Miss Helen Middleham

Profession: Paramedic

Registration Number: PA35777

Interim Order: Imposed on 05 Apr 2017

Hearing Type: Final Hearing

Date and Time of hearing: 09:00 29/08/2018 End: 16:00 30/08/2018

Location: Health and Care Professions Council, 405 Kennington Road, London, SE11 4PT

Panel: Conduct and Competence Committee
Outcome: Struck off

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Allegation

 

 

 Allegation as amended at the hearing

‘Whilst registered as a Paramedic and employed by North West Ambulance Service NHS Trust between April 2013 and February 2017:

1. In relation to Patient A, on or around 8 June 2016, you:
a) Did not act act and/or communicate appropriately, in that you:
i.  Told the patient in relation to her reported pain level “you would have had to have no arms and legs to have so much pain” and/or “not to be so dramatic, you wouldn’t have been able to walk to the ambulance if it was that” or words to that effect;

ii. Stood with your arms folded;
iii. Rolled your eyes;
iv. Tutted;

b) Falsified and/or incorrectly recorded the patient’s pain level on the Patient Report Form;

c) Inappropriately delegated the care of the patient to your Emergency Medical Technician colleague;

2. In relation to Patient B, on or around 20 November 2016, you:

a) Did not undertake an adequate assessment of the patient;
b) Did not review the patient’s maternity notes;
c) Did not contact the maternity triage unit;
d) Did not treat and/or record on the Patient Report Form completed by your Emergency Medical Technician colleague the patient’s pain level;
e) Did not offer the patient an ambulance transfer to hospital;
f) Did not review and/or countersign the Patient Report Form completed by your Emergency Medical Technician colleague;
g) Fabricated your application of the Manchester Triage System;

3. Between approximately 3 December 2016 and 30 December 2016, you fabricated a Patient Report Form in relation to your call out to Patient B on 20 November 2016;

4. Your actions described at particulars 1(b) and/or 2(g) and/or 3 were dishonest;

5. Your actions described at particulars 1 to 4 constitute misconduct and/or lack of competence;

6. By reason of your misconduct and/or lack of competence your fitness to practise is impaired.

 

 

 

Finding

Preliminary matters:

Application for hearing to be heard in private

1. Mr Waymont made an application that parts of the hearing be conducted in private, in view of health matters of the Registrant that would be raised during the course of the hearing. He referred to the HCPTS’ Practice Note, Conducting Hearings in Private. Mr Dite did not oppose the application and the Legal Assessor advised that it was appropriate to conduct those parts of the hearing in private. The Panel granted the application.

Application to amend the Allegation

2. Mr Dite applied to make a minor amendment to particular 1a) of the Allegation to delete the second word ‘act’ in that sub – particular. The Panel allowed the amendment, which was the result of a clerical error.    

Background

3. The Registrant, Helen Middleham, commenced her employment with the North West Ambulance Service (‘NWAS’) as a Paramedic on 2 April 2013. By the time of the events relevant to this case, the Registrant was a Band 5 Paramedic.   

4. The concerns giving rise to these proceedings came about as a result of the Registrant’s care for two patients in 2016:

• Patient A, a patient suffering from chest pain, on whom she attended on 8 June 2016 with MP who was then an Emergency Medical Technician (‘EMT’) and is now a Paramedic; and

• Patient B, a woman in labour, on whom she attended on 20 November 2016 with KT, also an EMT.
 
5. On 30 June 2016 Patient A made a complaint to NWAS regarding the way she had been treated by the Registrant. The complaint was passed to LC, an Advanced Paramedic, to investigate. In the course of his investigation LC interviewed Patient A over the telephone on 17 July 2016. He also interviewed the Registrant about the incident on 19 August 2016 and MP on 26 August 2016.

6. A complaint was received from Patient B’s mother on (or around) 1 December 2016 regarding the way the Registrant and KT had dealt with Patient B and the level of care she had received. The complaint was again passed to LC to investigate. He spoke to Patient B and her mother over the phone on 3 December 2016 and took statements from them. The Registrant was interviewed about the incident by LC on 9 December 2016. LC interviewed KT on 12 December 2016.

Decision on Facts

7. The Panel heard oral evidence on behalf of the HCPC from the following witnesses, -

• LC, Advanced Paramedic and the Investigation Officer NWAS, via video link;

• MP, EMT NWAS (now a Paramedic);

• Patient A;

• Patient B’s mother;

• Patient B;

• KT, EMT NWAS.

8. The Panel has concluded that each of these witnesses did their best to assist it. With the exception of KT, the Panel found the evidence of these witnesses to be generally credible and reliable. LC’s evidence was especially clear and compelling both as to fact and as to the opinion evidence he gave on Paramedic practice. The Panel did find KT’s evidence to be inconsistent on many points though it did accept an important part of what he told the Panel with regard to his management of his PRFs.    

9. The Registrant gave oral evidence. No further witnesses were called on her behalf. The Panel found the Registrant’s evidence to be inconsistent on important issues in the case. The Panel’s conclusions as to the credibility of her evidence are set out below in relation to the particular findings it has made. 

10. In making its decision, the Panel has taken into account all the evidence, both oral and documentary, as well as the submissions made by both Counsel as well as the written statements of the Registrant. The Panel has also received legal advice from the Legal Assessor, which it has accepted.

