Mr Laurence P Milton

Profession: Paramedic

Registration Number: PA16865

Interim Order: Imposed on 17 Jan 2018

Hearing Type: Review Hearing

Date and Time of hearing: 10:00 04/01/2018 End: 12:00 04/01/2018

Location: Health and Care Professions Tribunal Service (HCPTS), 405 Kennington Road, London, SE11 4PT

Panel: Conduct and Competence Committee
Outcome: Conditions of Practice

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Allegation

Allegations (as amended at Final Hearing):

 

During the course of your employment as a Paramedic for East of England Ambulance Service NHS Trust, whilst attending to Patient A on 15 November 2015:

 

1. you did not adequately assess Patient A’s cardiac rhythm on arrival at the scene;

 

2. you did not carry out Cardio Pulmonary Resuscitation (CPR) on Patient A in a timely

manner;

 

3. you did not attach defibrillation pads to Patient A; and

 

4. you did not adequately carry out full Advanced Life Support (ALS) on Patient A in that;

 

a) you were prompted to cannulate Patient A;

b) ALS was not performed for a sufficient amount of time; and

c) Patient A did not receive an adequate dose of drugs;

 

5. as lead clinician, you:

 

a) asked Colleague A and Colleague B if they would like to insert the cannula;

b) said “It’s okay, you can do it on my ticket” or words to that effect.

 

6. You said to Colleague A and Colleague B, “I hope we don’t get a ROSC [return of spontaneous circulation] because I have already told the wife he is dead and we are just doing this for show for the family”, or words to that effect.

 

7. The matters set out in paragraphs 1 – 6 constitute misconduct and/or lack of competence.

 

8. By reason of your misconduct and/or lack of competence your fitness to practise is Impaired.

 

Finding

Background


1. The Registrant was employed as a Paramedic for the East of England Ambulance Service NHS Trust (EEAST) between April 2003 and August 2016. On 15 November 2015, a Datix report (written concerns about the care of a patient) was completed by two student paramedics, Colleague A and Colleague B. The concerns related to the care provided to Patient A who had suffered a cardiac arrest. The Registrant was alleged to have failed to act in accordance with Advanced Life Support protocols in particular.

2. In its findings of fact the original Panel stated as follows. It recognised that the Registrant had been required to carry out a number of actions on arrival at the scene, including assessment of the Patient, dealing with the patient’s wife and conducting a safety assessment. In the circumstances, the Registrant should have assessed the patient’s cardiac rhythm as a matter of priority. Having decided to use a three lead ECG, the Registrant should have carried through this action until a cardiac rhythm assessment was made. However, having attached the leads, he abandoned this course of action prior to switching on the ECG monitor and on arrival of the ambulance crew, changing his mind and allowing the ambulance crew to attach the defibrillator which they had brought with them.

3. In doing so, the Registrant delayed the assessment of cardiac rhythm by the time taken to attach the defibrillator pads and to switch on the defibrillator. Thus, the original Panel found that this delay amounted to a failure on the part of the Registrant to adequately assess Patient A’s cardiac rhythm on arrival at the scene. That Panel went on to conclude that if an adequate assessment of the patient’s cardiac rhythm had been conducted by the Registrant on arrival at the scene, this would have indicated immediate commencement of CPR. Therefore, whilst that Panel accepted that CPR commenced after the arrival of the ambulance crew, this was not timely.

4.  In its findings, the original Panel went on to state that it was satisfied that the ALS procedure continued long enough to require (under relevant guidelines) more than two doses of adrenaline to be administered and that there should have been at least one, and likely more than one, additional dose.

5. The original Panel found that the statutory ground of lack of competence was not made out. This had been an isolated incident in an otherwise unblemished career of 13 years and did not represent a fair sample of the Registrant’s work. There was no evidence before the Panel to suggest that the Registrant lacked competence as a Paramedic.

6. However, that Panel found that the Registrant’s actions in failing to establish a cardiac rhythm at the earliest opportunity, failing to commence CPR at the appropriate time and in administering only two doses of adrenaline, when three or more were needed, fell well short of what was proper in the circumstances. These amounted to failures to comply with a number of the requirements of the HCPC’s Standards of Conduct, Performance and Ethics and the HCPC’s Standards of Proficiency for Paramedics. That Panel concluded that the Registrant’s failures were serious and amounted to misconduct.

7. In deciding the issue of impaired fitness to practise, the original Panel concluded that the Registrant’s actions had placed Patient A at risk of harm as the shortfalls in the care he had received did not maximise the chances of resuscitation. Such misconduct, the Panel found, could only act to harm the reputation of the profession in the eyes of the public. There was limited insight shown by the Registrant. While there were some indications of insight, such as the Registrant’s admission that a further dose of adrenaline might have been appropriate, the original Panel decided that this was not enough. It concluded that the Registrant had not undertaken the necessary reflection so as to fully accept that what he had done had been wrong and there had been no evidence before it to suggest remorse.

8. Whilst the Registrant’s misconduct was, in theory, capable of remediation, there was no evidence, especially without the necessary insight, to suggest that this had been achieved. There was a risk of repetition of the misconduct. The original Panel found that the Registrant’s current fitness to practise was impaired on the grounds of public protection and that a finding of impairment was also necessary in the wider public interest.

9. In considering the issue of sanction, the original Panel referred to the following mitigating factors: this had been an isolated incident in an otherwise unblemished career spanning 13 years; the Registrant had made partial factual admissions; he had attended the hearing and fully engaged in the process and had produced positive testimonials and character evidence. There were two aggravating factors, namely the Registrant’s lack of insight and the seriousness of the misconduct.

