Mr Kristian Williams

Profession: Paramedic

Registration Number: PA35583

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 03/12/2018 End: 17:00 10/12/2018

Location: Health and Care Professions Tribunal Service (HCPTS), 405 Kennington Road

Panel: Conduct and Competence Committee
Outcome: Struck off

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Allegation

Whilst registered as a Paramedic and working at South Western Ambulance Service NHS Trust: 

1. On or around 11 February 2016, you attended on Patient A and you:

a) Assessed Patient A as having a migraine;

b) Did not administer pain relief;

c) Did not administer an antiemetic;

d) Said what a load of bollocksand/or it’s just a migraine’ or words to that effect;

e) Did not record identifying any red flags with Patient A’s condition

 

2. On or around 6 April 2016, you:

a) Left work early at approximately 01:20

b) Did not respond to the emergency call at around 01:42/01:44;

c) Signed the morphine back as returned and recorded the time as at 01:45 which was not the case;

d) Did not notify a manager and/or the clinical hub and/or log off your vehicle mobile data terminal (MDT) before leaving your shift early.

 

3. On or around 7 June 2016, you attended on Patient B and you did not seek any further treatment for Patient B.

4. On an unknown date, you attended on Patient C and you:

a) Overruled a decision by a Paramedic colleague without clinical justification for doing so;

b) Did not complete appropriate assessments to rule out spinal injury; or

c) Did not immobilise the patient;

 

5. On or around 7 June 2016, you attended on Patient D and you:

a) Overruled a decision by a Paramedic colleague and/or GP without clinical justification for doing so;

b) Delayed in conveying the patient to hospital;

c) Made an inappropriate comment to or in the presence of Patient D in that you said ‘you’re obviously not having a stroke now’ or words to that effect.

 

6. On or around 7 June 2016, you attended Patient E and you inappropriately forced the patient to drink activated charcoal. 

 

7. Your actions at particulars 2c) and/or 2d) were dishonest. 

 

8. The matters set out at paragraphs 1 to 7 constitute misconduct and/or lack of competence.

 

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

 

Finding

Preliminary matters
Amendment to the Allegation
1. At the outset of these proceedings the HCPC told the Panel that it had notified the Registrant that it was withdrawing two of the Particulars. As a result a representative of the HCPC had renumbered the remaining Particulars. However, Ms Ryan submitted that the original numbering should be retained.
2. Ms. Ryan submitted that the amendments would not prejudice the Registrant. The Registrant did not seek to argue the point.

3. The Panel considered that the proposed amendment was not significant and served only to clarify correct numbering of the Particulars.

4. The Panel agreed that the numbering of the Allegation should remain as it was originally set out and there is no injustice to the Registrant.

Proceeding in Absence
5. At the outset of the hearing the Registrant took part in the proceedings via telephone. He explained to the Panel that he wished to take part in the proceedings, to the extent that he wished to give his own evidence via telephone. He did not wish to cross-examine witnesses or otherwise be involved. He stated that he did not wish to apply for an adjournment of the proceedings for a time and date when he was available to attend in person and he understood that the rest of the case would proceed without him.
6. The Panel was aware that the Registrant had the process explained to him by the Legal Assessor and that he understood the decisions that he was making. For example, he knew he could apply for the hearing to be adjourned but he chose not to. In all the circumstances the Panel was satisfied that the Registrant had voluntarily absented himself from some of the proceedings but that he would attend via telephone on the third day of this hearing to give evidence via telephone.

Background
7. The Registrant was employed by South Western Ambulance Service NHS Foundation Trust (the Trust) as a Paramedic. He initially joined the Trust in June 2004 and was employed as an ambulance technician and later qualified as a Paramedic. In April 2016 concerns were raised at the Trust regarding the Registrant leaving his shift early and entering an inaccurate time in the morphine book to suggest that the morphine had been returned later than it had been. Timed CCTV footage identified the discrepancy. An internal investigation was commenced and a number of other matters forming the subject of the allegations in this case were also investigated. A referral was subsequently made to the HCPC.

Decision on Facts
8. In coming to its decision on facts the Panel had regard to all the evidence both oral and documentary. It was reminded that it is for the HCPC to prove its case and that there was no burden on the Registrant to prove anything. The standard of proof applied when considering whether the allegations are made out is that of the balance of probabilities i.e. whether it is more likely than not to have occurred.

9. The Panel took into account the submissions made on behalf of the HCPC and the oral and written evidence of the Registrant. It had regard to the advice of the Legal Assessor. The Panel drew no adverse inference from the Registrant’s non attendance for parts of the hearing.