11. The HCPC bears the burden of proving its factual case to the standard of the balance of probabilities. An allegation of dishonesty requires cogent evidence and a very careful consideration of all relevant factors before such a finding is made: In re H (Minors) (Sexual Abuse: Standard of Proof) [1996] AC 563 at 586D-H and In re B [2008] UKHL 35 at [70], Quereshi v GMC [2015] EWHC 3729 (Admin) at [65]. The Panel has applied the same approach to Particular 1 b), 2 g) and 3.

‘Whilst registered as a Paramedic and employed by North West Ambulance Service NHS Trust between April 2013 and February 2017:’

12. The Registrant was registered as a Paramedic and employed by NWAS during this period and the acts and omissions that the Panel has found proved (see below) were carried out by her during that employment. Therefore, the stem of the Allegation has been found proved.

‘1. In relation to Patient A, on or around 8 June 2016, you:
a) Did not act and/or communicate appropriately, in that you:
i. Told the patient in relation to her reported pain level “you would have had to have no arms and legs to have so much pain” and/or “not to be so dramatic, you wouldn’t have been able to walk to the ambulance if it was that” or words to that effect;
ii. Stood with your arms folded;
iii. Rolled your eyes;
iv. Tutted;’

13. For convenience, the Panel set out its findings on each of these sub-particulars together, though it gave separate consideration to each of them. The Registrant admitted sub – particulars 1 a) ii and iii, but did not admit sub – particulars 1a) i and iv.

14. The Registrant attended at Patient A’s home on 8 June 2016 with MP. They arrived at around 9.55 hours. Patient A had been experiencing chest pain, which she reported in answer to questioning by MP in the presence of the Registrant. The evidence of Patient A was that the Registrant stood with her arms folded and rolled her eyes when Patient A spoke. She considered her mannerisms to be dismissive of what she was saying and the evidence of MP was that the Registrant was acting dismissively. The Registrant accepted in her evidence that she stood with her arms folded and that she may have rolled her eyes, though she had no recollection of having done so. The Panel has accepted the evidence of Patient A and MP on these two aspects of the Allegation.

15. MP’s evidence was that the Registrant ‘tutted’ when Patient A was telling her about her pain. Patient A mentioned this when interviewed by LC. In her written reflections the Registrant stated that she had no conscious recollection of doing this, but accepted that if both Patient A and a colleague had said that she did this, “it is likely that it happened”. In evidence she denied that she had done this and said in cross-examination that she had no reason to. However, in the circumstances the Panel has concluded that she tutted when Patient A told her about her pain.

16. Patient A was asked to score her pain and the Registrant’s evidence was that the patient told her that it was the worst pain she had ever had and scored it at 100. The Registrant did not accept that she had spoken the words alleged in sub – particular 1 a) i. Patient A’s evidence was that the Registrant told her that to have that level of pain she would have had to have had no arms or legs and she would not have been able to walk to the ambulance which was ‘a horrible thing to say’ and she felt that what the Registrant said to her was dismissive.

17. However, the Registrant said that the patient told her it was 9 out of 10, that she was explaining the degrees of pain on the ‘pain ladder’ of 1 -10 and she explained that a score of 9 related to pain experienced by persons who had suffered amputation of the leg or arm. She did not say ‘don’t be so dramatic’ as alleged in paragraph 1 a) i.

18. The Panel accepts that the word “dramatic” was not used in Patient A’s initial complaint to NWAS, although it was mentioned in her telephone interview with LC. It was not in Patient A’s witness statement for this hearing. The Panel was not satisfied that the words, “don’t be so dramatic” were used.

19. MP’s evidence was that the patient scored her pain at 8, told the Registrant that she was a nurse and that her pain score was what she said it was. He did not accept that the Registrant gave examples from the pain ladder. He said in evidence that he was very embarrassed and ‘wanted the ground to swallow me up.’

20. The Panel preferred the evidence of Patient A and MP to the Registrant’s evidence and has concluded that the Registrant did say to Patient A that to have that level of pain she would have to have had no arms or legs and would not have been able to walk to the ambulance.

21. The Panel considered whether the Registrant acted and/or communicated appropriately in respect of the acts proved under each of i – iv. The Panel found that these behaviours were dismissive of Patient A and indicated disinterest from the Registrant. They were capable of being interpreted as rude and patronising and were unprofessional. In the circumstances, this conduct on the part of the Registrant was unacceptable and inappropriate behaviour for a Paramedic.

22. Therefore, the Panel has found that the Registrant did not act or communicate appropriately with respect to each of the matters in sub - particulars i – iv, though not in relation to the words ‘not to be so dramatic.’ Accordingly, sub – particulars 1 a) i – iv have been found proved.

‘b) Falsified and/or incorrectly recorded the patient’s pain level on the Patient Report Form;’

23. The Registrant recorded Patient A’s level of pain on the Patient Report Form (‘PRF’) for the visit. She recorded it at ‘5’, whereas Patient A had, as the Panel finds, scored it at the higher end. The PRF is a record of the ambulance visit and LC’s evidence (accepted by the Panel) was that its completion was required for all patients who receive treatment from NWAS clinicians. The document records the presenting complaint, the treatment received by the patient, the clinical observations of the clinicians and other pertinent information.

