Mr Christopher Higgins
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During the course of your employment as a Paramedic at Yorkshire Ambulance Service NHS Trust, you:
1. Did not ensure that accurate records were made in relation to Patient Care Records (PCR) and/or Patient Report Forms (PRF) in that;
a) On or around 2 January 2014, it was recorded on the PRF that 10 mg of Morphine had been administered to Patient A but on the PCR you recorded that 20 mg of Morphine had been administered;
b) On or around 7 January 2014, you recorded on the PCR that 10 mg of Morphine had been administered to Patient C but on the PRF there was no record of any Morphine administered;
c) On or around 12 January 2014, it was recorded on the PRF that 10 mg of Morphine had been administered to Patient F but on the PCR you recorded that 20 mg of Morphine had been administered;
d) On or around 13 January 2014, you recorded on the PCR that 20 mg of Morphine had been administered to Patient G but on the PRF there was no record of any Morphine administered;
e) On or around 17 January 2014, you recorded on the PCR that 20 mg of Morphine had been administered to Patient H but on the PRF there was no record of any Morphine administered;
f) On or around 22 January 2014, you recorded on the PCR that 20 mg of Morphine had been administered to Patient I but on the PRF there was no record of any Morphine administered;
g) On or around 27 February 2014, you recorded on the PCR that 20 mg of Morphine had been administered to Patient M but on the PRF there was no record of any Morphine administered;
h) On or around 28 February 2014, it was recorded on the drug register that two 10 mgs of Morphine was administered to Patient N but on the PCR you recorded that 15 mg had been administered;
i) On or around 1 March 2014, you recorded on the PCR that 15 mg of Morphine had been administered to Patient O but on the PRF there was no record of any Morphine administered;
j) On or around 2 March 2014, you recorded on the PCR that 15 mg of Morphine had been administered to Patient P but;
i. On the PRF there was no record of any Morphine administered;
ii. On the drug register it was recorded that 20 mg of Morphine was administered.
k) On or around 1 March 2014, you recorded on the PCR that 20 mg of Morphine had been administered to Patient Q but on the PRF it was recorded that 10 mg of Morphine had been administered;
2. Did not record the disposal of Morphine on the controlled drug register in relation to;
i) Patient N;
ii) Patient O;
iii) Patient P.
3. Did not record the reason for administering high doses of Morphine on the patient’s PCR in relation to;
i) Patient M;
ii) Patient N;
iii) Patient O;
iv) Patient Q;
v) Patient P.
4. The matters set out in paragraphs 1 a) – k) and/or 2 are dishonest.
5. The matters set out in paragraphs 1 - 4 constitutes misconduct and/or lack of competence.
6. By reason of your misconduct and/or lack of competence your fitness to practice is impaired.
Service of Notice
1. The Panel found that there was good service of the Notice of Hearing by a letter dated 9 September 2017 which confirmed the date, time and venue for the hearing.
Proceeding in the absence of the Registrant
2. Mr Millin made an application for the hearing to proceed in the absence of the Registrant. He submitted that the Registrant has waived his right to attend the hearing. The Registrant has not engaged with the HCPC or responded in any way to the Notice of Hearing.
3. The Panel accepted the advice of the Legal Assessor and applied the guidance in the HCPTS Practice Note “Proceeding in the Absence of the Registrant”. The Panel exercised its discretion with the utmost care and caution.
4. The Panel first considered the circumstances of the Registrant’s absence. The Registrant has not engaged with the HCPC and the Panel concluded that he has waived his right to attend the hearing. He has not requested an adjournment and the Panel concluded that there is little prospect that he would attend a hearing at a later date if this hearing was adjourned. The Registrant may be disadvantaged by not attending the hearing, but the Panel decided that his interests were outweighed by the public interest. There is a strong public interest in the expeditious disposal of the case. In particular, the Panel took into account the passage of time since the alleged events in January to March 2014. The Panel also took into account the interests of the HCPC witnesses. Three witnesses were in attendance and ready to give their evidence to the Panel.
5. Having balanced the Registrant’s interests against the public interest, the Panel decided to exercise its discretion to proceed with the hearing in the absence of the Registrant.
Hearing in private
6. The Panel exercised its discretion to hear part of the case in private. This decision was limited to evidence concerning details of the Registrant’s health. The Panel decided that it was appropriate that this evidence was heard in private to protect the Registrant’s private life. The remainder of the case was heard in public.
7. The Registrant is a registered Paramedic who was employed as an Emergency Care Practitioner (“ECP”) in Accident and Emergency Operations from 15 December 2008 until 1 August 2015. ECP’s are lone workers who respond to emergency and urgent situations in specially equipped response cars. The Registrant had worked with Yorkshire Ambulance Service (“YAS”) for a number of years as a Paramedic before he became an ECP.
