provide an appropriate Patient Care Record in that you recorded inadequate details of the drugs given”.  It was further proposed that particular 1 (f) would be deleted in its entirety.  It was argued that the proposed amendments

• gathered all the allegations relating to the administration of medication in one particular and therefore avoided duplication;
• reflected the fact that the Registrant and his representatives had understood that the original particular 1 (f) related to a set of circumstances not in fact being argued by the HCPC and he had denied that allegation on that basis;
• more properly reflected the evidence heard by the Panel.  

8. In reaching its decision on the application for amendment, the Panel has taken account of the submissions of the parties and the advice of the Legal Assessor (to the effect that any amendment could be made provided there was no prejudice to the Registrant and that it could be done without injustice) which it has accepted, not least because the Registrant indicated that he would maintain his admission to the amended allegation 1 (e), and his denial of allegation 1 (f) would be sustained by the withdrawal of that particular.  The Panel also agreed that the amendments more accurately reflected the evidence that had been presented to the Panel.

9. The Registrant then admitted the amended particular 1 (e).

 
Background


10. The Registrant was a Duty Locality Officer (DLO) with East of England Ambulance Service (EEAST). He was responsible for the management of emergency care practitioners, paramedics, ambulance technicians and emergency care assistants (ECA). 

11. On 8 September 2013 the Trust received an emergency call in relation to a patient who was described as “fitting”. That evening the Registrant was working in a rapid response vehicle (RRV). He was dispatched to the scene and was advised by the emergency responder that the patient had been “fitting” for approximately 20 minutes. The call was categorised as ‘R1’ (life threatening).

12. The Registrant was the first to arrive at the scene. Upon his arrival he selected equipment from the boot of his vehicle and took it to the location of the patient.  However, he was unable to take a defibrillator with him as he had too many other items of equipment to carry.  The Registrant was let into the patient’s house by the patient’s wife and shown upstairs to a bedroom where the patient was in bed.  An ambulance crew followed, consisting of Witness 1, ECA, and SK, ECA. 

13. The Registrant provided clinical care to the patient with the assistance of both ECAs as follows.  The Registrant cannulated the patient and asked Witness 1 to draw up a vial of diazemuls (diazepam) with a saline flush, which was the wrong solution.  The preparation of such medication was outside the scope of her practice.  Nonetheless, Witness 1 prepared the vials as requested and showed them to the Registrant.  He asked her to put the solution through the cannula.  Thereafter the Registrant and SK prepared to take the patient to the ambulance.  Witness 1 then overheard SK tell the Registrant that the patient was “rasping at 8”, which is a low level of breathing.  The Registrant advised SK that the patient’s breathing would return back to normal.   

14. The patient then suffered respiratory arrest.  Witness 1 heard the Registrant and SK discussing that the patient was not breathing.    It was realised that the Registrant had not brought a BVM into the property, and therefore SK had to make a trip to the ambulance to obtain one, after which it was used on the patient. Soon after, the patient suffered cardiac arrest and there was a need for a defibrillator but the Registrant had not brought one to the scene.  SK then went to the ambulance a second time to retrieve it.  

15. The patient was moved from his bed to the floor.  The Registrant asked Witness 1 to prepare adrenaline, which was also outside the scope of her practice.  However, she did prepare the adrenaline and then the Registrant asked her to administer it through the cannula, which she did.

16. When the patient began to improve, he was placed on a carry sheet in order to move him downstairs and into the ambulance.  SK began packing up the equipment that had been used and whilst he did so the Registrant and Witness 1 moved the patient from his bedroom and down the stairs.  The Registrant led and went backwards down the stairs with the patient’s head facing towards him and pointing down the stairs.  Although Witness 1 considered that the patient’s positioning could compromise his airway she did not have time to suggest this to the Registrant as they were moving so quickly (the journey taking in all some 30 seconds).  At the bottom of the stairs the patient was transferred to a stretcher located at the front doorway and thence to the ambulance.

17. The patient was taken to hospital in the ambulance by the Registrant and by Witness 1, with SK following in the RRV.  The Registrant therefore delegated the task of asking the patient’s wife for relevant details and completing the Patient Care Record (PCR) to SK, who was able to partly complete it, but who omitted the doses of drugs given as he was unaware of these.  Upon arrival the Registrant handed over verbally to the hospital staff but, although he was given the partially completed PCR by SK did not then complete it as he was called to another job.  The evidence from Witness 2, the Trust Investigating Officer, was that the Registrant would have been expected to complete and handover the paperwork to the hospital before accepting another call out. Witness 1 saw that the PCR had been left in the resuscitation cubicle.  One of the doctors started asking her questions about the patient which she could not answer as the information requested was not on the PCR.  SK attempted to complete the form later but was unable to.  The Registrant returned to the hospital about 1½ hours later but although he took the PCR from SK and signed it off the Registrant also did not complete the same with full and adequate details of the medication that had been given to the patient or the amounts thereof.   
 