24. The Registrant admitted that she incorrectly recorded the patient’s pain level on the PRF for patient A, but she denied that she had falsified it.

25. It was common ground before the Panel that a patient’s pain score is the score given to the pain by the patient and not a score based on a notional objective standard. The Registrant’s evidence was that she had not given sufficient weight to the subjective element of the patient’s pain. She said that she had been taught that the box on the form for ‘Observations’, where the pain score is to be written, should contain an objective assessment. She also referred to what she said she had been told by colleagues. Looking back, she said that now having read further literature on the subject of pain scoring she had ‘got it wrong.’   

26. The Panel has found that the Registrant did understand pain scoring at the time. The Registrant qualified as a Paramedic in 2012 and had been working as a Paramedic since April 2013.The Registrant knew about pain scoring due to her training, her years of experience as a Paramedic and applying it on a regular basis as part of basic observations as appears on a standard PRF. Patient A also knew about pain scoring, as did MP. In all these circumstances, the Panel found it not credible that the Registrant did not understand pain scoring. The Registrant knew at that time that the patient’s true pain score was what the patient said it was. The Panel has therefore rejected her explanation as to why she incorrectly scored Patient A’s pain on the PRF and has concluded that she falsified the patient’s pain level.    

27. Therefore, the Panel has found sub – particular 1 b) to have been proved in that the Registrant incorrectly recorded and falsified the patient’s pain level on the PRF.    

‘c) Inappropriately delegated the care of the patient to your Emergency Medical Technician colleague;’

28. The HCPC’s case was that as Patient A had chest pain, the Registrant should not have delegated the patient’s treatment to the EMT; the Registrant should not have been driving and she should have been the one attending with the patient at the back of the ambulance. The case was advanced by reference to written guidance that had been issued to ambulance staff by NWAS in a Clinical Newsletter entitled, ‘To Drive or Attend – Is there a Choice’, derived from the HCPC letter “Driving v Attending” dated 27 July 2011. That guidance is general in the sense that a paramedic should only drive (i.e. not ‘attend’) if that is in the best interests of the patient in the particular circumstances.

29. Mr Waymont submitted that in the circumstances it was not necessary for the Registrant to accompany the patient in the back of the ambulance, as the patient’s condition had stabilised.

30. It was true that the patient’s chest pain had a score of 0 following the administration of medication and the second ECG showed that the previous ECG’s abnormal changes had reverted. However, the Panel has accepted LC’s evidence that the patient was still at risk of deterioration, that just because her pain had gone, this did not mean that the situation had been fixed. The situation was ongoing, cardiac improvement could not be ascertained before arrival at the hospital and in the circumstances the most senior paramedic should attend the patient. The Panel also accepted MP’s evidence that as this was a patient who had presented with cardiac-related chest pain, the lead clinician, i.e. the Registrant, should have stepped in.  

31. Therefore, the Panel has found particular 1 c) of the Allegation to have been proved.

‘2. In relation to Patient B, on or around 20 November 2016, you:
a) Did not undertake an adequate assessment of the patient;
b) Did not review the patient’s maternity notes;
c) Did not contact the maternity triage unit;
d) Did not treat and/or record on the Patient Report Form completed by your Emergency Medical Technician colleague the patient’s pain level;
e) Did not offer the patient an ambulance transfer to hospital;
f) Did not review and/or countersign the Patient Report Form completed by your Emergency Medical Technician colleague;’

32. For convenience, the Panel has again set out its findings on each of these sub-particulars together, though it gave separate consideration to each of them. The Registrant admitted each of a) – f) in their entirety and that she ought to have carried out each of those acts. Mr Waymont added the qualification as regards f) that she did review the PRF later, after the event.

33. The Registrant’s evidence was that she did try to obtain a history from the patient, did ask some questions relevant to Patient B’s medical condition and carried out some acts of medical assessment, but the patient’s mother was dominating the room and she believed that the mother wanted to drive her daughter to hospital by car and the Registrant did the best she could to assist in those circumstances. 

34. The Registrant attended with KT on Patient B at her home at about 08.30 on 20 November 2016. The Registrant was the clinical lead, being a Paramedic. Patient B was 37 weeks pregnant and her pregnancy was relayed to the ambulance and shown on the dashboard monitor as high risk.

35. Patient B had been to hospital at about 3am as her waters had broken and was subsequently discharged. The evidence of Patient B and her mother was that by the time the Registrant and KT arrived she was experiencing contractions at intervals of approximately two minutes. Their evidence was that Patient B was in considerable pain and had suffered heavy vaginal bleeding upstairs, before her mother had managed to help her dress and assist her downstairs onto the sofa in the living room, shortly before the ambulance crew arrived. 

36. Following their arrival, KT spoke to Patient B’s mother (who was a nurse) in the presence of the Registrant and his evidence was that he saw that Patient B was experiencing short contractions. Patient B was unable to communicate in view of her pain. Patient B’s partner was also in the room. Patient B’s evidence was that she was unaware of the Registrant for some time. Patient B’s mother explained that the Registrant was standing (leaning on the wall) next to the door into the living room, which was behind the sofa where she was lying.

