Mrs Judy R Wilmot
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During the course of your practice as a Paramedic at the South Western Ambulance Service NHS Foundation Trust / Great Western Ambulance Service NHS Trust whilst attending to Service User A on 7 October 2011 you:
1. Did not undertake and/or instruct Colleague A to do a blood glucose test.
2. Engaged in a discussion with Family A about febrile convulsion and as a result:
a) Family A were misinformed about Service User A’s diagnosis.
3. Did not take Service User A to hospital for further assessment when you should have done.
4. In relation to recording of the incident:
a) You did not complete the Patient Care Record before leaving the incident location.
b) You did not complete a Discharge of Care Form.
c) You did not record the discussion about not conveying Service User A to hospital.
5. You did not leave a copy of the Patient Care Record with Family A.
6. The matters set out in paragraphs 1-5 constitute misconduct and/or lack of competence.
7. By reason of that misconduct and/or lack of competence, your fitness to practise is impaired.
1. The Panel was satisfied, on the documentary evidence provided, that the Registrant, Mrs Judy R Wilmot, had been given proper Notice of this hearing in accordance with the Rules. Notice of this hearing was sent by first class post to her address on the Register by letter dated 23 June 2016. The Notice contained the relevant required particulars. A copy of the Notice was also sent to the Registrant by email.
Proceeding in Absence
2. The Panel heard the application from Ms Turner, on behalf of the HCPC, to proceed in the absence of the Registrant.
3. The Panel heard and accepted the advice of the Legal Assessor, who advised that the discretion to proceed in the absence of the Registrant was one that must be exercised with the utmost care and caution.
4. Having considered the circumstances, the Panel determined to proceed in the absence of the Registrant. The reasons are as follows:
· Service of the appropriate Notice of this hearing has been properly effected;
· The Registrant has sent two letters to the HCPC, on 22 April 2016 and 27 July 2016, and an email dated 29 June 2016, stating in all that she will not be attending the hearing;
· The Registrant has not requested an adjournment, and the Panel was of the view that it would be unlikely that the Registrant would attend in the future, even if were it to adjourn;
· There is a public interest in proceeding. The allegation dates back to October 2011. The Panel was mindful of the impact on the witnesses if it did not proceed and that memories fade with the passage of time;
· In all the circumstances, the Panel was of the view that the Registrant knew of today’s hearing and she has voluntarily chosen not to attend, thereby waiving her right to attend or be represented.
Application to amend the allegation
5. At the outset of the Final Hearing, Ms Turner, on behalf of the HCPC, made an application to amend the Particulars. Ms Turner submitted that this would more accurately reflect the nature of the evidence. She submitted that a letter, dated 7 July 2016, which detailed the proposed amendments had been sent to the Registrant and no objections had been raised by her.
6. The Panel heard and accepted the advice of the Legal Assessor. The Panel was of the view that the proposed amendments did not amount to major alterations of the particulars; rather, they gave greater clarity to them and better reflected the evidence anticipated to be adduced. The Panel was also of the view that the Registrant had been given adequate notice of the proposed amendments and had not raised any specific objections to them. The Panel therefore allowed the proposed amendments, concluding that there would be no unfairness to the Registrant in the particular circumstances of the case.
Application to proceed in private
7. During the course of the evidence, it was apparent that there may be references to the Registrant’s health or private life. The Panel was satisfied that, where such references would be made in the hearing, it was justified to hear those parts of the hearing in private in order to protect the private life of the Registrant.
Application to adduce the evidence of Witness 5 by telephone
8. The Panel considered an application by the HCPC to adduce the evidence of Witness 5 by telephone. The Panel accepted the advice of the Legal Assessor.
9. The Panel allowed the application for the following reasons:
· Witness 5 had made and signed a witness statement for the HCPC which was before the Panel, the contents of which were not disputed by the Registrant, as confirmed by a letter dated 27 July 2016;
· Witness 5 was not purporting to witness anything which occurred at the scene on 7 October 2011;
· The Registrant was neither present nor represented, so there was no cross examination to be put by her or her representative;
· There would be no unfairness to the Registrant in allowing the HCPC to adduce Witness 5’s evidence by telephone.