8. The Registrant’s Team Manager was MW. In November 2013, MW received reports from other ECPs that the Registrant’s signature was prevalent for signing out controlled drugs, namely Codeine, Diazepam and Morphine. He also noted that these drugs were being used regularly and in high doses. MW arranged a welfare meeting with the Registrant which took place on 21 November 2013. MW did not have concerns about the Registrant during the welfare meeting and he did not ask the Registrant about his professional use of controlled drugs. Nonetheless, MW reported his concerns about the high usage of these drugs to his manager who asked him to monitor the situation.
9. On 2 March 2014, a Paramedic noticed that a drug bag was missing from an emergency vehicle. The Registrant was the last Paramedic to use this emergency vehicle. A DATIX report (an electronic incident report) was subsequently submitted; the drug bag was never found.
10. On 3 March 2014, the Registrant was removed from patient-facing duties and an investigation was undertaken.
11. JS, a clinical supervisor, reviewed the incidents that the Registrant and the ECP vehicle had attended in order to establish what, if any, drugs had been used during the Registrant’s shift. JS identified that there was no discrepancy in the Morphine drug record at the ambulance station. The expected procedure is that the ECP removes four 10 mg Morphine ampoules from the safe at the ambulance station at the start of their shift and returns any unused ampoules to the safe at the end of their shift. It appeared from this record that the Registrant had accounted for the Morphine that he had used.
12. JS next reviewed the controlled drug record which is kept in the vehicle. This vehicle drug record includes a record of the patients to whom the Morphine had been administered to. JS became concerned that some of the entries in this controlled drug record were unclear or had been amended. JS therefore carried out a more extensive review of the paperwork.
13. The Registrant, in his ECP role, would usually be the first to see the patient. For each patient he completed a Practitioner Patient Care Record (PCR). The PCR is a paper form which consists of a top copy in a white colour and a carbon copy in a yellow colour. The carbon copy should be identical to the top white front sheet. The top white front sheet is sent to the YAS and is scanned as a record of the work undertaken by the ECP. The yellow copy remains with the patient or the patient’s carer. If the patient is transferred to hospital the receiving hospital will retain the yellow copy as part of its records of the patient’s admission.
14. If there is a requirement for the patient to attend the hospital Paramedics will attend in an ambulance and convey the patient to hospital. The Paramedics then complete a similar form which is entitled Patient Report Form (PRF), based on their observations of the patient, any information provided to them orally by the ECP, and the yellow carbon copy of the PCR. The Paramedics completing the PRF should therefore have received all relevant information including details of any Morphine administered to the patient by the ECP.
15. As a part of the review undertaken by JS, the PRFs were requested and, upon review, it was noticed that the Morphine doses recorded on the PRFs were inconsistent with the white top copy of the PCRs held by YAS.
16. JS’s review also identified cases where the Registrant recorded on the PCR that he had administered 5 mg of Morphine, but had not made a record of any disposal of the remaining 5 mg from the 10 mg ampoule.
17. On 5 March 2014, the police were notified and YAS initiated a Serious Incident Investigation. The Serious Incident Investigation was undertaken by GF, who was at that time Head of Quality at YAS. PF, who was at that time the Associate Medical Director for the YAS, reviewed the Registrant’s PCRs and his administration of Morphine. GF’s Serious Incident Report and PFs review identified that high levels of Morphine were documented as being administered to a number of elderly patients.
18. The matter was subsequently referred to the HCPC. On 27 October 2014, the Police informed YAS that no criminal charges would be brought against the Registrant.
Decision on Facts
19. The Panel heard evidence from the HCPC witnesses MW, GF, PF and JS. The Panel found that all the witnesses were credible and fair to the Registrant. The witnesses confirmed the Registrant’s experience and competence as an ECP.
20. The Panel found that the evidence of MW was fair, balanced and reliable. His oral evidence was consistent with his written evidence. GF was a reliable and credible witness who limited his evidence to the areas he felt confident in giving an answer. He was clear when he did not know the answers to questions. PF was a reliable, very clear and consistent witness. He was able to answer questions to the extent of the limit of his remit. JS was a reliable, helpful and knowledgeable witness.
21. There were no written submissions from the Registrant. The only document which records the Registrant’s position is a transcript made by the HCPC solicitors, Kingsley Napley, of the Registrant’s taped police interviews dated 6 March 2014 and 28 May 2014. The Panel carefully read the transcripts.