37. The evidence of Patient B’s mother was that she told the Registrant and KT that the contractions were two minutes apart and that Patient B was bleeding heavily. Her evidence was also that she told them that her daughter was high risk, her waters had broken, that she suffered a liver condition, that her baby had talipes and that they had been to the hospital earlier that day.

38. Patient B said that she was in agony but was not offered pain relief and commented in evidence that she “was begging for help”. In her written reflections, the Registrant accepted that she should have offered Patient B Entonox in the house or in the ambulance in order to relieve the patient’s pain and suffering.

39. The Registrant’s evidence was that she did start to take a history for Patient B, though she did not ask questions about prior bleeding or the risk factors but asked if there were complications. The Registrant did notice some bleeding when she briefly looked at the pad in Patient B’s underwear. However, she was unaware of the earlier bleeding. The assessment of the patient that she carried out was inadequate. She ought to have conducted a full set of observations, taken a detailed history and carried out a full examination. 

40. Patient B’s mother said to KT that she had not been able to get Patient B into the car and had called the ambulance. He then asked where the car was and told her to get it, which she did, and brought it round to the front of the house.

41. This was not what Patient B’s mother was expecting. She thought the ambulance would take her daughter to the hospital, believing the birth to be imminent. She concluded that the Registrant and KT were not going to help her daughter and that she had to get her to hospital herself as soon as possible. The Registrant’s evidence was that the mother was dominating the conversation and made it very clear that she wanted the crew to help her daughter into the car, so she could be driven to the hospital. 

42. The Registrant’s evidence was that she gave Patient B advice as to what to do if her condition changed so as to require urgent medical attention. She said that a 999 call should be made. However, she did not offer the patient an ambulance transfer to hospital. LC’s evidence was that the Registrant ought to have done so as the pregnancy was high risk and the birth imminent. In her reflective document the Registrant accepted that she should have offered an ambulance transfer.

43. The Registrant and KT helped to get Patient B into the front seat.    Patient B’s mother drove to North Manchester Hospital, which took around 30 minutes. The baby was born less than 20 minutes later.

44. Once Patient B’s mother had left in the car, the Registrant and KT went to the ambulance. They did not contact the maternity triage unit, as the Registrant during this hearing admitted she ought to have done in the circumstances. KT noted a few details on the PRF form. LC’s evidence was that the senior clinician in attendance was required to countersign the PRF. However, the Registrant admitted that she did not review and countersign the PRF for Patient B, which she ought to have done, as the attending senior clinician. Further, the Registrant did not ensure that the pain level of the patient was recorded (in the box) on the PRF, as she should have done.    

45. LC’s evidence was also that the Registrant ought to have contacted the receiving maternity unit in order that any necessary arrangements could be put in place. The Registrant accepted in her evidence that in hindsight she should have taken that step. In her written reflections she also stated that she could have gained more information about the patient by reading her maternity notes, which would have included information about the mother’s liver condition and the baby’s talipes.

46. In the circumstances, the Panel has found proved particulars 2 a) – f) of the Allegation in their entirety. In so finding, the Panel has preferred the evidence of the HCPC’s witnesses where their evidence conflicted with that given by the Registrant.

‘g) Fabricated your application of the Manchester Triage System;’

47. The HCPC’s case was as follows. The Manchester Triage System (‘MTS’) is a triage tool used to make a clinical decision in relation to how to prioritise a patient. It must be used in the presence of the patient before the decision is taken as to how to, for example, transport the patient. The Registrant had not done this. It was not applied by the Registrant in relation to Patient B, and she used it after the patient had left for the hospital by car as a justification for not having transported the patient in the ambulance. Having the EMT record on the PRF that the MTS had been applied was a fabrication made at the scene but after the patient had left. It was not true and was a dishonest act in those circumstances, to justify her incorrect handling of the incident and the mistake she made in choosing the incorrect MTS pathway was not an honest mistake.

48. The Registrant’s position was that the information that she gave to KT to record in the PRF reflected her understanding of the appropriate pathway for the patient’s condition at the time. She now accepted that her interpretation of the MTS pathway ‘discriminators’ was incorrect. She should have chosen the ‘orange’ and not the ‘yellow’ discriminator. And she should only have used MTS with the patient before a decision was made on the appropriate pathway, not to explain or record a decision that had already been taken. Her evidence at this hearing was that she did have the MTS in mind while she was in the house but did not consult the document setting out the discriminators until the patient had left for hospital and whilst the Registrant was in the ambulance.

49. The treatment pathways for the MTS were contained in a document, which specified a number of pathways. There were two of relevance. A ‘yellow’ pathway was in the following terms (relevant discriminator in bold below).

Factor                          Action
High blood pressure     Contact Maternity Triage to discuss most appropriate care.
                              Transport to ED or Maternity. Consider   patients own transport to nearest ED or MAT or UCS if appropriate.
Pv blood loss
History of trauma       Advise patient re analgesia if appropriate and any relevant health promotion or clinical advice. Including targeted worsening advice for patient.