10. The Registrant was a Paramedic at the Great Western Ambulance Service NHS Trust (GWAS), which later became the South Western Ambulance Service (SWAST).
11. On 7 October 2011, the Registrant, along with Colleague A (Witness 4), an Emergency Care Assistant (ECA), were the crew of the ambulance which responded to a 999 emergency call in respect of Service User A.
12. Service User A was a 10 year old boy who lived with his parents and his older sister, and who was sleeping in the same bed as his older sister on that night, as his grandparents had come to stay. His sister alerted his parents that he was kicking out and not responding to her. Service User A’s father (Person A) removed him from the bed and placed him on to the floor on the landing in the recovery position.
13. Service User A’s mother (Person B) dialled 999 at 22:34:44 to request an ambulance. A transcript of that 999 call shows that both parents spoke to the Control Room Operator before the ambulance arrived, and that the father described his son as conscious although not responding.
14. The double-crewed ambulance, driven by the Registrant, was dispatched at 22:35:15. The ambulance arrived at Service User A’s home at 22:45:16. The ECA was the first on the scene, whilst the Registrant parked the ambulance. The ECA entered the house and went upstairs to where Service User A was on the floor. Service User A’s father and grandfather were both present. Once the Registrant had parked, she joined the ECA and remained on the stairs.
15. The ECA conducted observations on Service User A and took a brief history from Person A. The observations included a pulse check, temperature, pupil reaction and respiratory rate, the results of which the ECA recorded on her glove, to transfer to the appropriate documentation later.
16. The family of Service User A believed that he had suffered some sort of seizure, which they said was the first time he had experienced such an episode. At the time that the Registrant and ECA attended, Service User A was conscious. He was not taken to hospital.
17. The Registrant and the ECA left the home of Service User A, and the Control Room Records show the ambulance was clear at 23:00:25. The ambulance was then passed a further emergency call at 23:01:29.
18. Service User A did recover from that episode, and was taken to his GP on Monday 10 October 2011. On Tuesday 11 October 2011, he suffered a seizure and could not be resuscitated. The post mortem results revealed that Service User A died from ‘Sudden Unexpected Death in Epilepsy’.
19. The allegations relate to failures and omissions in respect of: not taking a blood glucose test; inaccurate discussions about febrile convulsions which resulted in the family being misinformed about Service User A’s diagnosis; not taking him to hospital; and failings in respect of recording and documentation.
Decision on Facts
20. On behalf of the HCPC, the Panel heard evidence from:
· Witness 1 – the Investigating Officer, who at the time of the incident was registered with the HCPC and was Head of Incidents and Complaints at Great Western Ambulance Service (GWAS) (subsequently South Western Ambulance Service (SWAST);
· Witness 4 – the ECA who attended the emergency call-out with the Registrant, and who has since qualified and is now registered as a Paramedic with the HCPC;
· Person A – the father of Service User A;
· Person B – the mother of Service User A;
· Witness 5 (by telephone) – the Consultant Paediatrician who saw Service User A when he was brought to hospital on 11 October 2011 and who was involved in trying to resuscitate him.
21. The Registrant did not attend the hearing, nor was she represented. The Panel did not hold this against her and scrutinised all of the evidence objectively.
22. The Panel heard and accepted the advice of the Legal Assessor. Although the Registrant had written that she accepted the particulars of fact in the response pro forma document, dated 27 July 2016, which is persuasive, the Panel recognised that it had to be satisfied that the particulars of fact were capable of proof. It understood that the burden of proving each individual fact rests on the HCPC and that the HCPC will only be able to prove a particular charge if it satisfies the required standard of proof, namely the civil standard, whereby it is more likely than not that the alleged incident occurred.
23. In relation to the facts, the Panel considered all the evidence presented to it. It also took account of the information that the Registrant had provided in writing to the HCPC.
24. The Panel found this Particular proved.
25. The Panel had regard to the admission of the Registrant in the investigation interview on 11 May 2012 with Witness 1, to the effect that no blood glucose test (commonly referred to as ‘BM’) had been done as part of the assessment of Service User A. It also had regard to her admission in the pro forma questionnaire, dated 27 July 2016, which she completed and returned to the HCPC.