10. The Panel heard oral evidence from the following witnesses on behalf of the Council:
• Mr ID - Project Manager for the Trust who conducted the Trust investigation
• Ms MW - Emergency Care Assistant (ECA) for the Trust
• Ms LW - Ambulance Practitioner (Technician) at the Trust
• Ms VH - ECA for the Trust
• Ms RW - Paramedic at the Trust

11. The Registrant also gave evidence over the telephone to the Panel.

12. In relation to witnesses generally the Panel bore in mind that an honest witness can be mistaken and that a mistaken witness is not necessarily wrong about every fact. In general terms the Panel noted that there were significant differences in the accounts given by the HCPC witnesses and the evidence of the Registrant. This was especially so in relation to Particular 1.

13. In coming to its decision on facts the Panel reminded itself that the Registrant is a man of good character in the sense that he has no findings against him by the HCPC. The Panel took into account the testimonials which attest to his good character and to his standard of professional practice.

Particulars 1(a) – 1(d) – Found Proved
1. On or around 11 February 2016, you attended on Patient A and you:
a) Assessed Patient A as having a migraine;
b) Did not administer pain relief;
c) Did not administer an antiemetic;
d) Said ‘what a load of bollocks’ and/or ‘it’s just a migraine’ or words to that effect;
e) No evidence offered

14. In respect of this Particular, the Panel considered the evidence of MW and LG. LG explains that Patient A had had a sudden “thunderclap headache” and she felt as though something had gone “pop” inside her head. LG recorded this and other information on the Patient Clinical Record (PCR) at the time, before the Registrant and MW arrived on the scene as backup. LG describes the demeanour of Patient A as being in considerable pain. She was rocking back and forth, retching and largely unable to communicate. The lights were dimmed by LG.

15. When MW arrived, she said she knocked and loudly announced her presence. She was told to speak quietly by LG. MW also describes how the lighting in the house was dimmed and Patient A had her head in her hands and was rocking in pain. LG described how Patient A had taken paracetamol but had vomited them up. MW states that she was told this by LG when LG, ‘the first responder’ on the scene, was handing over the care of Patient A to the Registrant, the more senior clinician. Both witnesses describe how Patient A was taken to the ambulance and that it was MW who was in the back with Patient A. Neither of them described the Registrant as being in the back of the ambulance alone with Patient A. LG said she repeatedly asked the Registrant to give Patient A pain relief and asked him to cannulate the patient in order to do so. The Panel considered that the accounts of both HCPC witnesses corroborated each other.
 
16. The Registrant, by contrast, described Patient A as lucid, not complaining of pain, not feeling sick anymore and he said that she did not in his experience “look like someone with a severe sub arachnoid bleed”. He said that LG either did not tell him, or he did not hear her say, that Patient A had vomited up the paracetamol that she had taken. In his evidence he placed himself alone in the back of the ambulance talking to Patient A.

17. According to the Registrant, MW and LG were smoking whilst he was dealing with Patient A in the ambulance. At this point Patient A told him that she had taken liquid pain relief. MW and LG deny smoking and also that the Registrant was alone in the back of the ambulance at all. The Panel concluded that the evidence of MW and LG was more credible than that of the Registrant. MW and LG were concerned as to the seriousness of Patient A’s illness whereas it was the Registrant who was stating that it was a migraine. The Panel therefore rejects the possibility that MW and LG were smoking as the Registrant alleged. In the Registrant’s evidence he suggests that he heard that Patient A had taken paracetamol but he did not hear that she had thrown the tablets up. By contrast, MW who arrived at the house at the same time as him and heard the same handover briefing, did hear that the patient had vomited and had not digested the paracetamol.

18. The Registrant stated that he did not give Patient A pain relief because he was concerned about what medication she might have taken beforehand. However, he did not communicate this to his colleagues and he did not record this in the PCR. The information on the PCR supports the evidence of MW and LG regarding the symptoms and level of pain suffered by Patient A. The Registrant also suggested that the criticism made of him by LG was because she had something against him. No evidence was given for this. Further, LG raised the issue only after learning that Patient A had had a subarachnoid bleed, making her particularly concerned about the Registrant’s treatment of Patient A.

19. The Panel concluded that key aspects of the Registrant’s evidence were neither credible nor reliable. The Panel found the evidence of MW and LG more compelling than that of the Registrant.

20. Particular 1(a). At the outset of the proceedings the Registrant admitted that he had assessed the patient as having a migraine. The evidence of MW and LG confirm this to be the case. This Particular is proved.

21. Particular 1(b). The Registrant did not give pain relief and this is accepted by him and his evidence is corroborated by the evidence of MW and LG set out above. Although the Registrant explained he had a reason for not giving pain relief, i.e. that she had taken pain medication and he was unsure of what it was, he did not record this in the PCR and he did not communicate this to his colleagues. As noted above the Panel was not convinced by his version of events. This Particular is proved.

22. Particular 1(c). At the outset of the proceedings the Registrant admitted that he did not give an antiemetic drug. There is no record of him having done so and the HCPC witnesses corroborate this. The Registrant described Patient A as looking normal in colour whereas LG and MW describe her as retching. The PCR records this, and that she also vomited in the ambulance on the way to hospital. This Particular is proved.