Inappropriate history
Hot
Shoulder tip pain
Moderate pain 

50. A more serious, ‘orange’ pathway stated as follows (relevant discriminator in bold below).
Heavy PV Blood loss

PV blood loss and 20 weeks pregnant or more
Altered conscious level
In active labour
History of fitting
Very hot
Severe pain Immediate stabilisation and transfer to ED, consider hospital pre-alert.
Consider specialist referral pathways, e.g. stroke, cardiac, trauma, sepsis

The Registrant gave the information about MTS to KT for him to write it on the PRF. He wrote the following, -
‘PT HELPED TO MOTHER’S CAR [&] MOTHER HAPPY TO TAKE DAUGHTER BACK TO NMGH. MTS 37 PV BLOOD LOSS YELLOW ED OR MATERNITY.’   

51. The Panel’s conclusions are as follows. The MTS was a triage tool, to be used with the patient in order to select the most appropriate treatment pathway. The Registrant did not use MTS to select the pathway. As she told the Panel, she wanted to meet what she understood to be the wishes of Patient B that the patient travel to the hospital by car. She was concerned that a complaint would be made against her if she did not comply. She was very nervous about the possibility of a further complaint, in view of the complaint made by Patient A.

52. The mistake that the Registrant said she had made on the MTS discriminators was an obvious one. The criteria in the document clearly referred to P.V. bleeding in a pregnancy of 20 weeks or more. This patient was 37 weeks pregnant and the Registrant believed her to be overdue. The Registrant’s evidence was that she had “used the tool a lot” and LC’s evidence was that she had been trained on the triage tool and had been selected to pilot it. She had completed her training and had been signed off as competent for its use on 26 May 2016, having been audited on five occasions using it. The Panel has accepted this evidence and has concluded that in the circumstances the Registrant’s explanation that she made an honest and genuine mistake in selecting the wrong discriminator was not credible. The Registrant knew that she was selecting the wrong discriminator, as the orange discriminator clearly states that for 20+ weeks pregnancy transport by ambulance is required. The reason why as the Panel finds, she did so, was because she was fearful of a further complaint and wanted to provide a justification for letting Patient B go to hospital by the patient’s own transport (i.e the yellow discriminator), when she knew that she should have gone by ambulance (i.e the orange discriminator).     

53. Therefore, the Panel has found particular 2 g) to have been proved.  

‘3. Between approximately 3 December 2016 and 30 December 2016, you fabricated a Patient Report Form in relation to your call out to Patient B on 20 November 2016;’

54. The HCPC’s case was as follows. When LC was preparing for a disciplinary hearing at NWAS he noted that a second PRF in relation to Patient B had been uploaded onto the NWAS computer system. The first PRF had been uploaded on 30 November 2016 and the second PRF had been uploaded on 30 December 2016. The Registrant had been interviewed in relation to Patient B on 9 December 2016 and had not mentioned the existence of a second PRF during that interview. The second PRF was a fabrication, which the Registrant created at some time before 30 December 2016 and after the interview, which took place on 9 December 2016. The document was a fabrication because it had not been created at the time of the incident but after the Registrant’s interview by LC, in order to give the impression that she had treated Patient B more thoroughly than had been the case.

55. The Registrant denied that she had fabricated the PRF. Her evidence was that she saw that the PRF written up by KT was inadequate while she was with him in the front of the ambulance. At the end of the shift she took the envelope containing all the PRFs for that shift from the ambulance and into the ambulance station. Having decided to write up a new PRF form and to shred the PRF form written by KT in view of its inadequacies, she sat down at a desk at the station and wrote up the new form, copying across such relevant details as there were on the PRF that KT had written up. However, she mistakenly posted both PRF forms into the box where the forms were left for later secure collection.

56. The Panel has accepted the evidence relied on by the HCPC as to the dates on which each of the PRFs was uploaded.

57. The Panel rejected the Registrant’s account for the following reasons. It was inconsistent with previous explanations given by the Registrant when interviewed by LC about the PRF for Patient B. In that interview, the Registrant accepted that she had not seen KT’s PRF prior to the interview and had “completely forgotten” about that job by the time she had a meal break during that shift. Further, in that interview, she had not raised the existence of her own PRF for that incident. She also said in that interview that she thought that KT put the green copy of his PRF in the shredder, which contradicted her assertion in evidence that she had all the PRFs at the end of the shift. The Panel also noted that the Registrant’s assertions in evidence were inconsistent with evidence of KT on this point, which the Panel has accepted. KT was firm in his recollection that he had put his PRF into the secure box because that it was what he did every day.

58. Despite the Registrant’s explanations in evidence as to why she said what she did in that interview, the Panel found it to be incredible that she would not have told LC about her PRF in answer to the questions that he asked of her.

59. The Panel has concluded that the Registrant wrote information on the second PRF which she knew to be untrue. She detailed observations which she had not taken, she recorded that the patient had stated she had pain every seven minutes that her waters had not broken and also recorded a yellow for the MTS in relation to the patient taking her own transport. However, the true position, as she well knew, was that she had not conducted observations she purported to record, the patient’s waters had broken and she was having contractions every two minutes. Furthermore, the Registrant knew that the appropriate discriminator was not yellow but orange, which required her to take the patient to hospital by ambulance.

60. By her own admission, the Registrant’s mindset during her visit to Patient B was to avoid complaints. In view of the conclusions it has reached, the Panel has further concluded that her motive in creating this new PRF was to show her inadequate performance on the day of her visit to Patient B in as good a light as possible in order to bolster her position in the disciplinary proceedings.