18. The next day Witness 1 raised concerns regarding the clinical care provided to the patient (who had nonetheless survived the experience) by the Registrant. A Serious Investigation was initiated, the outcome of which was to initiate a disciplinary process.  During the period of the disciplinary process the Registrant was suspended from front-line duties and given office-based work, although for about six months of this period he was on sick leave. 

19. On 31 October 2013 Witness 2 was commissioned as the investigating officer. His investigation concluded in April 2014.  A disciplinary hearing was held on 7 May 2014 at which a number of the allegations against the Registrant were found proved and he was given a Final Written Warning and was also required to undertake an Action Plan, such to cover: clinical knowledge in relation to drug pharmacology; the “fitting” patient and the effects of hypoxia (lack of oxygen); observation of a variety of patients and clinical practice; and reading about the scope of practice for staff.

20. The Registrant appealed against that decision but the decision was upheld at an appeal hearing on 13 January 2015.   


Decision on facts


21. In considering this case the Panel bore in mind that the burden of proving the facts rests upon the HCPC and that the standard of proof is the civil standard of the balance of probabilities. It has taken account of all the evidence presented to it, namely the written and oral evidence of the witnesses listed below, together with the documentary evidence provided by both parties. It has also considered the submissions of Mr Chalmers and Ms Spencer, and has accepted the advice of the Legal Assessor.

22. The Panel heard from three witnesses on behalf of the HCPC:

Witness 1 – ECA;

Witness 2 – Head of Operations Analysis for EEAST and Investigating Officer;

Witness 3 – Consultant Paramedic for EEAST and Chair of the Disciplinary Panel

23. The Panel also heard from the Registrant and considered various testimonials, certificates and references relating to the Registrant.

Decisions in relation to each particular, as amended

During the course of your employment as a Paramedic with East of
England Ambulance Service NHS Trust,

1. On 8 September 2013, you were sent to attend an emergency call for a patient who was described as 'fitting', and:-

a. You did not take a defibrillator into the emergency scene to assist you in your treatment of the patient.

Found Proved

24. The Panel noted that the Registrant admitted this allegation and relied upon that admission in finding the allegation proved, taking account of the fact that the Registrant had received legal advice on the matter and was represented.  Moreover, the allegation was supported by the evidence of the HCPC witnesses and the documentary evidence, all of which the Panel accepted for the purpose of proving the allegation. 

25. The Panel additionally noted the Registrant’s evidence that, as he had arrived at the scene alone, he was unable to take the defibrillator with him into the patient’s house because he was carrying his responder bag in one hand and drugs and oxygen in the other, which he considered to be the essential items for a “fitting” patient.  He had been informed that another vehicle had been allocated to his job (although he understood that it could take anything from two to 40 minutes to arrive) and therefore knew that at some stage he would be able to rely upon that back-up crew.  He had earlier attended two other “fitting” cases that evening but on each occasion the ambulance crews had arrived before he did.

26. In cross examination he said that if he had been able to take the defibrillator with him he would have done so.  He had parked the RRV about 50 yards away from the patient’s home so as to leave enough room for the ambulance. He did not ask the patients wife to help with carrying in any equipment.   He said his vehicle was too far for the patient’s wife to carry any equipment and in any event she was inadequately dressed and would not know what equipment to look for.  Moreover, she had children to look after. 

27. The Registrant went on to say that upon arrival, the patient’s wife told him that, contrary to what he had been told when called to the job, the patient had not been “fitting” for 20 minutes but for up to an hour and a half therefore his priority was to deal with the patient.  He recalled that, although he did not ask either Witness 1 or SK to fetch either the defibrillator or the BVM when they arrived shortly after he did, this was because he was dealing with the patient and he wanted to put the cannula in place.  However, he did ask for the defibrillator to be fetched at a later stage.     

28. The Registrant accepted that the first line of the JRCALC guidance on assessment and management of convulsions in adults (table 3.54) states, ‘always take a defibrillator to a convulsing patient – this may be a presenting sign of circulatory arrest at the onset of a sudden cardiac arrest’.  Moreover, he agreed that a defibrillator should always be taken when dealing with a “fitting” patient and that it was of the “utmost priority”.  He maintained that had he been advised that the patient was a cardiac patient he would definitely have taken the defibrillator with him.

b. You did not take a bag valve mask (BVM) into the emergency scene which caused a delay in providing assisted ventilation to the patient.

Found Proved

29. The Panel noted that the Registrant admitted this allegation and relied upon that admission in finding the allegation proved, taking account of the fact that the Registrant had received legal advice on the matter and was represented.  Moreover, the allegation was supported by the evidence of the HCPC witnesses and the documentary evidence, all of which the Panel accepted for the purpose of proving the allegation. 