22. Although the transcript of the police evidence is hearsay evidence, the Panel decided to admit the evidence and give weight to it. The Panel took into account the nature of the evidence, that it was a formal interview under caution, its consistency with other evidence, and the fact that the Registrant has not disputed the content of the evidence.
Particular 1 - Stem
23. The evidence of GF was that the Registrant was not responsible for completing the PRF forms. These forms were completed by the Paramedics who arrived by ambulance and transported the patient to hospital. The Panel therefore did not find that the Registrant failed to ensure that accurate records were made in relation to the PRFs in relation to any of the sub-particulars of particular 1. The Registrant was responsible for completing the PCR for each patient and the Panel found that he did not ensure that accurate records were made in relation to some of the sub-particulars of particular 1.
24. Patient A had suffered a suspected neck of the femur fracture. The Panel was provided with the white copy of the PCR, completed by the Registrant which showed that 20 mg of Morphine had been administered and the PRF completed by the Paramedics which showed that 10 mg of Morphine had been administered.
25. Although it was possible that this discrepancy was due to an error by the Paramedics, the Panel decided that this was not likely and that it was the Registrant who was responsible for the inaccuracy. In reaching this decision, the Panel took into account all the evidence and in particular the following points.
26. The evidence of PF was that he looked at both copies of the PCR where they were available. He then compared both copies with the PRF to spot any discrepancies. PF found that the documents completed by the Registrant were inconsistent in relation to the amount of Morphine that had in fact been administered to the patients.
27. There was evidence in the police interviews that the Registrant completed paperwork retrospectively. In particular in the interview on 28 May 2014 the Registrant read a prepared statement in which he said: “I accept that I completed my paperwork retrospectively….” In the same prepared statement he added: “I have massive gaps in my memory and believe that I was working on autopilot most of the time”. He also struggled to remember what he had done earlier on in the day. This suggests that there was a greater chance of inaccuracy in the white copy of the PCR which would have been left with YAS.
28. The evidence of the two Paramedic witnesses MW and JS and the evidence of PF stating that administering a high dose of Morphine i.e, 15 mg or more, particularly in an elderly patient could lead to symptoms or signs of over opiation which includes unconsciousness, depressed breathing, pin-point pupils and respiratory distress. However, the information obtained by PF about the patients admitted to hospital was that none of the patients arrived over medicated or suffering with opiate toxicity.
29. The Panel reviewed all the records relating to the patients admitted to hospital and noted that there were different ambulance crews completing the PRFs. The Registrant was the only individual involved consistently in all the cases, so it was more likely than not that his PCR record was inaccurate.
30. This conclusion was further supported by the facts the Panel has found proved with the support of corroborating evidence (particulars 1(g), 1(h), 1(i) and 1(j)(ii).
31. The Panel found particular 1(a) proved.
32. Patient C was found on the floor in pain. The PCR completed by the Registrant records that 10 mg of Morphine was administered whereas the PRF does not record that any Morphine was administered.
33. For the reasons set out in relation to particular 1(a), the Panel found that it was more likely than not that the Registrant’s PCR record was inaccurate.
34. The Panel found particular 1(b) proved.
35. Patient F was a patient with a possible fractured hip. The PCR completed by the Registrant records that 20 mg was administered whereas the PRF records that 10 mg of Morphine was administered.
36. For the reasons set out in relation to particular 1(a), the Panel found that it was more likely than not that the Registrant’s PCR record was inaccurate.
37. The Panel found particular 1(c) proved.
38. Patient G had suffered a fall and head injury. The PCR completed by the Registrant records that 20 mg of Morphine was administered whereas the PRF records that no Morphine was administered.
39. For the reasons set out in relation to particular 1(a), the Panel found that it was more likely than not that the Registrant’s PCR record was inaccurate.
40. The Panel found particular 1(d) proved.
41. Patient H was a patient with a head injury following a fall. The PCR recorded that 20 mg of Morphine was administered to Patient H, whereas the PRF did not record any administration of Morphine.
42. The Panel noted that there were several inconsistencies between the PCR and the PRF, some of which showed fundamental inaccuracies as follows:
• the PRF shows that the ambulance crew left the scene at 18.52 whereas the PCR shows that the Registrant left the scene at 19.20;
• it appears that the Paramedic on the ambulance was the clinician who cannulated the patient. Therefore it is unlikely that the Registrant would have cannulated the patient beforehand, although he recorded on the PCR that he administered medication intravenously at 18.30 and 18.32;
• the PRF and the PCR state that Patient H was unconscious according to the Glasgow coma score (a scoring system that determines the level of consciousness of a patient) and therefore the Patient would have been highly unlikely to have required Morphine;
• the PCR shows that the Morphine was recorded to have been administered in 2 doses 2 minutes apart. The evidence of JS was that Morphine has a peak effect after 20 minutes so the Paramedic would need to wait at least 20 minutes before administering a second dose if required. The Paramedic would need to rely on the Patient to say if the pain had subsided. However, this would not be possible because this patient was reported as unconscious.