26. The Panel took into account the ECA’s evidence that she herself had not undertaken a blood glucose test in respect of Service User A, nor had she been instructed to undertake one by the Registrant. The copy of the Patient Care Record (PCR) completed by the Registrant has a stroke through the box entitled BM, for recording a blood glucose test, from which the Panel inferred that no test had been undertaken. The evidence of the parents was also that there had been no blood glucose test undertaken, nor had one been suggested to them, and the Panel accepted this evidence.
27. The Panel found this Particular proved.
28. The Panel had regard to the Registrant’s admissions in the investigation interview (12 May 2012) that discussions regarding febrile convulsions had taken place, together with her admission in the pro forma questionnaire.
29. The Panel also had regard to the evidence of the ECA to the effect that it was she who had started the discussions regarding febrile convulsions and their potential causes, but that the Registrant had also subsequently become involved in the discussions. The Panel accepted the evidence of Person B, who described how, following the discussions of febrile convulsions, she had researched the subject on the internet the next day, and discovered that it was a condition which occurred in younger children, generally up to the age of 5 or 6 years. From this, the Panel inferred that the discussions about febrile convulsions had taken place, and the nature of such discussions was such that it had both misinformed and misled the parents about Service User A’s diagnosis.
30. The Panel found this Particular proved.
31. The Panel accepted the evidence of Service User A’s parents, both of whose evidence the Panel found compelling. Both parents were consistent in their evidence to the effect that, from their knowledge and experience of their son, he was not fully recovered by the time the Registrant and the ECA left their home, and it was another 40 minutes after they had left before he returned to normal.
32. The Panel was of the view that there had been a significant lack of inquiry by the Registrant about Service User A’s condition, in particular not exploring with the parents what they considered to be normal behaviour for their son.
33. The evidence of the parents was supported by the evidence of Witness 5, the Consultant Paediatrician, who explained that even if, objectively, a patient appeared normal, and the observations supported that, the best guide is what the parents say, because the clinician would not know what was normal behaviour. He also said, “It is standard practice for a child to attend Accident and Emergency following their first seizure, febrile or non-febrile, by ambulance if they have not fully recovered…The risk with paramedics leaving the scene before a patient is back to normal is that it is more difficult to predict that they will make a full recovery.”
34. The Panel also accepted the evidence of Person A that he had assisted Service User A downstairs by standing behind him and taking hold of him under both arms to support him. Person A conceded that this assistance may not have been observed by the Registrant, who had gone down the stairs first, followed by the ECA next and then him behind Service User A, assisting him. The Panel inferred from the fact that Service User A had needed to be assisted downstairs by his father that Service User A had not, at that stage, returned to normal. The Registrant in her investigation interview had described that Service User A was upset and confused, but that she had put this down to him being woken up and concerned that his grandparents were unwell.
35. The Panel concluded that there had been an inadequate assessment by the Registrant of the condition of Service User A, a patient they had never encountered before, and that this had led to poor decision-making by the Registrant, and specifically in the decision of whether or not to take Service User A to hospital. The Panel was satisfied that the Registrant had not given due consideration to the condition of Service User A, and, in particular, she had not used the knowledge and experience of the parents in respect of their son. The Panel took account of its finding in Particular 1 (that the Registrant had not undertaken a blood glucose test), which supported its view that there had been a poor clinical assessment, which had led to poor decision-making on the part of the Registrant. This is further supported by the relatively short time (15 minutes) spent on the scene by the ambulance crew.
36. The Panel noted that the ECA’s evidence was that she thought that Service User A ought to have gone to hospital but she had felt unable to challenge the Registrant, the Paramedic. It also noted that the Registrant in her investigation interview had said that she had made a mistake.
37. In light of the above, the Panel was satisfied to the required standard that the Registrant did not take Service User A to hospital, but that in the circumstances as existed at the time, she should have done so.
38. The Panel found this Particular proved.
39. It had regard to the Registrant’s admission in the investigation interview that she had not completed the PCR at the scene. It also took account of the evidence of the ECA that the PCR was not completed until later, after they had left Service User A’s home and at a time when they were back in the ambulance, having attended a subsequent emergency call. The Panel also accepted the evidence of the parents that they were not left with any paperwork by the Registrant or the ECA when the ambulance left the scene.