23. Particular 1(d). At the outset of the hearing the Registrant denied this allegation. However, in oral evidence he said he might have said “it’s just a migraine” to his colleagues. Both MW and LG refer to him using the words “what a load of bollocks” and “it’s just a migraine”. The Panel concluded that he did use the words as alleged but that it is not clear on the evidence before the Panel that those words were used in front of Patient A.

24. The Panel found this Particular proved on the basis that he used those words or something similar.

25. Particular 1(a) – 1(d) is proved in its entirety.

Particulars 2(b) – 2(d) – Found Proved
2. On or around 6 April 2016, you:
a) No evidence offered;
b) Did not respond to the emergency call at around 01:42/01:44;
c) Signed the morphine back as returned and recorded the time as at 01:45 which was not the case;
d) Did not notify a manager and/or the clinical hub and/or log off your vehicle mobile data terminal (MDT) before leaving your shift early.

26. At the outset of the hearing the Registrant admitted this Particular in its entirety. The Panel had regard to the CCTV footage that was presented to it. The Panel also had regard to the evidence of ID who described how there was a call out to the Registrant’s vehicle at 1:42 and then again at 1:44 after the control room had been alerted that the Registrant’s vehicle had not mobilised. The Panel had no reason to doubt the evidence of ID who gave an explanation of what happens when a call is put through to a Paramedic.

27. Particular 2(b). The Registrant accepted that he did not respond to the call as he was not present and had left the building. This Particular is proved.

28. Particular 2(c). The Panel took into account the Registrant’s admission. It also had regard to the CCTV footage where the Registrant is seen entering the room and signing the morphine book. The Panel has also seen an extract from that book. ID told the Panel that on the original CCTV footage the time of the recording is 1:17 and the accuracy of the time had been checked. The Registrant recorded on the Book the returning time of 1:45. It is therefore clear that the Registrant recorded the incorrect time. ID also told the Panel that the Registrant does not wear a fob watch as he prefers to tell the time from his mobile phone. The Registrant does not deny that this is his usual practice. On the CCTV footage the Registrant is seen taking his phone out of his pocket, looking at it briefly and returning it to his pocket and he then carries on writing in the book. The Registrant told the Panel that he cannot recall why he looked at his phone and said that he was guessing the time and this explains why he wrote down the incorrect time. The Panel rejects the Registrant’s evidence as inherently implausible. He is seen looking at his phone and he therefore would have known the correct time. The Panel concluded that he chose to write down an incorrect time. This Particular is proved.

29. Particular 2(d). The Panel took into account the Registrant’s admission. The Registrant stated that he did try to call the sick line but there was no answer. He said that he should have stayed on the call for longer.

30. ID told the Panel that the sick line, would divert to the control room if there was nobody on call on the sick line as would be the case overnight. He also explained that the Registrant could have contacted the control room, or a Bronze Officer, or there would be other colleagues present in the building to contact. He also explained that the Registrant was required to log off his mobile vehicle terminal MDT when not working, as this was necessary to alert control room that the ambulance was not in operation.

31. The Registrant accepted that other than trying to call the sick line he did not make any other attempts to speak to any other work colleague about leaving work early and he did not log off the MDT. He explained that at the time he had a lot of personal issues he was dealing with and that he was not in the right frame of mind. He also told the Panel that on the evening in question he had attended at an incident which reminded him of his personal circumstances and was very upsetting. He said that he had told the control room that his last job had affected him, and the control room told him to return to base. There is no documentary or oral evidence to corroborate this version of events and in any event it contradicts the Registrant’s own later evidence where he stated that he did not discuss how he was feeling with his colleagues that evening as he did not wish to be seen as weak. The Panel reject the Registrant’s varied explanations as implausible.

32. This Particular is proved.

Particular 3 – Found Proved
3. On or around 7 June 2016, you attended on Patient B and you did not seek any further treatment for Patient B.

33. The Panel had regard to the evidence of VH. She raised a concern in relation to how the Registrant dealt with Patient B. Patient B had an on-going problem with a slipped disc. The family had managed to get him downstairs from his bedroom but on the way back upstairs he slipped and they were unable to move him. KW arrived on the scene. VH did not recall an assessment of the patient but remembers the patient being administered some of his own oral morphine.  He was also administered Entonox by the Registrant. The Registrant then attempted to lift the patient and managed to “drag him up the stairs by pushing and pulling him until he got him back to bed”. VH was concerned several times that the moving of the patient was not working and that one of them could get injured. The patient was advised that he should see his GP the next day but nothing further was done.

34. The Panel had regard to the evidence of VH. It was clear from her evidence that she did not get on with the Registrant. The Panel also found that her evidence was tainted, to an extent, by her dislike of the Registrant. In this regard it treated her evidence with some caution. The Registrant explained to the Panel why he believed it was appropriate to leave the patient at home. In particular he noted that the patient had his own medication and the GP had visited him that day and was visiting him the next day.