43. The Panel concluded that it was not likely that 20mg of Morphine had been administered to Patient H, as recorded by the Registrant on the PCR.
44. The Panel found particular 1(e) proved.
45. Patient I had suffered a soft tissue injury.
46. PF’s evidence was that Patient I was conveyed to hospital. However, on examining the documentation provided to the Panel, there was no PRF, but two PCRs. One of the PCRs appears to have been completed by a Paramedic who attended the scene shortly before the Registrant arrived. The documents indicate that this Paramedic handed over Patient I to the Registrant and that Patient I was discharged at scene, and was not conveyed to hospital.
47. The PCR completed by the Registrant shows that 20 mg of Morphine was administered. However, there is no other document available to compare this PCR with.
48. The Panel therefore found particular 1(f) not proved.
49. Patient M was an 85 year old man with chest pain. The Panel was provided with the white top copy of the PCR completed by the Registrant which recorded that he administered 20mg of Morphine to Patient M in two doses each of 10 mg. The PRF completed by the Paramedics does not record the administration of any Morphine.
50. The Panel was not provided with the yellow carbon copy of the PCR completed by the Registrant for Patient M. Nevertheless, the witnesses GF, PF and GS gave the Panel a description of the pattern of documentation used by the Registrant. The PCR comprised of a white top copy and a carbonated yellow copy which was given to the conveying ambulance crew. The yellow carbon copy did not include the Morphine recorded on the white top copy of the PCR completed by the Registrant.
51. In his review of the vehicle drug register, JS identified that the vehicle drug register had been altered from 1 x10 mg to 2 x 10 mg of Morphine.
52. In his police interview, the Registrant described his practice. He stated he would retrospectively complete some of the paperwork. The Panel was able to deduce from the detailed information provided that this element of the police interview related to Patient M. The Registrant said that he could not remember the job, but “a lot of my writing was retrospective and I struggled to remember what I had done earlier in the day”.
53. The police interview includes the following police question in relation to Patient M: “I’ve spoken to his daughter who was with him the whole time you were there. She disputes you gave him any morphine whatsoever. She says you never gave her father any morphine while you were there. She’s ??? didn’t have any morphine. He had two puffs of GTN spray and you gave 4 aspirin”.
54. The information provided by Patient M’s daughter to the police is consistent with the PRF completed by the Paramedics.
55. The Panel decided, taking into account the corroborative evidence in the police interview, that it was unlikely that the discrepancy between the PCR and the PRF for Patient M was due to an error by the Paramedics who had completed the PRF. The discrepancy was due to the Registrant’s failure to ensure that an accurate record of the medication administered to Patient M was made on the PCR.
56. The Panel found particular 1(g) proved.
57. Particular 1(h) referred to an inconsistency between the vehicle drug register and the PCR. Both documents were provided to the Panel. The Panel compared the vehicle drug register with the PCR for Patient N, who was a 92 year old dementia patient with a head injury. The vehicle drug register showed that two 10 mg of Morphine had been administered whereas the PCR showed that 15 mg of Morphine had been administered.
58. The Panel therefore found particular 1(h) proved on the documentary evidence and the oral evidence.
59. Patient O was a 72 year old Alzheimer’s patient with a wrist injury. For Patient O the Panel was provided with both the top white copy of the PCR and the yellow carbon copy of the PCR. The two copies were identical except that the yellow carbon copy did not include 15 mg of Morphine administered to the patient. The Panel also noted that the yellow carbon copy did not record in the free text any cannulation, however, the top copy includes at the end of the free text section a record of cannulation.
60. The PRF completed by the Paramedics did not include the 15 mg Morphine and was consistent with the yellow carbon copy of the PCR.
61. The Panel concluded that the Registrant added information to the white top copy of the PCR after he had left the yellow carbon copy for the ambulance crew. The discrepancy between the PCR and the PRF was therefore the Registrant’s responsibility.
62. In addition JS’s evidence, confirmed by the documents, was that whilst the top white copy of the PCR records that 15 mg of Morphine was administered to Patient O, the vehicle drug register records that 20 mg of Morphine was administered.
63. The Panel found particular 1(i) proved on the documentary evidence and the oral evidence.
64. Patient P was an 84 year old female Dementia patient with a hip injury.
65. The PCR completed by the Registrant records that 15 mg of Morphine was administered, whereas the PRF does not record that any Morphine was administered.