30. The Panel noted the Registrant’s evidence.  He stated that he normally carried a BVM in his responder bag and one or two spares in his vehicle.  However, that evening he had used one of his BVMs and had given one to a crew at the hospital as they had been asked to attend a patient who had suffered a cardiac arrest and they did not have one.  It was a very busy night (in all, he attended some 16 jobs in a 12 hour shift) and, although he had subsequently returned to the ambulance station for just over an hour prior to being asked to attend the patient, he became engrossed in some managerial duties (restocking about 17 drugs bags for the night and day crews).  He knew that he had no BVMs left and had intended to restock his own responder bag, but it had slipped his mind. 

31. In cross-examination he accepted that a BVM was crucial if a patient was not breathing and, if one had been in his responder bag, he would have used it as soon as they noticed that the patient had stopped breathing.  He suggested that he had overlooked his lack of a BVM because he had multiple managerial jobs to attend to at the station.  

c. You instructed an Emergency Care Assistant (ECA) to act outside of the Trust's protocol and/or gave incorrect instructions in that:

i. You directed an ECA to draw up diazepam which is a controlled drug.
ii. You directed an ECA to draw up diazepam with a saline solution.
iii. You directed an ECA to administer diazepam intravenously.
iv. You directed an ECA to prepare adrenaline.
v. You directed an ECA to administer adrenaline intravenously.

Found Proved

32. The Panel noted that the Registrant admitted all the individual allegations (i) to (v) and relied upon that admission in finding the allegation proved, taking account of the fact that the Registrant had received legal advice on the matter and was represented.  Moreover, the allegation was supported by the evidence of the HCPC witnesses and the documentary evidence, all of which the Panel accepted for the purpose of proving the allegation. 

33. Accordingly, the allegation that the Registrant instructed an ECA to act outside of the Trust’s protocol and/or gave incorrect instructions is found proved.

34. The Registrant confirmed that the patient was very unwell when he arrived, as evidenced by the patient’s wife confirming that he had “fitted” 3 times that day for more than an hour in total.  His focus therefore was on dealing with the patient.  He went on to confirm that it was accepted practice in their area for ECAs to draw up, prepare and administer drugs under the supervision of the paramedics in order to assist them as much as possible.  Moreover, most of the ECAs wanted to go on to become paramedics and therefore wanted to develop this part of their practice.  Their supervision would consist of them showing the paramedic the vials before they were drawn up, reading out the batch numbers, and being observed by the paramedic when administering medication.  The Registrant stated that Witness 1 had administered controlled drugs under his, and other paramedics’ supervision before, on a number of occasions.

35. In relation to the administration of diazemuls, Witness 1 stated that she had prepared 10 mls of the drug for administration and that the Registrant told her to inject all of it into the cannula over the course of 5 to 10 seconds.  She recalled that she counted about 8 seconds.  The Registrant disputed this, stating that he had always been trained to draw up the drug with a saline solution and to give the drug in two 5 ml doses over the course of two minutes.  This was what had happened on that night.  5 mls was administered by Witness 1 and when the patient started to show signs of “fitting” again another 5 mls was given.  He maintained that if 10 mls were given as described by Witness 1 then it was likely that the patient would suffer respiratory failure. 

36. In cross examination he acknowledged that he had stated during his interview with the Trust that he had administered the first bolus of the drug but was “fairly certain” (allowing for the lapse of time since the incident) that Witness 1 had given it under his supervision.  He suggested that he might have interpreted the question he was asked during the interview as seeking to establish whose decision it was to administer the drug.  However, he agreed that he was aware of the limitations of the ECA’s practice at the time but understood that under supervision they could be more involved.  He accepted that he had not read all of the documents in the Trust Intranet on the subject and that as a manager he should have done so.  In relation to the administration of adrenaline, it came in a syringe and did not need to be drawn up.  However, he accepted that the administration of both the diazemuls and the adrenaline was outside the scope of Witness 1’ practice. 

37. In relation to mixing drugs with a saline solution, he stated that he had not seen any bulletins advising that this was not best practice (since diazemuls/diazepam was a fat emulsion and therefore would not mix with water, the main component of a saline solution).  He pointed out that this was only clarified by EEAST in a Clinical Update issued in February 2014.  However, he accepted that he should have been aware of this far earlier and that he now understood that it was best practice not to mix diazepam with a saline solution.

38. The Panel has reminded itself that these particular allegations against the Registrant are confined to the issue of asking an ECA to work outside the scope of her practice and of giving incorrect instructions in relation to mixing the diazemuls with a saline solution and considers that it does not need to make any finding about whether the diazemuls was administered in one 10 ml dose or two 5 ml doses.  Moreover, there is no allegation before it that suggests that the patient’s subsequent respiratory failure was caused by any such overdose – indeed, Witness 2 accepted in his evidence that he did not know whether there was such a causal link.  The Panel has therefore made no finding on the matter.

d. In using a carry sheet to move the patient from the scene you did not ensure that the patient’s airway was correctly maintained.