40. The Panel found this Particular proved.
41. The Panel had regard to the Registrant’s admission in the investigation interview that she had not completed a Discharge of Care Form (DCF) at any time, as no DCF form was in the bag. The Panel also accepted the evidence of the parents that they were not left with any paperwork by the Registrant or the ECA when the ambulance left the scene.
42. The Panel found this Particular not proved.
43. The Panel took account of the copy of the PCR before it which was ultimately completed by the Registrant. In it she had recorded that she had given advice to observe Service User A for the next hour and, if he was no better or deteriorated, to call 999. She had also recorded advice to take Calpol if necessary and, if worried, the next day to call 999, go to a walk in centre, hospital or GP. The Panel was of the view that, although this was a brief and somewhat vague record of the discussions, it could not be satisfied to the required standard that she had not recorded the discussion about not conveying Service User A to hospital.
44. The Panel found this Particular proved.
45. The Panel had regard to the Registrant’s admissions in the investigation interview that she had not completed the PCR at the scene and had not provided a copy to the family. The Panel also accepted the evidence of the parents that no paperwork had been left by the Registrant or the ECA when the ambulance left the scene.
Submissions on Grounds and Impairment
46. The Panel next considered whether the matters found proved, as set out above, amounted to misconduct and/or lack of competence and, if so, whether by reason thereof, the Registrant's fitness to practise is currently impaired.
47. The Panel considered the submissions made by Ms Turner on behalf of the HCPC. She submitted that the facts were sufficiently serious in nature to tend towards misconduct. She submitted that the failings amounted to a number of breaches of the HCPC “Standards of Conduct, Performance and Ethics” and the HCPC “Standards of Proficiency” for paramedics.
48. In relation to impairment, Ms Turner submitted that the Panel should consider whether the Registrant’s conduct had brought the profession into disrepute and had damaged public confidence in the profession. She submitted that this consideration should include an assessment of her insight and any remorse. She highlighted the lack of information available to the Panel as a result of the Registrant’s non-attendance.
49. The Panel heard and accepted the advice of the Legal Assessor. The Panel was aware that any findings of lack of competence and/or misconduct and impairment were matters for the independent judgement of the Panel.
50. The Panel was aware that consideration of impairment only arises in the event that the Panel judges that the facts found proved amount to misconduct and/or lack of competence. It took account of the Registrant’s admissions that the facts found proved amount to misconduct and/or lack of competence. It was also aware that what has to be determined is current impairment; that is, looking forward from today.
Decision on Grounds
51. The Panel considered the issue of lack of competence. The Panel was of the view that this was not a lack of competency case: the omissions and failings of the Registrant on 7 October 2011 were not referenced by a fair sample of her work which would tend to demonstrate that she lacked the clinical skill and competency to practise safely as a paramedic. This was a single emergency call-out in relation to one patient. The Registrant had been an experienced and skilled paramedic with the knowledge and experience of what to do.
52. The Panel considered the issue of misconduct both in respect of the individual particulars and cumulatively.
53. In relation to Particular 1, the Panel was of the view that undertaking a blood glucose test in accordance with the Guidelines for Paramedics was a fundamental aspect of the assessment. In failing to either undertake one herself or instruct the ECA to do so, the Registrant showed a lack of appreciation for Service User A’s condition. In the Panel’s view this was a serious failing, such that it amounts to misconduct.
54. In relation to Particular 2(a), the Panel was of the view that Service User A was not presenting with febrile convulsions and there were several indications as to why he was not. In particular, he was several years older than the oldest age of 5 or 6 years old at which children suffer such a condition and did not present with a temperature. In allowing the discussion to continue, the family was misinformed of the diagnosis for their son. In the Panel’s view this was a serious failing, such that it amounted to misconduct.
55. In relation to Particular 3, the Panel was of the view that communication, and in particular, listening to the concerns of the parents of a child, is a fundamental aspect of patient assessment. On this occasion, the Registrant had not taken adequate regard of Service User A’s presenting condition, nor properly sought the opinion of his parents who would better know whether or not their son was back to normal.