66. For the reasons set out in relation to particular 1(a) the Panel found that it was more likely than not that the Registrant’s PCR record was inaccurate.
67. The Panel found particular 1(j)(i) proved.
68. Particular 1(j)(ii) referred to an inconsistency between the vehicle drug register and the PCR. The PCR and the vehicle drug register were provided to the Panel. The Panel compared the vehicle drug register with the PCR for Patient O. The vehicle drug register showed that 20 mg of Morphine had been administered whereas the PCR showed that 15 mg of Morphine had been administered.
69. The Panel therefore found particular 1(j)(ii) proved on the documentary evidence and the oral evidence.
70. Patient Q was a 92 year old female who suffered a fall leading to hip pain.
71. The PCR completed by the Registrant records that 20 mg of Morphine was administered, whereas the PRF records that 10 mg of Morphine was administered.
72. For the reasons set out in relation to particular 1(a) the Panel found that it was more likely than not that the Registrant’s PCR record was inaccurate.
73. The Panel found particular 1(k) proved.
74. In the case of Patients N, O and P the Registrant recorded on the PCR that he administered 15 mg of Morphine. If he had administered 15 mg of Morphine as recorded he was required to dispose of and record the disposal of the remaining 5 mg of Morphine from the second 10 mg ampoule.
75. This requirement is set out in the Management of Controlled Drugs Standard Operating Procedure (SOP). This SOP requires that unused Morphine is disposed of in the “DOOP” container and recorded in the vehicle drug register. The record should include the incident number, the amount disposed of and the running balance.
76. The Panel was provided with the vehicle drug register. On the drug register there is no record of 5 mg of Morphine being disposed of. Instead, there are discrepancies, as identified by JS, between the PCR and the drug register. For example for Patient N the drug register records that 20 mg Morphine was administered, whereas the PCR records that 15 mg of Morphine was administered.
77. The Panel found particular 2(i), 2(ii) and 2(iii) proved.
78. The Panel noted the age and presentation of the relevant patients:
• patient M was aged 85 with chest pain;
• patient N was 92 with a head injury;
• patient O was 72 with a wrist injury;
• patient Q was 92 with a hip injury;
• patient P was 84 with a hip injury/pain.
79. The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) issue guidance for Paramedics on the administration of Morphine. The JRCALC guidance states that care should be taken with elderly patients.
80. The evidence of JS, confirmed by PF, is that it is rare to give an elderly person a large dose of Morphine. JS confirmed in his oral evidence that there may be circumstances in which a large dose could be appropriate because each patient is individual. However, such an exceptional step should be recorded.
81. In relation to Patient M, JS confirmed that the administration of 20 mg of Morphine over 14 minutes was a “high dosage”. JS had concerns about the administration of either 20 mg or 15 mg of Morphine to Patient N, an elderly patient with a head injury. He stated that although Morphine can be administered for head injuries, the patient should be closely monitored. For Patient O, JS stated that 15 mg was “a lot to administer for a wrist injury”. JS was similarly concerned about the high dose of 20 mg for Patient Q and Patient P.
82. The Panel reviewed the PCR’s completed by the Registrant for patients M, N, O, P and Q. There was no record of any reasons for the administering high doses of Morphine.
83. The Panel found particular 3(i), (ii), (iii), (iv) and (v) proved.
84. The Panel accepted the advice of the Legal Assessor on the test to apply when considering dishonesty. It considered whether the HCPC has discharged the burden of proof. The Panel first considered the Registrant’s state of mind. Having considered the Registrant’s understanding and beliefs, it applied an objective test, and considered whether the Registrant’s conduct in particular 2 was honest or dishonest by the standards of ordinary decent people.
85. The Panel first considered whether the Registrant’s conduct in particular 1 was dishonest. Particular 1(f) was not proved and therefore is not dishonest.
86. The evidence of all the HCPC witnesses was that the Registrant was an experienced, reliable and competent ECP who knew what he should have done. He knew the importance of keeping accurate records, particularly in the administration of controlled drugs.
87. The Panel did not hear evidence from the Registrant about his state of mind at the time of the relevant events. The Panel therefore considered what inferences it could draw about his state of mind from the whole of the evidence.