35. The Panel finds this Particular proved in that the Registrant did not seek any further treatment for Patient B but the Panel concluded that the Registrant’s conduct was appropriate in the circumstances.

36. This Particular is proved.

Particulars 4(a) – 4(c) – Found Proved
4. On an unknown date, you attended on Patient C and you:
a) Overruled a decision by a Paramedic colleague without clinical justification for doing so;
b) Did not complete appropriate assessments to rule out spinal injury; or
c) Did not immobilise the patient;

37. The Panel heard from RW. She had expressed concern regarding how the Registrant dealt with Patient C.

38. The patient was an elderly man who had fallen backwards down the stairs. He was observed to be a little confused and incoherent. There was a possibility that he had been briefly knocked unconscious. He also had underlying cardiac history. RW was the Paramedic first on the scene and she called for assistance. She explained that she had kept the patient in the position that he had fallen, whilst awaiting back up. She stated that she had decided that the patient needed to be immobilised and transferred to hospital on a stretcher. When the Registrant arrived at the scene, she said that he did not examine the patient and said that he believed the patient to be fine and that he should stand up. The patient initially sat up, then stood up and the Registrant walked him to the living room.        

39. The patient was in any event conveyed to hospital after a discussion with family members.

40. RW was concerned that the Registrant did not conduct an appropriate assessment of Patient C before asking the patient to get up. She said that the Registrant did not use Canadian C Spine Rules used by SWAST for spine injuries, therefore putting the patient at risk. When she returned to base she immediately raised her concerns with a manager. The Registrant was asked to return to base and a discussion with management was held about the incident. As a result, the Registrant was reminded by management of the need to follow the correct procedure when there is the risk of a spinal injury and was given a copy of the relevant guidance. The Registrant referred to this meeting as “an informal chat”.

41. The Registrant told the Panel that he had conducted an assessment of Patient C, and discussed and agreed this with RW before asking the patient to move.

42. Particular 4(a). The Panel had regard to the evidence of RW. She was so concerned about what had happened that she reported the matter to a manager on return to base. It is accepted by the Registrant that he was ordered to return to base for a discussion about what had happened. The Panel did not accept the Registrant’s evidence that he had a discussion with RW when he was at the patient’s side as to the best action to take. RW does not describe such a discussion and the fact that she reported her concerns on return to base supports her evidence that there was no such discussion as alleged by the Registrant. It was clear from the evidence of RW that she had assessed the patient and had decided on a course of action. The Panel concluded that the Registrant overruled RW’s decision without clinical justification. This is corroborated by the Registrant’s observation at the meeting with RW and management shortly after the incident that he had acted on “gut instinct”.

43. The Panel finds this Particular proved.

44. Particular 4(b). RW told the Panel that the Registrant knelt down beside the patient and said words to the effect “get up then”.

45. RW explained that she felt the patient needed to be immobilized because he was confused, had low blood pressure, was over 65, and had fallen down some stairs, meaning that he may have a spinal injury. She said he was a compliant patient. The Registrant told the Panel that he believed that there was a discussion between himself and RW about what should happen to the Patient. By contrast RW states that there was no such discussion. She said when the Patient was asked to get up that she was “swept sideways” as she was not expecting the Registrant to take this course of action. The Registrant’s evidence was inconsistent; he said that he did not touch the patient but observed the situation. He said there were no scuff marks on the wall, no ripped clothing, no blood, and that RW was not holding the patient’s head still. He then said later on in evidence that he might have checked the patient’s ankles and undertaken an MSC test. Even on the Registrant’s own evidence he did not check the patient’s spine for tenderness at all.

46. The Panel found the evidence of RW that the Registrant did not palpate the patient’s spine to be more credible, given the inconsistencies in the Registrant’s own very varied account. The Panel also accepted the evidence of ID that in the circumstance of this case a C-spine assessment should have been undertaken.

47. On the basis of all the evidence before it the Panel concluded that the Registrant did not complete appropriate assessments to rule out spinal injury.

48. This Particular is proved.

49. Particular 4(c) The Registrant in oral evidence accepted that he did not immobilize the patient. This is corroborated by the evidence of RW.

50. This Particular is proved.

Particular 5(b) – Found Proved
Particulars 5(a) and 5(c) - Found Not Proved
5. On or around 7 June 2016, you attended on Patient D and you:
a) Overruled a decision by a Paramedic colleague and/or GP without clinical justification for doing so;
b) Delayed in conveying the patient to hospital;
c) Made an inappropriate comment to or in the presence of Patient D in that you said ‘you’re obviously not having a stroke now’ or words to that effect.