Not Proved

39. The Panel noted the evidence of Witness 1 that she did not at that time realise that a carry sheet should not have been used but that she agreed that an IBEX chair was not suitable as the patient was at the time unconscious.  However, she was concerned that the Registrant wanted just her to assist him moving the patient instead of SK due to the patient’s weight (around 15 stone).  Moreover, she considered that the way that the Registrant proposed moving the patient, with the patient going down the stairs head first, meant that the patient’s airways could not be maintained in such a position.  The Panel further noted that EEAST subsequently issued a Clinical Update on 9 October 2013, a month after this incident, which stated that “With immediate effect the routine use of the carry sheet should cease”, some of the reasons for which were an inability to monitor the patient and an inability to manage effectively the patient’s airway.

40. The Registrant described, and demonstrated, what he had done and how he had taken hold of his end of the carry sheet.  He did so in such a way that the patient’s head was immediately in front of the Registrant’s chest area.  Moreover, he folded down the edge of the carry sheet which caused the patient’s head to tilt back and down thereby opening his airway.  The position of his head also meant that at all times the Registrant could observe and monitor the patient’s airway and could see his chest rising and falling as he breathed.  The Registrant said that he had been taught this technique and that it was highly effective. 

41. The Panel accepted the Registrant’s evidence on this point.  It was confident, clear and detailed.  In particular, the Panel was impressed by his demonstration, which indicated that he was reliving the incident.  Moreover, by her own admission, Witness 1 was at the time unaware of the concerns about the suitability of using the carry sheet.  In addition, as she was holding the end of the carry sheet furthest away from the patient’s head, the Panel considered that she would not have had the same view of the patient, or of his airway, as the Registrant did.  Finally, the Panel noted that Witness 1 stated that “I do not know if the patient’s airways were obstructed while on the carry sheet as I was concentrating on getting down the stairs quickly, as [the Registrant] was moving quickly and the patient was heavy”.

42. In reaching its decision the Panel took account of the wording of the allegation, which was that the Registrant “did not ensure that the patient’s airway was correctly maintained”.  However, as the only other person present accepts that she did not know if the patient’s airways were obstructed then this, coupled with what the Panel considers to be a very credible explanation by the Registrant of how he ensured that the airways were maintained, leads the Panel to the conclusion that the HCPC has failed to prove its case to the required standard.  The allegation is therefore Not Proved.               

e. You did not provide an appropriate Patient Care record in that you recorded inadequate details of the drugs given.

Found Proved

43. The Panel noted that the Registrant admitted this allegation and relied upon that admission in finding the allegation proved, taking account of the fact that the Registrant had received legal advice on the matter and was represented.  Moreover, the allegation was supported by the evidence of the HCPC witnesses and the documentary evidence, all of which the Panel accepted for the purpose of proving the allegation. 

44. The Panel noted the Registrant’s evidence on this point and his acceptance that he did not fill in the PCR to the accepted standard.  He had not recorded on the PCR, for instance, the doses of the various drugs that had been given, or the fact that the diazemuls had, as he alleged, been given in two 5 ml doses.  He maintained, however, that upon arrival at the hospital he had informed the doctor/consultant of the exact details of what had been done and the medication that had been given and these details had been written onto a “whiteboard”.  He explained that he had been called away to another job and had not realised that both ECAs had also left the hospital, Witness 1 to go home as she had completed her shift, and SK to attend another job.  The Registrant was only able to re-attend at the hospital about 1½ hours’ later, when he signed off the partially completed PCR.  He stated that had he known that both ECAs had left the hospital at the same time as he did he would have remained and completed the PCR.  However, he reiterated that he was one of only 3 paramedics on duty that night and was required to attend other jobs. 

45. The Panel also noted that the PCR gave incorrect information about the treatment of the patient.  It was recorded, for instance, that the cannula was in the left arm when it was in the right arm; that Hartmanns had been administered when it was not; and there were no details of the doses of the drugs given.

Decision on grounds


46. Having found the above facts proved in this matter, the Panel went on to consider whether the facts found proved, individually or collectively, amounted either to misconduct or to a lack of competence.

47. In relation to Misconduct the Panel noted the advice of the Legal Assessor who referred to the cases of Roylance v General Medical Council [2000] 1 A.C. 311, Cheatle v General Medical Council [2009] EWHC 645 (Admin), Nandi v. General Medical Council [2004] EWHC 2317, Spencer v General Osteopathic Council [2012] EWHC 3147 (Admin), R v. Nursing and Midwifery Council (ex parte Johnson and Maggs) (No 2) [2013] EWHC 2140 (Admin) and Schodlok v GMC [2015] EWCA Civ 769. The Panel noted that misconduct must be serious and amount to a registrant falling far below the standards expected of a Registered Paramedic.

48. As for lack of competence, the Panel noted the Legal Assessor’s advice that such connotes a standard of professional performance which is unacceptably low and which, (save in exceptional circumstances), had been demonstrated by reference to a fair sample of the registrant’s work. The benchmark by which to gauge impairment was the standard required of a competent registered paramedic.