88. The Panel noted that there was a pattern of behaviour across a number of patients. This was not a case of an isolated error. The same inaccuracy in record keeping is repeated in patient records that are otherwise full and comprehensive. On the basis of the evidence of MW, and PF the reason for the inaccuracy in the record keeping is that the Registrant made late additions to the white top copy of the PCR after giving the yellow carbon copy to the attending Paramedics. The Panel inferred that the Registrant knew that the retrospective changes he made to the white PCR copy would not be on the yellow carbon copy which was submitted to the receiving hospital. The Panel concluded that the changes the Registrant made to the records retrospectively were deliberate, not accidental and related to the administration of Morphine.
89. In his police interview the Registrant acknowledged that he completed the records retrospectively and stated that he had poor memory. This is an untested account. The Registrant’s account does not explain why the retrospective entries show a pattern in relation to the administration of Morphine. The Registrant’s explanation is not inconsistent with the Panel’s determination that the Registrant’s actions were deliberate. The Registrant was aware that he was making records of the administration of controlled drugs retrospectively which he should not have done.
90. By the standards of honesty and reasonable people it is dishonest for a Paramedic to deliberately make a record retrospectively when he knows that his record may be false.
91. The Panel found particular 4 proved in relation to particular 1(a) to (k) with the exception of 1(f).
92. The Panel next considered the Registrant’s subjective state of mind in relation to particular 2.
93. The Panel considered what inferences it could draw about the Registrant’s state of mind from the whole of the evidence. The Registrant’s explanation in his police interview was that he did not record that he had disposed of the 5mg of Morphine because he was “stressed and pushed and not being able to think straight”.
94. The Panel considered whether the Registrant deliberately decided not to record the disposal of the waste morphine, or whether his omission was due to error.
95. The Panel’s view was that it was more likely that the Registrant did not deliberately decide not to record the disposal. At the time of the events the vehicle drug register did not clearly indicate where to record the disposal of drugs, nor was there evidence of how this should be recorded on the drug record. This therefore could have been an unconscious omission on the part of the Registrant.
96. Having considered the Registrant’s subjective state of mind the Panel found that the Registrant’s conduct in particular 2 was not dishonest by the standards of honest and reasonable people.
97. The Panel found particular 4 not proved in relation to particular 2.
Decision on Grounds
98. The Panel heard and accepted the advice of the Legal Assessor. The question of whether the proven facts constitute misconduct or a lack of competence is for the judgment of the Panel and there is no burden or standard of proof.
99. The Panel decided that none of the proved particulars constitute a lack of competence. The Registrant was a skilled, experienced and competent ECP, as confirmed by the witnesses. He completed detailed and comprehensive case histories in PCRs. He had a high level of knowledge, understanding, skill, and ability.
100. There is no statutory definition of misconduct, but the Panel had regard to the guidance of Lord Clyde in Roylance v GMC (No2)  1 AC 311: “Misconduct is a word of general effect, involving some act or omission which falls short of what would be proper in the circumstances. The standard of propriety may often be found by reference to the rules and standards ordinarily required to be followed by a …practitioner in the particular circumstances…”. The conduct must be serious in that it falls well below the required standards.
101. In reaching its conclusions that some of the proven facts constituted misconduct the Panel considered the HCPC Standards of Conduct, Performance and Ethics (the Standards). The Panel considered that the Registrant’s actions and failures breached Standard 1 which obliged him to act in the best interests of service users, Standard 7 “you must communicate properly and effectively with service users and other practitioners”, Standard 10 “you must keep accurate records”, and Standard 13 “you must behave with honesty and integrity and make sure that your behaviour does not damage public confidence in you or your profession”.
102. In considering the seriousness of the Registrant’s conduct, the Panel considered the context and surrounding circumstances. The Registrant had health problems, but those problems were not so serious that the Registrant considered he was unable to work as an ECP, nor did he raise any concerns about his health impacting his performance at work during the welfare meeting with MW.
103. The Panel has found that the Registrant was responsible for the inaccurate PCR records and that his actions was dishonest. The Registrant’s dishonesty is particularly serious because it occurred in the context of his professional duties.
104. The dishonesty involved the administration of controlled drugs with the associated risk of harm to patients. Although there was no evidence of actual harm to patients, there was the potential for harm because the record of the medication administered was incorrect. If Morphine had been administered in the high dosages recorded on the PCRs but not communicated to the ambulance crew there was a risk that a further dose of Morphine might be administered by the ambulance crew or the hospital leading to an overdose. Alternatively, if Morphine had not been administered, there was a possible risk of harm to patients if appropriate pain relief had not been administered when it was required.
105. The Registrant was in a position of trust and autonomy. When he acted dishonestly he abused the trust that had been placed in him by YAS. He took advantage of his autonomous role to deliberately misrepresent the details of the Morphine that he had administered.