51. The Panel had regard to the evidence of VH. She described attending Patient D, who was suspected of having a stroke, and suffered with alcoholism. The GP had been contacted by telephone and had spoken to the husband. The GP had advised that the patient should be taken to hospital to have this explored. A paramedic colleague, CI, had first attended the patient at her caravan and had called for backup to take the Patient to hospital. This colleague did not attend to give evidence before the Panel and there was no statement from that individual although there was documentary evidence from her on the matter. She left the scene early as it was the end of her shift and the Registrant was given a handover from her.

52. VH described how she was outside the patient’s caravan while the Registrant and a student paramedic were inside with the patient and her husband. VH also told the Panel that the Registrant was with the patient for some time, assessing her and “exploring options”. She was concerned that the Registrant did not take Patient D to a hospital more quickly.

53. The Registrant told the Panel that he had been given a handover from the colleague and that he had made his own assessment of the situation.

54. In respect of Particular 5(a), the Panel concluded that the Registrant had a clinical justification for overruling the decision of the first Paramedic on the scene. That first Paramedic had given him a handover but he undertook his own assessment and came to his own clinical decision about the case. The Panel also noted that the GP had not assessed the patient in person.

55. The Panel therefore concluded that the Registrant did not act improperly and that rather than overruling the decision of a colleague he made his own clinical assessment of the situation.

56. This Particular is not proved.

57. In respect of Particular 5(b) the Panel accept the evidence that the Registrant delayed in taking the patient to hospital. However it noted that the Registrant was properly considering other options as to the appropriate care for this patient. The Panel considers that there is no criticism of the Registrant in this regard.

58. This Particular is found proved for the above reasons only.

59. In respect of Particular 5(c), the Panel had regard to the evidence of VH as to how she described the comment having been said. In interview VH recalled that when the Registrant arrived on the scene he said ‘well you’re obviously not having a stroke now’ to the patient. However, the Panel had some concerns about the evidence of VH given her dislike of the Registrant. On the balance of probabilities, the Panel accepted the Registrant’s evidence that this was a direct comment, said with the intention of reassuring the patient that she was not having a stroke.

60. On the balance of probabilities the Panel found this Particular not proved.

Particular 6 – Found Not Proved
6. On or around 7 June 2016, you attended Patient E and you inappropriately forced the patient to drink activated charcoal.

61. The Panel had regard to the evidence to VH. She said that a female patient had taken an overdose and her family were present and distressed.  VH observed the Registrant giving activated charcoal to the patient. She said he was forcibly insisting that the patient drink the solution. She recalled that the Registrant was holding the bottle to the patient’s mouth despite the fact that she was trying to push it away. She stated that she recalled the patient’s son saying to leave it even though the husband of the patient said it was ok for her to have it. VH said that she felt that the Registrant lacked sensitivity to the situation and to the patient and was too forceful in administering the charcoal.

62. The Registrant denied being forceful to the patient. He stated that he was holding the bottle and was encouraging the patient that it was in her best interest to drink the solution, and it was not surprising that most patients would not like drinking the solution.   

63. The Panel considered the differing version of events. The Panel also took into account the evidence of ID that the student paramedic who was present at the time corroborated the Registrant’s version of events. ID also told the Panel that it was appropriate for a paramedic in the circumstances to be assertive. The Panel also noted that the Registrant was in the ambulance with the patient whereas VH was outside the ambulance looking on. Given that there were two conflicting accounts with a report of a corroboration for the Registrant’s case, the Panel found that the HCPC had not made its case.

64. Based on the evidence before it the Panel found this Particular not proved.

Particular 7 – Found Proved
7. Your actions at particulars 2c) and/or 2d) were dishonest.

65. The Panel has already found the facts of Particular 2(c) and 2(d) proved. In its reasons set out above the Panel rejects the Registrant’s version of events. The Panel relied on the CCTV evidence and the evidence of ID. The Panel therefore went on to consider whether the conduct found proved was dishonest. In this regard the Panel took into account that there are no HCPC findings against the Registrant and it had regard to the positive testimonials. The Panel also had regard to the test for dishonesty as set out in the case of Ivey v Genting Casinos and as explained by the Legal Assessor.

66. The Panel concluded in respect of Particular 2(c) that the Registrant knew the precise time that he was signing the morphine book as he is seen looking at his mobile telephone on the CCTV. The Panel rejects the Registrant’s evidence that he was guessing the time. The oral evidence of ID was that the sign in time used by the Registrant was one that would not raise suspicion if noticed by someone at a later stage. The Panel observed that, even on the very short extract of the morphine book available to it, several clinicians had recorded sign in times of 45 minutes past the hour, as the Registrant did. The Panel considered that the Registrant knew at the time that what he was doing was wrong and dishonest. The Panel also considered that ordinary members of the public would also consider that deliberately entering an incorrect time in the morphine book would be considered dishonest.

67. Further, the Panel considered that the Registrant knew that he should notify somebody before he left his shift early. The Panel also considered that he knew that by not logging off the MDT, the control room would be unaware that he had left his shift early. The Panel concluded that the Registrant knew what he was doing and that he knew he was acting dishonestly.