49. The Panel also considered the HCPC Standards of Conduct, Performance and Ethics (SCPE), and the HCPC Standards of Proficiency for Paramedics.
50. In considering misconduct, the Panel reviewed the matters found proved separately and collectively.  It reminded itself that the allegations found proved concerned failures to bring essential equipment with him to an emergency; asking a junior colleague to carry out tasks that were not within the scope of their practice and giving her incorrect information; and failing to adequately record the medication given.

51. The Panel considered the possible breaches of the above-mentioned standards and concluded that there had been breaches of the HCPC Standards of Conduct, Performance and Ethics numbered 1, 5, 7 and 10.  Moreover, it concluded that standards 1a.1, 1a.5, 1a.6, 1a.7 and 1b.1 of the HCPC Standards of Proficiency for Paramedics had also been breached.

52. In relation to allegations 1 (a) and 1 (b), the Panel noted the Registrant’s explanation that he was unable to take the defibrillator with him as he was carrying other equipment and medication.  However, he accepted that he knew sufficient details about the patient to conclude that his condition was serious and he therefore should have ensured that both the defibrillator and the BVM were readily available to him.  He also knew that he was going to be the first person on the scene and that it could not be confidently predicted when the ambulance crew would arrive.  He was, and is, a very experienced paramedic and accepted in evidence that he knew that such equipment was essential.  The lack of the equipment meant that there was a delay in treating the patient, which could have been fatal (although the patient survived).  The Panel therefore concluded that his failings in relation to allegations 1 (a) and 1 (b) fell far short of the standards expected of a registered paramedic.

53. In relation to allowing and requiring an ECA to work outside of the scope of her practice, and giving her incorrect information, the Panel noted the Registrant’s explanation that it was custom and practice to allow ECAs to carry out tasks such as the administration of controlled drugs under supervision.  However, he accepted that it was outside official Trust policy to do so.  Moreover, although the Panel has made no finding in relation to how the diazemuls was administered (one 10 ml doses as Witness 1 stated or two 5 ml doses as the Registrant maintained) it notes that this is exactly the sort of risk which the restrictions on the ECAs’ scope of practice is intended to avoid.  As for giving her incorrect information about mixing diazemuls with a saline solution, it was the Registrant’s duty as an experienced paramedic to keep his clinical knowledge up to date.  The Panel therefore concluded that his actions in relation to allegation 1 (c) did fall far short of the standards expected of a registered paramedic.

54. Finally, in relation to allegation 1 (e), the Panel reminds itself that ensuring that adequate records are kept about the treatment and medication given to a patient is vital as it is the only certain way of informing those treating the patient subsequently what has occurred in the past.  This is particularly important when recording what medication has been given.  The failing was compounded in this instance by the Registrant signing off the PCR knowing that SK had not completed the form properly.  Accordingly, the Panel concludes that his failings in relation to allegation 1 (e) fell far short of the standards expected of a registered paramedic.     

55. The Panel therefore concluded that individually, and together, the facts found proved were examples of the Registrant falling sufficiently far below the standards expected of a registered paramedic so as to constitute misconduct.


56. The Panel went on to consider the ground of lack of competence. It noted that no witness had expressed any other concerns (save those detailed above) about the standard of the Registrant’s work.  Moreover, the Registrant had produced a number of testimonials, amongst which was a 25 Year NHS Long Service Award.  In addition, the Panel considered that it only had sight of an extremely limited sample of the Registrant’s work (essentially involving one incident during one night in a career spanning over 30 years) which it did not consider comprised a fair sample and, therefore, taking all of these factors into account, the Panel concluded that his actions did not fall so far short as to establish a lack of competence of the Registrant’s behalf.


Decision on impairment


57. In reaching its decision on impairment, the Panel has taken account of the submissions of the parties, (in particular those of Ms Spencer to the effect that the Registrant was “neutral” on the question of Impairment), the documentary and oral evidence of the Registrant, the testimonials and certificates produced by the Registrant, and the advice of the Legal Assessor. It has also taken account of the HCPC Practice Notes “Finding that Fitness to Practise is “Impaired” and “Fitness to Practise – What does it mean?”


58. The Panel is aware that, in determining whether fitness to practise is impaired, it must take account of a range of issues which, in essence, comprise two components, namely the ‘personal’ component (the current competence and behaviour of the individual Registrant) and the ‘public’ component (the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession). It appreciates that not every finding of misconduct will automatically result in a Panel concluding that fitness to practice is impaired. Moreover, it cannot adopt a simplistic view and conclude that fitness to practise is not impaired simply on the basis that, since the allegation arose, a Registrant has corrected matters or “learned his/her lesson”. Although the Panel’s task is not to punish past wrongdoings, it does need to take account of past acts or omissions in determining whether a Registrant’s present fitness to practice is impaired. In addition, when assessing the likelihood of a Registrant causing similar harm in the future, the Panel should take account of both the degree of harm if any, caused by a Registrant and that Registrant’s culpability for that harm. Finally, the Panel is to consider whether a Registrant has demonstrated insight into his attitude and failings and remediated them.