106. The Panel found that the Registrant’s dishonest conduct in failing to ensure that accurate records were made in relation to the PCRs (particulars 1 and 4) fell well below the standards for Paramedics and was sufficiently serious to constitute misconduct.
107. The Panel next considered particular 2. The Management of Controlled Drugs SOP clearly states that the disposal of unused Morphine should be recorded in the controlled drug register. Although it was not clear where this record should be made on the register, the usual practice, as confirmed by JS, was that a record was made on the vehicle’s drug register.
108. In addition, the Registrant accepted in his police interview that he knew the procedure, but had not followed it. The Panel has found that this may have been erroneous, rather than a deliberate dishonest act. Nevertheless, there were errors involving a controlled drug and the Registrant’s behaviour was a clear departure from the policy.
109. The Panel found that the Registrant’s conduct in particular 2 fell well below the standards for Paramedics and was sufficiently serious to constitute misconduct.
110. Although the Panel found particular 3 proved, the Panel were not provided with a policy to state that Paramedics were required to record the reasons for administering high doses of Morphine. JS was questioned in oral evidence and said that he had checked and had not found a policy that required such a record to be made. JS explained that it was good practice and indeed his practice to record this information.
111. The Panel recognised that it is good practice to record the reasons for the administration of high doses of Morphine. However, in the Panel’s judgment the Registrant’s conduct in Particular 3 was not so serious that it constituted misconduct.
112. The Panel found that the Registrant’s conduct in particular 1, 2 and 4 constituted misconduct.
Decision on Impairment
113. The Panel applied the guidance in the HCPTS Practice Note “Finding that Fitness to Practise is Impaired” and accepted the advice of the Legal Assessor. The Panel considered the Registrant’s fitness to practise as at today’s date.
114. There were no submissions from the Registrant and the Panel have no information on his current employment or circumstances. There has been a complete lack of engagement and the Registrant provided no information to assist the Panel in assessing his level of insight. The Panel were therefore unable to identify any evidence whether the Registrant has developed any insight at all. The Panel noted that the police transcript interviews show very limited insight. Significantly, the Registrant did not recognise his dishonesty.
115. The Panel considered the four examples where a decision maker might conclude that a Registrant’s fitness to practise is impaired given by Dame Janet Smith in her Fifth Shipman Report. The first example is that the practitioner presents a risk to patients. The Panel has found that the Registrant’s conduct involved a potential risk to patient safety. There is no evidence that the risk has been removed or reduced by any remedial action taken by the Registrant.
116. The second example is that the practitioner has brought the profession into disrepute. The Registrant was in a position of trust and autonomy. By his dishonesty he abused the trust placed in him. He has harmed the profession through his dishonest behaviour and again there is no evidence of any remedial action by the Registrant.
117. The third example is that the Registrant has breached one of the fundamental tenets of the profession. Honesty is a fundamental tenet of the profession and the Registrant is in breach of that tenet by his dishonesty and the serious breaches of the HCPC standards.
118. The fourth example is that the Registrant’s integrity could not be relied on. YAS had relied on the Registrant’s honesty and integrity in placing him in the trusted autonomous role as an ECP. The Registrant’s dishonesty had the consequence that his integrity could now not be relied on.
119. Using the examples above to apply the Dame Janet Smith test, it indicates that the Registrant is currently not fit to practise.
120. The Panel considered whether the Registrant’s misconduct is remediable. Although it would be possible to remedy record keeping failures, it is difficult to remedy dishonest misconduct found by the Panel. The Panel does not know the Registrant’s motivation for his dishonest record keeping in relation to use of Morphine, a Class A drug. It is therefore difficult for the Panel to assess the prospect that remedial steps taken by the Registrant might reduce the risk of repetition to an acceptable level. There is currently no evidence that the Registrant has developed insight, or that he has taken any remedial steps. The Panel therefore concluded that there is a high risk of repetition of similar misconduct.
121. The Panel next considered the critically important public policy considerations highlighted in the case of Cohen v GMC  EWHC 581 in particular “the need to protect the individual patient, and the collective need to maintain confidence in the profession as well as declaring and upholding standards of conduct and behaviour”.
122. The Panel has identified a high risk of repetition of similar misconduct and the potential for patient harm. There is therefore a continuing need to protect patients.
123. The Panel considers that the facts of this case indicate a requirement for the Panel to make a finding of current impairment to maintain confidence in the profession and the regulatory process. In particular, the public would be very concerned that the case involved vulnerable patients who relied on the Registrant as a Paramedic to accurately record and ensure the proper use of Class A drugs. The Registrant’s acts breached the trust placed in him as an autonomous practitioner to maintain transparent records. There were multiple cases where the Registrant’s records were dishonestly inaccurate. The fact that the motive for the Registrant’s actions is unknown would also be a concern for members of the public. Members of the public would be shocked and troubled if the Panel did not find that the Registrant’s fitness to practise is impaired in these circumstances.