61. Therefore, the Panel has found Particular 3 proved in that, on a date between 9 – 30 December 2016, the Registrant fabricated a PRF in relation to her call out to Patient B on 20 November 2016.
‘4. Your actions described at particulars 1(b) and/or 2(g) and/or 3 were dishonest;’

62. The HCPC’s case on dishonesty as to particular 1b) was that the Registrant was dishonest in falsifying the pain level of Patient A on the PRF. By recording a pain level that the patient had not reported the Registrant was being dishonest because she knew about pain scoring and knew that the Patient had told her she had a much higher pain level. She recorded information which was not true. Recording untrue information was dishonest in those circumstances.

63. The HCPC’s case on dishonesty as to particular 2 g) was that the Registrant selected the yellow discriminator in order to justify her incorrect decision-making in relation to the incident, knowing that it was the wrong discriminator. 

64. The HCPC’s case on dishonesty as to particular 3 was that the fabrication of the second PRF by the Registrant was dishonest in view of how and why she created that document and its contents of the document (to improve her position in the disciplinary proceedings), the time when she created it, as well as the contents of the PRF, which falsely exaggerated the level of care she had given to the patient.

65. The Registrant denies that she was dishonest on any of the three occasions alleged.

66. The proper approach to the meaning of dishonesty was set out by the Supreme Court in Ivey v Genting [2017] UKSC 67. Lord Hughes stated at [74] –

‘…. When dishonesty is in question the fact-finding tribunal must first ascertain (subjectively) the actual state of the individual’s knowledge or belief as to the facts. The reasonableness or otherwise of his belief is a matter of evidence (often in practice determinative) going to whether he held the belief, but it is not an additional requirement that his belief must be reasonable; the question is whether it is genuinely held. When once his actual state of mind as to knowledge or belief as to facts is established, the question whether his conduct was honest or dishonest is to be determined by the fact-finder by applying the (objective) standards of ordinary decent people. There is no requirement that the defendant must appreciate that what he has done is, by those standards, dishonest.’

67. The Panel concluded that in relation to Particular 1(b), to deliberately falsify the pain level of Patient A on the PRF, was dishonest in the circumstances found in relation to Particular 1 (b).

68. In relation to Particular 2(g), by deliberately selecting what the Registrant knew to be the wrong discriminator so as to justify her decision not to take the patient by ambulance, the Registrant was dishonest in the circumstances found in relation to Particular 2 (g).

69. In relation to Particular 3, the Panel has concluded that the Registrant’s fabrication of the PRF for the purposes of justifying her professional performance for her disciplinary proceedings was also dishonest in the circumstances found in relation to Particular 3.

70. The Panel found that the testimonial evidence was of limited value in its consideration as to whether dishonesty was proved, in the circumstances.

71. Accordingly, the Panel found Particular 4 proved in its entirety.

Decision on Grounds

72. The Panel received further legal advice from the Legal Assessor on the issue of statutory ground and has directed itself in accordance with that advice.

73. The facts proved will amount to the statutory ground of misconduct if they establish conduct that fell short of what would have been proper in the circumstances and if, in context, the conduct was sufficiently serious, bearing in mind any relevant mitigating factors: Roylance v GMC [2000] 1 AC 311, PC at pp. 330 to 331 and R (Campbell) v GMC [2005] 1 WLR 3488, CA at [19] - [21].

74. Competence describes knowledge and skills, i.e. what a registrant ‘can do.’ The appropriate standard to be applied is that applicable to the post to which the practitioner had been appointed and the work she was carrying out: Holton v GMC at [70] - [71]. Competence of a registrant is generally to be decided by reference to a fair sample of their work: R (on the application of Calhaem) v GMC [2007] EWHC2606 (Admin) at [39].

75. Mr Dite submitted that this was really a case about misconduct and the facts established statutory misconduct. He submitted that the relevant rules and standards were as follows, -

• HCPC Standards of Conduct, Performance and Ethics (2016); Standards 1,2,4,9 and 10 in particular;
• Standards of Proficiency for Paramedics (2014), Standards 1,2,4,8,9,10 and 14 in particular;

76. Mr Waymont in his written closing submissions, accepted that the “charges which the panel find proved as fact” would amount to misconduct.

77. The Panel considered that the matters charged in the Particulars of the Allegation did not represent a fair sample of the Registrant’s work as a Paramedic and did not amount to lack of competence.

78. However, the Panel was satisfied that the Registrant had breached the HCPC Standards of Conduct, Performance and Ethics (2016) as follows –

1.2 “you must work in partnership with service users…”
2.1 “you must be polite and considerate”
2.2 “you must listen to service users…and take account of their needs and wishes”
2.3 “you must give service users… the information they want or need…”
4.1 “you must only delegate work to someone who has the knowledge, skills and experience needed…”
6.1 “you must take all reasonable steps to reduce all risks of harm to service users… as far as possible”
6.2 “you must not do anything, or allow someone else to do anything, which could put the health or safety of a service user at… unacceptable risk”
9.1 “you must make sure that your conduct justifies the public’s trust and confidence in you and your profession”
10.1 “you must keep full, clear and accurate records for everyone you care for, treat or provide services to”.

79. In relation to the Standards of Proficiency, the Panel has found it not necessary to make any findings in view of the conclusions it has reached.