56. In the Panel’s view, this lack of communication led to the incorrect decision not to transport Service User A to hospital. Although he had not in fact suffered as a result of that decision, the failure to take him when she should have done so meant that the potential risk of some underlying cause for the episode was not able to be assessed through neurological observations, which the Consultant Paediatrician confirmed would have been undertaken by the hospital. The Panel’s view was that this was serious and amounted to misconduct.
57. In relation to Particular 4(a) and (b), the Panel was of the view that not completing the PCR before leaving the incident, or completing the DCF, whilst examples of poor practice, were not so serious in isolation as to amount to misconduct. However, when taken together with Particular 5, and not leaving a copy of the PCR with the family, this was serious, because the family would not have a copy to refer to or to provide to another health care professional should the condition of Service User A have deteriorated that night or over the weekend.
58. The Panel also found that the Registrant had breached the following “Standards of Conduct, Performance and Ethics”:
1 You must act in the best interests of service users
5 You must keep your professional knowledge and skills up to date
7 You must communicate properly and effectively with service users and other practitioners
10 You must keep accurate records
59. The Panel also found that the Registrant had breached the following “Standards of Proficiency” for paramedics:
1a.1 be able to practise within the legal and ethical boundaries of their profession
1a.5 be able to exercise a professional duty of care
1a.6 be able to practise as an autonomous professional, exercising their own professional judgement
1b.3 be able to demonstrate effective and appropriate skills in communicating information, advice, instruction and professional opinion to colleagues, service users, their relatives and carers
1b.4 understand the need for effective communication throughout the care of the service user
2a.1 be able to gather appropriate information
2a.2 be able to select and use appropriate assessment techniques
60. In all the circumstances therefore, the Panel found that the facts found proved amounted to misconduct.
Decision on Impairment
61. Having determined that the Registrant's actions amounted to misconduct, the Panel went on to consider whether her fitness to practise is currently impaired as a consequence of that misconduct.
62. The Panel had regard to the HCPC's Practice Note on “Finding That Fitness to Practise is Impaired”, and in particular the two aspects of impairment, namely the ‘personal component’ and the ‘public component’.
63. The Panel first considered the personal component.
64. The Panel was of the view that the Registrant had shown some insight into her failings on that night. In coming to this view, it had regard to her admissions during the investigation and the fact that, when asked what she would do differently, being aware of the Ambulance Service Guidelines, she said she would have taken the child to hospital.
65. The Panel noted the Registrant’s document of May 2015, in which she disputed that she had not exercised appropriate judgement in the decision not to take Service User A to hospital. However, the Panel noted that this document related to the particulars as they were before they were amended at the Final Hearing. Therefore, the Panel was of the view that it did not assist it in assessing the Registrant’s current level of insight. Furthermore, in the absence of the Registrant, the Panel was not able to further assess her current level of insight.
66. The Panel was of the view that the Registrant’s misconduct was remediable, and there was evidence that she had completed training with GWAS to remediate her practice. She had also participated in an agreed Action Plan. Furthermore, the Learning and Development Officer within GWAS was satisfied that she had completed all the required elements of this Action Plan, as evidenced in her review dated 5 September 2012. The Panel also acknowledged that GWAS had allowed her back to autonomous practice in August 2012.
67. However, in the absence of any recent information, the Panel was of the view that the Registrant had not demonstrated full insight and full remediation.
68. The Panel then went on to consider the public component.
69. The Panel was of the view that the public would be concerned to hear that an ambulance crew had responded to an emergency call, but once there had failed to:
· conduct an adequate assessment on a 10 year old child;
· properly communicate with the parents in seeking their opinion of their child’s condition;
· document their visit and leave a copy of that documentation with the family to provide to other health care professionals in the event of deterioration necessitating further medical intervention; and
· take a child to hospital in circumstances when she should have done so.
70. In these particular circumstances, the Panel was of the view that public confidence in the profession would be undermined if a finding of impairment were not made in this case.
71. The Panel therefore concluded that the Registrant’s fitness to practise is currently impaired.
Decision on Sanction
72. Having determined that the Registrant’s fitness to practise is currently impaired by reason of her misconduct, the Panel next went on to consider whether it was impaired to a degree which required action to be taken on her registration by way of the imposition of a sanction.