68. The Panel concluded that the Registrant acted dishonestly. This Particular is found proved in respect of Particular 2(c) and 2(d).

Decision on Grounds
69. On the basis of the facts found proved the Panel went on to consider whether those facts amounted to misconduct and/ or lack of competence. It took into account the submissions made by Ms Ryan on behalf of the HCPC and it had regard to the oral evidence of the Registrant. The Panel also had regard to the advice of the Legal Assessor.

70. In considering this matter the Panel exercised its own judgement. The Panel also took into account the public interest which includes protection of patients, maintenance of public confidence in the profession and the declaring and upholding of proper standards of conduct and behaviour.

71. The Panel first considered whether the facts found proved amounted to misconduct as distinct from a lack of competence. In particular the Panel had regard to the distinction between misconduct and lack of competence as identified in the case of Calhaem v GMC [2007] EWHC 2606 Admin.

72. The Panel considered that the Registrant had the requisite knowledge and the requisite experience and skill to carry out the tasks that were expected of him. He completed his degree as a Paramedic in 2012 and had practised for 12 years. No issues as to his lack of competence prior to 2016 were brought to the Panel’s attention. Having regard to all the facts of this case the Panel therefore did not consider this to be a lack of competence case.

73. The Panel next considered whether the facts found proved amount to misconduct. It noted that not all breaches of the HCPC Standards of Performance, Conduct and Ethics amount to misconduct.

74. The Panel considered that a number of the facts that the Panel found proved did not amount to misconduct. In this regard the Panel considered this to be the case in respect of the following matters:
• In respect of Particular 3 the Panel was of the view that the Registrant’s conduct in not seeking further treatment was not unreasonable given that Patient B had been seen by his GP that day, was going to be seen again by his GP the following morning and the patient had his own prescribed pain relief.
• In respect of Particular 5, the delay transporting Patient D to hospital, the Panel concluded that the delay was justified as the Registrant was in the process of undertaking his own assessment to form his own clinical opinion, and was exploring alternative care pathways.

75. The Panel considered that the Registrant’s treatment of Patient A, and Patient C fell far below the standard expected of a Paramedic. The Panel also considered that the Registrant’s conduct in leaving his shift early, not telling anyone and deliberately falsifying the morphine book with the incorrect time fell seriously short of the standards expected of a Paramedic.

76. The Panel considered that the Registrant breached the following standards of proficiency for Paramedics:
Standard 9  be able to work appropriately with others
Standard 9.1  be able to work, where appropriate, in partnership with service users, other professionals, support staff and others
Standard 14.9  be able to gather appropriate information
Standard 14.10 be able to select and use appropriate assessment techniques
Standard 14.12  be able to conduct a thorough and detailed physical examination of the patient using appropriate skills to inform clinical reasoning and guide the formulation of a differential diagnosis across all age ranges.

77. The Panel also considered the HCPC Standards of conduct, performance and ethics and it considers that the Registrant breached:
Standard 1  Promote and protect the interests of service users and carers
Standard 2  Communicate appropriately and effectively
Standard 2.2  You must listen to service users and carers and take account of their needs and wishes.
Standard 2.5   You must work in partnership with colleagues, sharing your skills, knowledge and experience where appropriate, for the benefit of service users and carers.
Standard 6.1   You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.
Standard 9   Be honest and trustworthy
Standard 9.1   You must make sure that your conduct justifies the public’s trust and confidence in you and your profession.

78. The Panel noted that in respect of Patient A, it was clear that she was very unwell. The PCR describes her “red flag” symptoms and the level of pain the patient was in. She could barely speak, she had been vomiting and she required pain relief. LG repeatedly asked for the patient to be given pain relief and to be cannulated. Her requests were ignored by the Registrant.  In the Registrant’s evidence he repeatedly said that the patient did not present like other sub-arachnoid haemorrhage patients he had seen in the past. It was clear to the Panel that he formed an instant conclusion that Patient A was suffering from a migraine without taking account of his clinical colleagues’ assessment or concerns and without his own clinical justification. The PCR identified a number of red flags that were ignored by the Registrant; such as the sudden onset of a “thunderclap” headache and the patient describing the feeling of something going “pop” in her head. The Registrant should have given her pain relief and he should have cannulated the patient.  As a result of the Registrant’s failings this patient suffered harm. She was left suffering, in considerable pain, wholly unnecessarily, until she was taken to the hospital and treated there. The Registrant’s conduct fell far below the standards of a reasonably competent Paramedic.

79. Furthermore, the Panel took the view that the derogatory comment made by the Registrant about the patient “just having a migraine” reinforces how he regarded that patient. Whilst the Panel accepts that the comment may not have been said in front of the patient, it served to denigrate the seriousness of the patient’s condition to his colleagues. This fell seriously short of the standard expected of a Paramedic.