80. The Panel has concluded that the totality of the matters found proved, including several acts of dishonesty, constitutes conduct which falls far below the standards required of a registered Paramedic and amounts to misconduct.

81. In all the circumstances, the Panel has concluded that the statutory ground of misconduct in relation to the facts proved is well founded. 

Decision on Impairment 

82. The Panel took into account all the submissions made by Mr Dite and Mr Waymont on the issue of statutory ground and current impairment and all the evidence so far as relevant to those issues. The Panel directed itself in accordance with the advice given by the Legal Assessor, who referred to the principles set out in Cheatle v GMC [2009] EWHC 645 (Admin) at [21] and [22] and in CHRE v NMC & Grant [2011] EWHC 927 (Admin) at [64] – [76], to the guidance given in the Practice Note, ‘Finding that Fitness to Practise is Impaired’ and to the Overarching Objective contained in Art. 3(4) and 3(4A) and paragraph 18(10A) of Schedule 1, Health and Social Work Professions Order 2001, as amended.

83. The Panel had regard to the extent of the Registrant’s failings in her treatment of Patient A and Patient B, including dishonestly falsifying Patient A’s PRF and fabricating a PRF in relation to her call out to Patient B. The Panel also took into account the extent to which the Registrant had breached the HCPC’s Standards of Conduct, Performance and Ethics.

84. The Registrant’s position was that she had learned from her mistakes. She had carried out extensive research and further learning on the various areas to remedy the shortcomings in her practice. This was part of a detailed personal development plan in which she has addressed the areas of practice that required improvement. She has also produced detailed reflective pieces and essays and carried out relevant work placements. She also apologised to Patient B at the time and expressed remorse when giving evidence, particularly in relation to Patient B and the risks that she created both for her baby and Patient B herself. Mr Waymont also relied on testimonial evidence.     

85. The Panel considered that the Registrant has taken steps of remediation in relation to the clinical aspects of her misconduct and did show remorse in relation to Patient B in particular, and apologised to her.

86. However, the Panel has concluded that the Registrant still presented a risk to patients. She told the Panel that she would have delegated the care of the patient to an EMT if the circumstances relevant to Patient A were to happen again. There was also a risk that she would act again in the same way as she did in relation to Patient B, as regards to her decision-making. The Registrant has taken some steps to correct the attitude that led to her subordinating her concern about a complaint to the proper care of Patient B. However, she has not practised as a Paramedic since leaving the employment of NWAS and such evidence as she has produced did not satisfy the Panel that she would prioritise the care of a patient in similar circumstances.

87. Furthermore, the Panel was not satisfied that she has remedied her behavioural and attitudinal problems. There is a risk that the Registrant would repeat her dishonest behaviour, particularly in view of her attempts before the Panel in her evidence to cover up her dishonesty. This also presents a risk to patients because service users cannot trust her integrity and there is a continuing risk that she would put her own interests before those of her patients. Furthermore, there is a particular risk to patients in view of the Registrant’s propensity to fabricate documents relating to their care, which could endanger their health and wellbeing.  

88. In view of the conclusions it has reached, the Panel has decided that:

• The Registrant has put service users at unwarranted risk of harm and is liable to do so in the future.
• The Registrant has brought her profession into disrepute and is liable to do so in the future.
• The Registrant has breached fundamental tenets of her profession relating to care for patients and probity, and is liable to do so in the future; and
• The Registrant has acted dishonestly and is liable to act dishonestly in the future. 

89. Accordingly, the Panel was satisfied that the Registrant’s fitness to practise is currently impaired in relation to the personal element of impairment.

90. The Panel was also mindful of the wider public interest considerations in this case, particularly the need to declare and uphold proper standards of conduct and behaviour and maintain confidence in the reputation in the Paramedic profession. The Panel concluded that the public would be appalled by the Registrant’s rude and dismissive treatment of Patient A, her inadequate treatment of Patient B and by her dishonesty.

91. In all the circumstances, the Panel has concluded that a finding of impaired fitness to practise is necessary in order to protect the health, safety and wellbeing of the public, to maintain public confidence in the profession and to maintain proper professional standards and conduct for members of the profession.

Decision on sanction

92. In considering which, if any, sanction to impose the Panel had regard to the HCPC Indicative Sanctions Policy (ISP) and the advice of the Legal Assessor.

93. The Panel reminded itself that the purpose of imposing a sanction is not to punish the practitioner, but to protect the public and the wider public interest. The Panel ensured that it acted proportionately, and in particular it sought to balance the interests of the public with those of the Registrant, and imposed the sanction which was the least restrictive in the circumstances commensurate with its duty of protection.

94. The Panel heard submissions from Ms Shameli and Mr Waymont. Mr Waymont referred the Panel to further documentation provided by the Registrant relating to the Registrant’s attendance at a CPD event in Manchester on 28 June 2018 relating to the management of obstetric emergencies and new-born and paediatric assessment skills. Mr Waymont also highlighted the Registrant’s testimonials and “thank you” letters. He invited the Panel to carefully consider the options of imposing a Conditions of Practice Order or a Suspension Order.