59. The Panel noted the Registrant’s evidence that he joined the ambulance service in 1987 when he was allocated to patient transport.  After two years he qualified as an Emergency Medical Technician and then in 1995/6 he qualified as a paramedic. The Panel understands that, until this episode, the Registrant had an otherwise unblemished record spanning some 30 years.  He told the Panel that he had retired from the service on 30 November 2015 but wished to retain his registration as he wanted to do bank work as a paramedic, which he had always loved doing.  One advantage of concentrating just on front-line duties would be that he would not have any managerial responsibilities.  He confirmed that he had kept his clinical knowledge up to date and produced his certificates of attendance for EEAST’s Update Training for CPD for 2013 to 2014 (in January 2014) and for EEAST’s Advanced Life Support Training (including Manual Defibrillation) which he attended in October 2015.

60. He was asked what he would now do differently overall and replied that he would not ask any ECA to draw up drugs but would do it himself; he would always have a BVM with him; he would never accept another call without completing the PCR for the previous case. He said the difficulty of not being able to carry all the equipment had been solved some three months after the incident by EEAST issuing backpacks as the recovery bags, which enabled personnel to have both hands free and thus to be able to carry not only the drugs bag and the oxygen as he had done that evening, but also the defibrillator. In fact some people had, before this incident, started using backpacks to house the recovery bag but his line manager had told him that they were soon “coming in” and not to bother providing his own.

61. He went on to say that he had been suspended from frontline duties a few days after the incident and had not practised as a paramedic since.  He had been allocated office duties.  He had not actually seen the Action Plan until after the appeal in January 2015.  He confirmed the evidence of Witness 3 that he had completed a reflective piece as part of that action plan (which Mr Bailey confirmed had been marked as a “Pass”) and that all that was now required was for him to carry out three “ride outs” (accompanying and observing other paramedics whilst they carried out their emergency duties).  However, he had not managed to go on these ride outs before retiring.  The Panel noted that the reflective piece had not been produced in evidence before it.

62. He went on to tell the Panel that the patient survived and was placed on long-term palliative care. As far as the Registrant was aware, the patient was still alive up to a few months before the hearing.  The Registrant stated that he was very sorry that he had not been able to achieve a better result for him.

63. In answer to some questions from Mr Chalmers, the Registrant accepted that he had not read the HCPC Standards “completely” but that he was aware of them.  He accepted that his actions had breached a number of them.

64. He explained that during the Trust investigation he had not been well and had been off ill for about six months during it.  When interviewed in October 2013 he had been under a lot of stress.  He accepted that some of his answers then given could be interpreted as not being insightful but he maintained that, since that time, he had given a lot of reflection to this incident.  The Action Plan had taught him to consider things in greater depth, to conduct deeper research and to become more thoughtful about his practice.  Moreover, if he returned to frontline paramedic duties he would have more time to keep up to date, which being a manager had hampered.    

65. The Panel first considered the personal component.  It took account of the fact that this episode was an isolated occurrence which took place during one night of a lengthy career.  Moreover, the Registrant admitted to his failings and has reflected upon them.  In addition, the Panel is satisfied that he is remorseful and deeply regrets what has happened.  Moreover, it considers that he genuinely believes that he will not repeat his actions.

66. However, the Registrant’s failings on that one occasion covered a number of areas of paramedic practice, which causes the Panel significant concerns particularly given his experience and seniority.  The Panel notes that he had been removed from front-line duties shortly after this incident and has not been able to complete the Action Plan by going on ride outs, so any insight obtained and reflection that he has carried out has not been tested in the field.  Accordingly the Panel is concerned that there remains a risk of repetition albeit small. 

67. In addition, although the Panel accepts that the Registrant has carried out some reflection and remediation, it notes that he candidly accepted that he had not fully read the HCPC standards.  In addition, the Panel does not consider that he has demonstrated that he has gained full insight into the potential risks of his actions, which could have had devastating consequences.  As stated above, the Panel has not, for instance, been presented with the reflective piece that he prepared for the Action Plan. 

68. In conclusion, the Panel is led to the conclusion that, on the evidence currently before it, there is a likelihood of repetition and that the Registrant does not have full insight into his actions and therefore his fitness to practise continues to be impaired on a personal level.

69. In addition, there remains consideration of the public element and the need to set down a marker to remind the Registrant and other paramedics of the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession. The Panel considers that, given the nature and variety of the Registrant’s failings, there was a disregard of his duties towards not only his patient but also his colleagues which go to the heart of a paramedic’s profession.  Accordingly, the Panel concludes that a finding of impairment on public interest grounds is appropriate.