80. The Registrant had a duty to remain available to respond to callouts until the end of his shift. By leaving early he put patients at risk of harm. In this particular case he was called upon to attend a 999 call before the end of his shift and as a result of his non-attendance there was a delay in a patient being responded to by 15 minutes. If the Registrant felt he had to leave his shift early he had numerous opportunities to inform someone. He deliberately chose to cover up his leaving early by falsifying the morphine book record. The Panel considered that he was putting his own emotional needs in not wanting to show weakness to colleagues, above the needs of patients. By acting dishonestly in this way, he fell far short of the standards expected of a Registered Paramedic.

81. In respect of Patient C the Registrant also formed a snap decision as to what was wrong with the Patient. Any reasonably competent Paramedic would have undertaken a full spinal assessment prior to moving the patient. He did not undertake this assessment. Yet again he did not listen to, or take account of, his colleague’s handover information. His conduct with respect of Patient C fell far short of the expected standards.

82. The Panel therefore concluded that the Registrant’s failings referred to above were serious and amounted to misconduct.

Decision on Impairment 
83. The Panel has taken into account that the purpose of these proceedings is not to punish or re-punish the practitioner for past misdoings but to protect the public against the acts and omissions of those who are not currently fit to practise. In approaching this task the Panel applied its own professional judgment. The Panel had regard to the practice note issued by the HCPTS. The Panel took account of the case of the CHRE v Grant [2011] which reminds Panels of the need to consider the public interest. In particular the Panel noted paragraph 74;

“In determining whether a practitioner’s fitness to practise is impaired by reason of misconduct, the relevant Panel should generally consider not only whether the practitioner continues to present a risk to members of the public in his or her current role, but also whether the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular circumstances.”

84. The Panel also considered the case of Cohen-v- GMC [2008] EWHC 581 (Admin). At paragraph 65 of Cohen Silber J. states “it must be highly relevant in determining a doctor’s fitness to practice is impaired that first his or her conduct which led to the charge is easily remediable, second that it has been remedied and third that it is highly unlikely to be repeated”.

85. The Panel first considered the personal component of impairment. The Panel considered that the Registrant had some limited insight into how he interacted with colleagues. However, he still failed to recognise that he had not listened to, or taken into account, his colleagues’ handover information. The Registrant had very little, if any, insight into his own clinical failings and, in particular, his tendency to jump to conclusions and make snap judgements about a patient, without considering the evidence available from others or undertaking his own adequate assessment. He also minimises the concerns of other clinicians. Even when he was asked to return to base to discuss Patient C with a manager and RW, he did not seem to recognise this as a formal management critique of his clinical practice but rather described it as an “informal chat”.

86. When the Registrant had been interviewed by the Trust he said “I do understand that maybe I got into the situation too fast, over confident. I need to slow down, assess and discuss”. This appeared to demonstrate to the Panel that the Registrant had some insight into his failings. However, in oral evidence to the Panel he seemed to blame his problems on colleagues who, he felt, do not like him. The Panel concluded that the Registrant had no insight into the fact that his colleagues were raising clinical concerns and they, rather than patients, were best placed to comment on his shortcomings. The Panel was of the view that the Registrant put patients at risk of harm and in respect of Patient A caused actual harm. Given the Registrant’s lack of insight there is a high risk of repetition of the misconduct identified if the Registrant were practising as a paramedic.

87. With respect to his leaving work early, the Panel took into account the Registrant’s difficult personal circumstances at the time, and the actions he had taken subsequently to address these, including developing appropriate coping mechanisms. The Panel therefore felt that the risk of repetition of leaving early due to stressful triggers is low. However, with regard to both acts of dishonesty of record falsification and not signing the MDT to hide his absence, the Panel find that he has no insight into the fact that he was dishonest. Therefore the Panel cannot be sure that the Registrant would not commit further dishonest acts in the future.

88. The Panel was of the view that the public would be very concerned and alarmed to know that the Registrant behaved in the ways that he did. His misconduct undermines public confidence in the profession and fails to uphold proper standards of conduct and behaviour.