73. The Panel accepted the advice of the Legal Assessor and exercised its independent judgement. The Panel had regard to the Indicative Sanctions Policy, and understood that the Policy is designed to help panels to achieve a consistent approach to the imposition of sanction, but it is not intended to fetter a panel's discretion in any particular case.
74. The Panel understood that the purpose of a sanction is not to be punitive. In this regard, the Panel was mindful that although this was a very sad case, where Service User A had tragically died four days later, the Registrant’s actions had not been a contributory factor to his death, as evidenced in the statement of the Consultant Paediatrician, Witness 5.
75. The Panel considered the sanctions in ascending order of severity. It was aware that the purpose of sanction is to protect members of the public and to safeguard the wider public interest, which includes upholding professional standards, together with maintaining public confidence in the profession and the regulatory process.
76. The Panel did not consider that the options of taking no further action or mediation to be appropriate or proportionate in this case. Given its earlier findings that the failings in respect of Service User A and his family had been serious in nature and would cause the public to be concerned, it was of the view that neither option would address the wider public interest.
77. The Panel next considered a Caution Order. The Panel was mindful of its findings that there had been several failings which were serious in nature. However, it also took account of the fact that these failings represented a single emergency call in respect of one patient.
78. These failings were in the context of the Registrant having been employed by GWAS, which later became SWAST, on a full time contract from September 1999 until the end of August 2013, after which she worked as a Bank Paramedic up to November 2014. There was no evidence before the Panel to suggest that the Registrant had anything other than an unblemished career either before or since the incident on 7 October 2011.
79. The Panel had regard to its earlier findings that the Registrant had shown some insight, albeit that in the absence of recent information it was not full insight. She had admitted the HCPC allegations in full and she had made admissions during the Ambulance Service’s investigation. Although she had not attended the Final Hearing, she had nevertheless engaged with the Regulator, acknowledging the documentation they had sent, providing information, completing the pro forma questionnaire, making admissions within it, and explaining that she would be absent.
80. The Panel had regard to its finding that the Registrant had undertaken remediation in the shape of training with GWAS, and had participated in an agreed Action Plan. The Panel was of the view that it was significant that the evidence before it was that the Learning and Development Officer within GWAS was satisfied that the Registrant had completed all the required elements of the Action Plan and the Registrant had been placed back on autonomous duty from August 2012, and there was no suggestion that there had been any repetition.
81. The Panel concluded that a Caution Order makes the statement that when failings come to light, such as those of the Registrant on 7 October 2011, then the Regulator will act to maintain public confidence in the profession.
82. The Panel was satisfied that the specific circumstances of this case were such that a Caution Order was the appropriate and proportionate sanction.
83. In considering the length of the Caution Order, the Panel had regard to the Indicative Sanctions Policy and, in particular, paragraph 23, which states that a period of 3 years is the benchmark. However, in this particular case, the Panel, in recognising the need to give appropriate weight to the wider public interest, including the deterrent effect to other Registrants, determined that the length of the Order should be for the maximum period of 5 years. It was of the view that this would send the message to fellow professionals of the need for proper and considered assessment of patients, together with the importance of recognising the experience of the parents or carers of patients and taking the time to seek their opinions. The failure to do this has the potential to compromise patient care.
84. In ensuring that a Caution Order was the appropriate and proportionate response, the Panel went on to look at a Conditions of Practice Order and a Suspension Order.
85. In respect of a Conditions of Practice Order, the Panel acknowledged that it did not know of the current situation of the Registrant. However, the position was that she had, in effect, undertaken conditions of practice with the Ambulance Service in the form of the Action Plan following the incident, which had been carried out to the satisfaction of the Service. Therefore the Panel concluded that there were no appropriate or verifiable conditions that it could frame.
86. In respect of a Suspension Order, the Panel was of the view that this would be disproportionate to the circumstances of the case and to the Registrant herself. To impose a Suspension Order given the circumstances restricted to one event would be unduly punitive.
That the Registrar is directed to annotate the register entry of Mrs Judy R Wilmot with a caution which is to remain on the register for a period of five years from the date this order comes into effect.
No notes available
History of Hearings for Mrs Judy R Wilmot
|Date||Panel||Hearing type||Outcomes / Status|
|12/09/2016||Conduct and Competence Committee||Final Hearing||Caution|