Decision on sanction


70. In reaching its decision on sanction the Panel has taken account of the submissions of both parties, the Indicative Sanctions Policy (ISP) document dated September 2015 (appreciating that it is a guide and no more) and the advice of the Legal Assessor, which it has accepted.  The Panel is mindful that the purpose of sanctions is not to be punitive, although they may have that effect.  It appreciates that the primary purpose of any sanction is to address public safety from the perspective of the risk which the registrant concerned may pose to those who use or need his or her services.  It notes, however, that in reaching their decisions, panels must also give appropriate weight to the wider public interest, which includes: the deterrent effect to other registrants; the reputation of the profession concerned; and public confidence in the regulatory process. In addition, the Panel notes that it must act proportionately, which requires it to strike a balance between the interests of the public and those of the Registrant.

71. The Panel has also taken account of the submissions of both parties.  Ms Spencer advised the Panel that the Registrant was 60 years old and had been married for over 40 years.  Just prior to the incident that gave rise to these proceedings, the Registrant’s wife was diagnosed with a health condition that severely impacted upon his family and adversely influenced the Registrant in his work.  However, his wife had now returned to work as a GP’s administrator. 

72. Besides wishing to return to being a front-line paramedic, the Registrant also had the opportunity of working for a doctor’s practice.  Although he had officially retired, he did not feel as though his work serving the public was done.  He felt that he could still contribute and make a difference.  Ms Spencer reiterated that the Registrant had no intention of returning to a management post and that this would give him more time to enhance his skills and clinical knowledge. 

73. The Panel has taken account of the aggravating and mitigating features of this matter, all very fairly outlined by Mr Chalmers and agreed to by Ms Spencer.


74. The aggravating features of this case relied upon by Mr Chalmers were that it involved multiple examples of failings in a paramedic’s core practice and a disregard of duties to both patients and colleagues.


75. As for the mitigating factors, Mr Chalmers asked the Panel to take account of the fact that this was an isolated incident in a long and celebrated career; that there was no evidence of any previous, or subsequent, concerns about his practice; that he had made admissions to all those matters found proved; that he had undertaken some reflection; that he had a degree of insight which could therefore be developed; and that he had expressed true remorse.


76. Ms Spencer asked that the Panel took the following additional matters into consideration, namely that there had been pressures at work during the night in question; and that the testimonials demonstrated that he was very well thought of by his peers.  She suggested that taking no action and imposing a Caution Order might not reflect the seriousness of the case and invited the Panel to consider making a Conditions of Practice Order, with which the Registrant would happily comply.  She suggested that a Suspension Order would be unduly punitive and would not allow the Registrant to improve his practice or develop full insight.  The Panel took the opportunity during her submissions of advising that it did not consider this to be a case where a Striking-Off Order was appropriate. 

77. In answer to some questions from the Panel, the Registrant clarified that “ride outs” were actually a form of supervision and mentoring which involved the paramedic accompanying his/her supervisor and having their performance monitored.  It was not a supernumerary role but involved active participation under supervision.  The Panel noted that the Registrant would be happy to agree to such a condition if it was thought appropriate.  He also maintained that prospective employers would have no difficulty agreeing to such a supervision requirement.     


78. The Panel began by considering taking no action.  It noted paragraph 9 of the ISP which indicates that taking no action “may be appropriate in cases where a finding of impairment has been reached on the wider public interest grounds…but where the registrant has insight, has already taken remedial action and there is no risk of repetition”.

 
79. The Panel reminded itself of the nature of the facts found proved, which involved a failure to act in the best interests of a patient and of colleagues.  Moreover, it had made a finding of impairment on both personal and on public interest grounds.  Accordingly, the Panel concluded there would be an expectation that the regulator would consider that the matter was too serious not to be marked by a sanction and would otherwise be disproportionately lenient. 


80. The Panel went on to consider Mediation but concluded that it was inappropriate in this case and had no bearing on the issues in this matter.


81. The Panel then considered the sanction of a Caution.  The Panel noted paragraph 22 of the ISP which states:


“A caution order is an appropriate sanction for cases, where the lapse is isolated, limited or relatively minor in nature, there is a low risk of recurrence, the registrant has shown insight and taken appropriate action.  A caution order should 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.  A caution order is unlikely to be appropriate in cases where the registrant lacks insight.”


82. However, for the same reasons as for taking no action, and noting that meaningful practice restrictions could be imposed, the Panel concluded that a Caution Order would be inappropriate in this case.


83. The Panel went on to consider a Conditions of Practice Order.  The Panel noted paragraphs 24 to 30 of the Indicative Sanctions Policy which state:

“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, beyond the conditions imposed, the registrant is capable of practising safely and effectively.
Conditions of Practice Orders must be limited to a maximum of three years and should be remedial or rehabilitative in nature.  Before imposing conditions a Panel should be satisfied that:


• the issues which the conditions seek to address are capable of correction;
• there is no persistent or general failure which would prevent the registrant from doing so;
• appropriate, realistic and verifiable conditions can be formulated;
• the registrant can be expected to comply with them; and
• a reviewing Panel will be able to determine whether those conditions have or are being met.