89. The Registrant’s fitness to practise is currently impaired on both the personal and public components of Impairment.

Decision on Sanction

90. In considering what, if any, sanction to impose the Panel had regard to the HCPC Indicative Sanctions Policy and the advice of the Legal Assessor. It also took into account Ms Ryan’s submissions and all the evidence that the Registrant had presented to it thus far.
91. The Panel notes that the purpose of fitness to practise proceedings is not to punish the practitioner for past misdoings but to protect the public against the acts and omissions of those who are not currently fit to practise. It is part of the public interest not to permanently deprive the public of an otherwise competent practitioner.
92. In considering the appropriate sanction if any, the Panel had regard to the aggravating and mitigating factors in this case.
93. In mitigation the Panel noted that the Registrant admitted a few of the allegations. The Registrant had had significant personal problems at the relevant time and there are testimonials which refer to his ability as a paramedic (albeit they are somewhat dated).
94. There are a number of aggravating factors in this case. Patient A suffered actual harm. The Registrant failed to appropriately assess Patient C and by leaving his shift early there was a delay of 15 minutes for the patient being responded to by the ambulance service. His misconduct and dishonesty therefore put patients at risk of harm. The Registrant demonstrated no real insight into his clinical failings. Further, in acting dishonestly, the Registrant abused the trust his employers were entitled to place in him.
95. The Panel was concerned by the oral evidence it heard from the Registrant. It appeared to the Panel on numerous occasions that he sought to change his evidence as to what assessment he allegedly undertook. The Panel was also concerned by the Registrant’s evidence where he specifically sought to blame other colleagues for raising the criticisms against him. The Panel had also found that the Registrant had used false stories to support his case, for example, by stating that colleagues were smoking when he was caring for Patient A and so they had not heard the patient speak to him. His oral evidence demonstrated a significant lack of insight into his clinical failings and a lack of recognition or understanding of what he did wrong.
96. In addition, the Registrant has not acknowledged or admitted his dishonesty. Although he pleaded extenuating personal circumstances during the relevant period, he nevertheless has not suggested that those circumstances caused him to either act dishonestly or suffer serious lapses of clinical judgement. He lacks insight and still denies the underlying facts of the case.
97. The Panel reminded itself that this is a serious case involving departures from fundamental tenets of the Paramedic profession. The lack of insight means that there is an ongoing risk of repetition of clinical misconduct and dishonesty.
98. The Panel found that, given the seriousness of the misconduct, the continuing risk of harm to patients and the continuing risk of dishonest behaviour, it would be inappropriate to take no action. It went on to consider the available sanctions in ascending order.
99. The Panel considered whether a Caution Order would be sufficient. A Caution Order would not restrict the Registrant’s ability to practise and therefore such an order would not protect patients and would undermine public confidence in the HCPC as regulator. In any event the findings of this Panel are too serious for a caution order to be imposed.
100. The Panel then considered whether the imposition of a Conditions of Practice Order would be sufficient. The Panel took the view that it would be difficult to formulate workable conditions where dishonesty has been found proved. Further, the Panel’s findings demonstrate that the Registrant did not listen to, and overruled, colleagues’ clinical decisions. The Panel concluded that a Conditions of Practice Order would not be practicable or workable.
101. The Panel then went on to consider the imposition of a Suspension Order. Such an order would provide public protection in that the Registrant would be unable to practise as a Paramedic for a period of time. During any period of suspension, a Registrant would be expected to be able to develop insight and remedy the failings identified. However, the Registrant has failed to show insight into his serious clinical failings at this hearing as he continued to hold colleagues’ clinical concerns in low regard and sought to personalise matters rather accept his own culpability. He also sought to minimise, in oral evidence, the meeting with management following his attendance at Patient C, referring to it as an “informal chat” as opposed to a formal management critique. In addition, the Registrant has not acknowledged, nor shown any insight into his dishonest actions and their potential impact. The two acts of his dishonesty, coupled with the false elements of his evidence, show a continued pattern of dishonesty, without insight or remediation. The Panel therefore has no reason to believe that a period of suspension would lead to the development of any meaningful insight that might over time reduce risk to the public.
102. The Panel concluded that a Suspension Order would neither reflect the seriousness of the case nor properly uphold standards nor maintain confidence in the profession.
103. The Panel therefore considered that the only appropriate and proportionate Order would be a striking off Order. In coming to its decision the Panel took into account the public interest which includes protection of patients, maintenance of public confidence in the profession and the declaring and upholding of proper standards of conduct and behaviour.
104. A striking off Order prohibits the Registrant from practising in his chosen profession as a paramedic. The Panel gave careful consideration as to whether a Striking Off Order was the only appropriate and proportionate order in this case. It noted that there was no compelling evidence of insight or remediation, such that the Panel could be satisfied that the dishonesty would not occur in the future.
105. The Panel noted paragraph 48 of the Indicative Sanctions Guidance which states:
Striking off should be used where there is no other way to protect the public, for example, where there is a lack of insight, continuing problems or denial. A registrant’s inability or unwillingness to resolve matters will suggest that a lower sanction may not be appropriate.
106.  A Striking Off Order prohibits the Registrant from practising in his chosen profession as a paramedic. The Panel concluded that the public interest in ensuring that patients are safe, the need to uphold proper standards, maintain public confidence in the profession and in the regulatory process outweighs the Registrant’s right to practise in his chosen profession.

Order

The Registrar is directed to strike the name of Mr Kristian Williams from the Register on the date this order comes into effect.

Notes

The hearing took place at 405 Kennington Rd, Kennington from Monday 3 - Friday 7 December 2018.

 

Hearing History

History of Hearings for Mr Kristian Williams

Date Panel Hearing type Outcomes / Status
03/12/2018 Conduct and Competence Committee Final Hearing Struck off