124. The Panel therefore concluded that the Registrant’s fitness to practise is currently impaired on the basis of the personal component and the public component.
Decision on Sanction
125. 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.
126. 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.
127. In reaching its decision, the Panel considered the aggravating and mitigating factors in this case. The aggravating features involved the following:
• the Registrant’s behaviour, which the Panel deemed to be deliberate, wilful and pre-mediated and involved multiple patients (10) over a period of 3 months;
• the potential for patient harm including the risk of over-medication of patients or failure to provide pain relief that was required, lack of continuity of care, and risks arising from the fact that the YAS were unable to identify what happened to the Morphine;
• dishonesty involving a Class A drug;
• multiple breaches of a fundamental tenet of the profession;
• breach of trust by an autonomous trusted practitioner;
• the absence of any information from the Registrant relating to any insight, remediation or remorse.
128. The mitigating features were:
• the Registrant had a long and unblemished career with no previous fitness to practise findings;
• the Registrant was seen by his colleagues as a respected and competent ECP and at the time of his employment at YAS was highly trusted.
129. The seriousness of this case and the ongoing risk of repetition meant that taking no action was not an option and a Caution Order, even for the maximum duration, would not provide adequate protection to the public or the required level of public reassurance. Mediation is not appropriate in this case.
130. The Panel next considered a Conditions of Practice Order. This case includes a finding of dishonesty and the Panel has decided that there is an ongoing risk of repetition. There are no workable conditions which would address the risk the Panel has identified. Further, the Registrant has not engaged with the HCPC and the Panel does not have a sufficient degree of confidence that he would comply with conditions. Conditions of practice would therefore not be sufficient to protect the public, given the nature of the misconduct and the ongoing risk of repetition.
131. The Panel next considered the more restrictive sanctions of a Suspension Order or a Striking Off Order. When considering the proportionality of a Suspension Order the Panel carefully considered and evaluated the mitigating circumstances.
132. The mitigating circumstances the Panel has identified in this case are positive aspects relating to the Registrant’s previous history. However, they do not reduce the gravity of his misconduct. In the Panel’s judgment the mitigating factors in this case did not indicate that Suspension Order would be the proportionate sanction.
133. The Registrant has not demonstrated any insight, nor is there any indication that he is motivated to resolve the issues. The Panel did not identify any realistic prospect that the Registrant will be able to remedy the matters and provide the necessary reassurance to a future panel that the risk of repetition is low.
134. Members of the public would be extremely concerned about the findings the Panel has made, particularly the finding of dishonesty. In the Panel’s view the Registrant’s dishonesty is at the higher end of the spectrum of gravity because it was repeated, deliberate conduct and it involved Class A drugs. Members of the public would expect the regulator to take action to mark the seriousness of the Registrant’s misconduct. In the Panel’s judgment a Suspension Order would not be sufficient. It would not have a sufficient deterrent effect and it would not maintain the reputation of the profession. The Panel therefore decided that a Suspension Order would not be sufficient to protect the public and maintain public confidence in the profession and the regulatory process.
135. The Panel considered the guidance in the ISP on striking off orders and decided that it applied to the circumstances of this case. The ISP states: “Striking off is a sanction of last resort for serious, deliberate or reckless acts involving abuse of trust such as sexual abuse, dishonesty or persistent failure. 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 that a lower sanction may not be appropriate.” The Registrant’s misconduct includes dishonesty, persistent failure and an abuse of trust. There is a lack of insight and the Registrant has not demonstrated a willingness to resolve matters.
136. The Panel decided that a Striking Off Order is also appropriate in the wider public interest. A Striking Off Order provides members of the public and the paramedic profession with sufficient reassurance that the regulator has taken the Registrant’s misconduct extremely seriously and has marked its disapproval by the highest sanction that is available to the Panel.
137. The Panel recognised that the consequences for the Registrant of the imposition of this sanction may be severe and may damage his financial interests and his reputational interests. Nevertheless, the Panel concluded that its primary duty to protect the public and the wider public interest outweighed the Registrant’s interests. The maintenance of the reputation of the profession was more important than the protection of the Registrant’s interests.
138. The Panel decided that the appropriate and proportionate order is a Striking Off Order.
No notes available
History of Hearings for Mr Christopher Higgins
|Date||Panel||Hearing type||Outcomes / Status|
|29/01/2018||Conduct and Competence Committee||Final Hearing||Struck off|