Conditions of practice provide a very flexible means of disposing of cases.  A combination of conditions may be imposed, including formal education and training requirements.  Equally, in some cases it will be appropriate to impose a single condition for a relatively short period of time to address a specific concern (e.g. to undertake specific remedial training).  In imposing conditions of practice, Panels must recognise that, to a large extent, the registrant will be trusted to comply with them.  Consequently, before doing so, Panels need to be confident that the registrant will adhere to those conditions of practice.


The imposition of conditions requires a commitment on the part of the registrant to resolve matters and therefore conditions of practice are unlikely to be suitable in cases:


• where there are serious or persistent overall failings;
• the registrant lacks insight or denies any wrongdoing; or
• involving dishonesty, breach of trust or the abuse of service users.


Whilst conditions can be drafted so that they are verifiable, including providing mechanisms for verifying compliance, Panels must remember that, to a large extent, the registrant will be trusted to adhere to the conditions.  Where the allegation before the Panel is based upon actions which constitute dishonesty, breach of trust or abuse, conditions of practice are unlikely to be appropriate unless the Panel is satisfied that the registrant’s conduct was minor, out of character, capable of remediation and unlikely to be repeated. 

If a Panel is considering imposing conditions in such a case, the Panel will need to consider carefully whether it is likely that the registrant can be trusted not to breach those conditions of practice.


If conditions of practice are being considered as a means of controlling the practice setting in which a registrant operates, careful thought needs to be given as to whether they are a realistic and appropriate remedy.  In particular, the same or similar conditions of practice may not work for all professions.


Above all, conditions must be realistic and there is a limit to how far they may extend.  For example, a combination of conditions which require a registrant not to carry out home visits, out of hours working, unsupervised care, or care outside of a particular setting may, in reality, amount to a suspension and thus be far too wide.  Equally, care must be taken to ensure that the combined effect of the conditions imposed does not amount to a requirement only to perform the role of an unregistered assistant or support worker.”


84. The Panel considered that these paragraphs are particularly applicable to the Registrant’s situation and that none of the adverse matters listed above apply to his case.  The Panel took account of the fact, whilst not relying on it, that his previous employers, EEAST, considered that it would not have any issue with the Registrant’s practice provided that he completed the Action Plan by undertaking a short period of supervision covering three shifts. 


85. In addition, the Panel reminded itself of the Registrant’s significant experience and his desire to return to front-line duties without having any management responsibilities.  It took into account the numerous mitigating features in the case and concluded that a Conditions of Practice Order met the needs of this case and was appropriate to reflect the seriousness of the case and maintain the trust of the public in the regulator.  Moreover, it would allow the Registrant, who is otherwise a competent and committed paramedic, to continue his practice.

86. It follows that the Panel agreed with Ms Spencer and considered that the next most onerous sanction, namely that of a Suspension Oder, would be disproportionate in the circumstances of this case.     

Order

ORDER: The Registrar is directed to annotate the Register to show that, for a period of 12 months from the date that this Order comes into effect (“the Operative Date”), you, Stephen E Meyern, must comply with the following conditions of practice: 


1. You must promptly inform the HCPC if you take up any employment as a paramedic and must promptly inform the HCPC if you cease to be so employed.

2. You must promptly inform the HCPC of any disciplinary proceedings taken against you by any such employer.

3. You must inform the following parties that your registration is subject to these conditions:

A. any organisation or person employing or contracting with you to undertake professional work;

B. any agency you are registered with or apply to be registered with (at the time of application); and

C. any prospective employer (at the time of your application).

4. You must place yourself and remain under the supervision of a workplace supervisor or paramedic mentor of at least five years qualification as a paramedic and who is regulated by the HCPC and supply details of your supervisor to the HCPC within seven days of his or her appointment. You must attend upon that supervisor as required and follow their advice and recommendations.

5. Before undertaking autonomous work as a paramedic you must (1) satisfactorily complete a period of supervised practice as a paramedic, such to constitute at least 10 shifts of supervised call-out duty and (2) forward a copy of your supervisor or paramedic mentor’s report on those shifts to the HCPC.   

6. Once you have completed 10 shifts of supervised call-out duty as a paramedic, if your supervisor or paramedic mentor certifies in writing to both yourself and to the HCPC, that you are safe and competent to undertake autonomous practice as a paramedic then you will be allowed to undertake such autonomous practice and conditions 4 and 5 will cease to have effect.

7. You must, within 28 days of the operative date of this order, forward to the HCPC a copy of the reflective essay which you prepared in response to EEAST’s Action Plan and to which you referred in evidence.

Notes

No notes available

Hearing History

History of Hearings for Mr Stephen E Meyern

Date Panel Hearing type Outcomes / Status
04/03/2019 Conduct and Competence Committee Review Hearing Voluntary Removal agreed
09/03/2018 Conduct and Competence Committee Review Hearing Conditions of Practice
09/03/2017 Conduct and Competence Committee Review Hearing Conditions of Practice
09/03/2016 Conduct and Competence Committee Final Hearing Conditions of Practice