95. The Panel decided that the aggravating features were:

• the Registrant’s lack of insight particularly relating to the dishonesty and the attitudinal issues;

• the absence of any evidence that the Registrant has developed insight into her attitudinal behaviour or reflected on the decision of the Panel in the four months since the Panel’s decision;

• the nature of the dishonesty in the course of the Registrant’s professional duties involving two patients and occurring on three occasions;

• the risk of repetition and the continuing risk that the Registrant would put her own interests before those of her patients;

• the risk of harm to patients

96. The Panel decided that the mitigating features were:

• The Registrant’s apology to Patient B and expression of remorse in relation to clinical errors she admitted that she made;

• Remedial action taken by the Registrant in relation to clinical shortcomings in her practice;

• Positive testimonials and “thank you” letters in relation to her practice as a Paramedic prior to the events in 2016 and in relation to the Registrant’s current employment as medical secretary.

97. The Panel has found that the misconduct in this case involved attitudinal matters. It therefore would not be easy to remedy. The Registrant has not submitted any evidence to demonstrate to the Panel that her attitude has changed, that she has a plan to change her attitude, or that she is willing to change her attitude. The only step she has taken is to attend a CPD course relating to clinical skills.

98. The Panel did not accept Mr Waymont’s submissions that the misconduct in particular 1(c) was limited to a clinical misjudgement that was easily remediable. The Panel considered that the Registrant’s dismissive attitude to Patient A influenced her decision making in relation to her delegation of the patient’s care to her colleague. In her evidence to the Panel at the hearing the Registrant said that she would have made the same decision in the same circumstances.

99. The Panel also did not accept Mr Waymont’s submissions that the Registrant’s lack of confidence was the underlying reason for her dishonesty and that remedial action to address the lack of confidence could reassure the Panel that there would in the future be no risk of repetition. Although there is some evidence that the Registrant sometimes lacked confidence, the Panel did not consider that this was the explanation for the Registrant’s dishonesty. There were other motivations underlying each incident of dishonesty including disregard in relation to Patient A and an intent to protect her own position in disciplinary proceedings in relation to Patient B.

100. The Panel considered the options of taking no action and a Caution Order, but decided that they would not be sufficient to address the risk of repetition the Panel has identified, nor would they be appropriate having regard to the seriousness of the Registrant’s misconduct. Mr Waymont in his submissions recognised that neither option would address the need for a more serious sanction.

101. The Panel next considered a Conditions of Practice Order. The Panel decided that if the shortcomings in the Registrant’s practice had been limited to the clinical errors, a Conditions of Practice Order would have been appropriate. However, conditions could not adequately address the risk of repetition of dishonesty or of the attitudinal issues. The Registrant has not addressed the Panel’s concerns about her attitude, outlined in the original decision in April 2018. In these circumstances, conditions would not provide an adequate degree of public protection or provide the necessary degree of public reassurance.

102. The Panel next gave careful consideration to the option of imposing a Suspension Order. A Suspension Order would provide a measure of public protection by guarding against the risk of repetition of misconduct. A Suspension Order would provide the prospect of the Registrant returning to practise as a Paramedic in the future which would be in her financial interests. It would also enable her to utilise her clinical skills for the benefit of the public.

103. Nevertheless, a Suspension Order is not appropriate in cases where the misconduct is very serious and the Panel has insufficient confidence that the Registrant will be able to return to safe practice in the future because of underlying attitudinal issues. The Panel considered very carefully the prospect that the Registrant will be willing and able to remedy the underlying concerns. The Panel was not persuaded, on the evidence placed before it, that the Registrant has sufficient understanding and insight. The Registrant has had four months to reflect on the decision of the Panel, but there was nothing to indicate that this has led to any change. There was nothing to suggest that a longer period of reflection would make a difference.

104. The Panel carefully evaluated the mitigating circumstances, but considered that they had limited weight. The remedial action taken by the Registrant has been in the area of professional skills rather than in relation to the attitudinal concerns. The Registrant’s expression of remorse did not reassure the Panel in relation to the fundamental matter of her integrity. The testimonials and “thank you” letters testify to the Registrant’s clinical skills and the absence of any further concerns about her honesty, but they did not reassure the Panel that there was no continuing risk of repetition of the allegations found proved.

105. For the above reasons the Panel did not consider that a Suspension Order was sufficient to uphold public confidence in the profession and the regulatory process. The misconduct is particularly serious and members of the public would expect the regulator to regard such conduct as incompatible with continued registration, especially when there is no evidence of a commitment from the Registrant to acknowledge and address the Panel’s concerns. The dishonesty is combined with a lack of insight and it includes an attempt by the Registrant to cover up and put her own needs before that of her patients or colleagues.

106. The Panel therefore considered the option of a Striking Off Order and decided that it was the appropriate and proportionate sanction. The Panel considered the Registrant’s interests, but decided that they were outweighed by the need to protect the public and the wider public interest. The Panel noted that many of the factors highlighted in the case law which indicated that a Striking Off Order may be appropriate were present in this case including proven dishonesty in the course of professional duties, a breach of trust, lack of insight and a cover up.

Order

Order: The Registrar is directed to strike the name of Helen Middleham from the Registrar.

Notes

No notes available

Hearing History

History of Hearings for Miss Helen Middleham

Date Panel Hearing type Outcomes / Status
29/08/2018 Conduct and Competence Committee Final Hearing Struck off
11/04/2018 Conduct and Competence Committee Final Hearing Adjourned part heard