10. That Panel stated that the Registrant was capable of effective practice but that it did not consider that it was possible to formulate workable, verifiable and relevant conditions of practice in the circumstances of the case, because the Registrant was aware of the appropriate procedure and had chosen not to follow it.

11. That Panel imposed a Suspension Order and in its decision to do so, stated that this would afford the Registrant an opportunity to reflect on his misconduct and to develop full insight. It would also provide a clear marker to the wider profession that such misconduct was unacceptable, whilst acting similarly to protect the reputation of the profession. The original Panel concluded that a period of six months was the minimum necessary to achieve those aims and stated that the Panel conducting that review might be assisted by the following:

a. The Registrant’s attendance at the review hearing.

b. A reflective piece demonstrating the necessary level of insight and acceptance, and exploring the boundaries of autonomous practice relative to adherence to evidence-based guidelines.

c. Evidence of CPD undertaken by the Registrant in order to maintain and develop his professional skills, especially in the delivery of ALS.

d. Any other evidence which the Registrant considered might assist that Panel.

Decision

12. Ms Vriri, on behalf of the HCPC, summarised the background to this review. She submitted that if the Panel considered that the Registrant continued to be impaired, it should exercise its powers of sanction under Art. 30(1), Health and Social Wok Professions Order 2001, as amended. Ms Richardson made available to the Panel a number of documents and, although the Registrant did not give evidence, he did answer questions from the Panel.  Those documents included a reflective piece on autonomous practice, two references from Paramedic colleagues and a ‘CPD Diary 2016-2018’. They also included the original of a workbook. Ms Richardson, on behalf of Mr Milton, made submissions on behalf of the Registrant.

13. The Legal Assessor advised that the first issue for the Panel is whether or not Mr Milton’s fitness to practise is currently impaired by reason of the misconduct found by the original panel.  In practical terms there is a persuasive burden on him to show that his fitness to practise is no longer impaired and that all the shortcomings which led to the original finding of impairment have now been overcome (see Abrahaem v GMC [2008] EWHC (Admin) at [23]). Should the Panel conclude that the Registrant’s fitness to practise continues to be impaired, it should then decide how to exercise its powers under Art. 30(1) in accordance with the guidelines set out in the HCPTS’ Indicative Sanctions Policy.

14. The Panel concluded that the Registrant’s responses to its questions and the reflective piece provided did show insight into the shortcomings in his practice in Advanced Life Support (ALS). However, the Panel was not satisfied that those shortcomings have, as yet, been fully remediated. The Panel was not satisfied that the necessary further training and development had been completed. The CPD Diary extended to just over 3 pages. There was reference to an ‘ALS Protocol Discussion’ as part of an essay on several topics and a ‘learning outcome’ relating to ‘ALS and anatomy revision.’  However, there was only one course referred to, which the Registrant said he had completed two days before this hearing. This was a course organised by colleagues and very little detail was given as to its contents. Therefore, no accredited course on ALS was attended or done. Accreditation is an indicator of the quality and sufficiency of a course. Although CPD may be done through unaccredited courses, it is more difficult to prove the validity of the work undertaken. In those circumstances, the Registrant has not persuaded this Panel that all the relevant shortcomings in the Registrant’s practice have been remedied. Therefore, the Registrant’s fitness to practise remains impaired.

15. The Panel decided that a Conditions of Practice Order was the appropriate response to the impairment. The conditions would require that the Registrant must not work as an autonomous practitioner until he has completed an appropriate course on ALS and provided satisfactory evidence of its completion to the HCPC. The necessary conditions shall also require that the Registrant provide a further reflective piece on what he has learned from the course and how it might assist him in his future practice.

16. In the circumstances, the Panel decided that the necessary period of the Conditions of Practice Order was one of 6 months.

17. This case will be further considered before the end of that period by a reviewing Panel. That Panel may be assisted by the Registrant’s attendance at the hearing;
and by any further evidence that he may wish to provide, in addition to compliance with the conditions of practice imposed by this Panel today.

Order


ORDER: the Registrar is directed to annotate the HCPC Register to show that for a period of 6 months from the expiry of the current Order (14 February 2018) you, Mr Laurence P. Milton, must comply with the following conditions of practice:

1. Within 6 months from the expiry of the current Order you must:

(1) satisfactorily complete and pass an accredited course on Advanced Life Support provided by the UK Resuscitation Council or similar body and;
(2) forward a copy of proof of your attendance at that course to the HCPC.
(3) provide a reflective piece detailing your developed understanding, following conclusion of the ALS course. This should also be forwarded to the HCPC prior to the hearing date.

2. You must not practise as a lead Paramedic unless you have complied with paragraph 1 of these conditions.  

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

A. any organisation or person employing or contracting with you to undertake professional work;
B. any agency you are registered with or apply to be registered with (at the time of application); and
C. any prospective employer (at the time of your application).      
  

Notes

No notes available

Hearing History

History of Hearings for Mr Laurence P Milton

Date Panel Hearing type Outcomes / Status
03/01/2019 Conduct and Competence Committee Review Hearing Struck off
04/07/2018 Conduct and Competence Committee Review Hearing Conditions of Practice
04/01/2018 Conduct and Competence Committee Review Hearing Conditions of Practice
10/07/2017 Conduct and Competence Committee Final Hearing Suspended