Mr Laurence P Milton

Profession: Paramedic

Registration Number: PA16865

Hearing Type: Review Hearing

Date and Time of hearing: 09:00 04/07/2018 End: 11:30 04/07/2018

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

 

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) ]Found Not Proved]

 

b) [Found Not Proved]

 

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. [Found Not Proved]

 

Finding

Preliminary Matters

Service of notice/proceeding in absence

1. The Panel was informed that notice of this hearing was sent to the Registrant’s address by first class post and email dated 6 June 2018. The Panel was satisfied that notice of the hearing had been served in accordance with the rules.

2. Ms Senior applied for the hearing to proceed in the Registrant’s absence. Ms Senior informed the Panel that the Registrant had responded to the notice of hearing in an email to the HCPC dated 7 June 2018 in which he indicated that he wished to submit documentary evidence for this review hearing. Ms Senior also referred the Panel to the Registrant’s email to the HCPC dated 28 June 2018 to which he attached documents for the Panel’s consideration. Ms Senior also referred the Panel to a file note dated 2 July 2018 which records a telephone conversation between the HCPC case manager and the Registrant in which the Registrant confirmed that he would not be attending the hearing and had been “advised by his representative that the information he is providing should be sufficient”. The Registrant also confirmed that he would be available on his mobile telephone, should the Panel have any questions of him, and provided his mobile telephone number.

3. The Panel was informed by the Hearings Officer that two attempts had been made to contact the Registrant on his mobile and home telephone numbers, however neither phone was answered. The Hearings Officer told the Panel that he had left voicemails informing the Registrant that he could telephone the Hearings Officer if he wished.

4. The Panel received and accepted the advice of the Legal Assessor. The Panel was satisfied that the Registrant was aware of this review hearing and had chosen not to attend. The Panel considered that no purpose would be achieved in adjourning the hearing and took into account the public interest in conducting this review, given that the order is due to expire in August 2018.

5. For all these reasons, the Panel determined to proceed with the review hearing in the Registrant’s absence, satisfied that the Registrant has voluntarily absented himself from attending the hearing.

Background

6. 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 (ALS) guidelines in particular.

7. 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 basic 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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

17. The Suspension Order was first reviewed at a hearing on 4 January 2018 at which the Registrant was present and was represented. That reviewing panel concluded that the Registrant’s responses to its questions and his reflective piece, showed insight into his shortcomings in his practice in Advanced Life Support (ALS). However, that panel was not satisfied that the Registrant’s shortcomings, had been fully remediated and concluded that the Registrant’s fitness to practice remained impaired.

18. The reviewing panel on 4 January 2018 imposed a 6 month Conditions of Practice Order which required the Registrant within 6 months from the expiry of the suspension order to satisfactorily complete and pass an accredited course on Advanced Life Support provided by the UK Resuscitation Council or similar body and to provide proof of his attendance at that course to the HCPC

Decision 

19. The Panel heard submissions on behalf of the HCPC from Ms Senior who referred the Panel to the background of the case and to the documents provided by the Registrant. The Panel received and accepted the advice of the Legal Assessor.

20. The Panel first considered whether the Registrant’s fitness to practice remained impaired. The Panel carefully considered the documents provided by the Registrant which consisted of ALS Training Reflection, CPD Diary 2016 – 2018, Certificate of successful completion of an Immediate Life Support Course on 14 February 2018, an unsigned and undated letter regarding further training undertaken by the Registrant and reflective pieces by the Registrant regarding his practice and the incident giving rise to these proceedings.

21. The Panel considered that whilst the Registrant has said that he has, following the incident and investigation, spoken to and sought the advice of a number of colleagues and other professionals, he has not demonstrated full insight into his own misconduct or the harm caused to the public and the damage to the reputation of the paramedic profession by his misconduct.

22. The Panel considered that the previous review panel had reasonably required the Registrant to complete an accredited course on Advanced Life Support. Whilst the Panel noted the Registrant’s comments that it was difficult to find such a course, the Panel considered that such courses are widely available and that the course could have been undertaken before this review date. The Panel also noted that in his email of 28 June 2018, the Registrant stated that he had been examined for the ALS “on 26th”, however the Registrant has not provided any evidence that he has successfully completed an accredited ALS course. The Panel considered that the Immediate Life Support Course undertaken on 14 February 2018 is not what was required. This is a lower level of accredited training which does not meet the mediation required. In particular, that course does not evidence the Registrant’s competence in administering intravenous medication in a resuscitation situation which was directly relevant to the findings made agains
t the Registrant.

23. Furthermore, the Panel has been provided with no information from the Registrant as to what he has been doing since being which he had been doing since being employed as a paramedic in 2016. Whilst the Registrant provided a CPD log, the Panel considered that it lacked any specific information as to level of training undertaken or what had been learned from his CPD. In the Panel’s view, the CPD log read like an index of activities rather than informing the Panel as to how the Registrant had learned from undertaking the CPD.

24. The Panel considered that the Registrant could benefit from seeking the advice and assistance of the College of Paramedics and the HCPC in tailoring and presenting his CPD courses positively.

25. Accordingly, the Panel determined that the Registrant’s shortcomings have still not been fully remediated. Notwithstanding the view of the previous review Panel, this Panel was not satisfied that the Registrant has demonstrated full insight into the effects of his misconduct on patients, colleagues and the general public.

26. For the above reasons the Panel concluded that the Registrant’s fitness to practice remains impaired.

27. In relation to sanction, the Panel was satisfied that the Registrant’s misconduct remains remediable. The Panel was also of the view that Conditions of Practice Order remains the proportionate and appropriate order. The Panel determined to vary the current conditions of practice which will be in force for a further period of 6 months from the end of the current Conditions of Practice Order.

 

Order

Order:

The Registrar is directed to vary the Conditions of Practice Order against the registration of Mr Laurence P Milton for a further period of 6 months upon the expiry of the existing order. The Conditions are:

1. you must satisfactorily complete and pass an accredited course on Advanced Life Support provided by the UK Resuscitation Council or similar body and;

A. forward a copy of proof of your attendance and your successful completion at that course to the HCPC.
B. 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.
C. provide evidence of any CPD undertaken which should include details of any courses, whether online or otherwise and a description of its contents.

2. You must provide to the HCPC prior to the next review hearing evidence of any employment, whether paid or unpaid which you have undertaken since your suspension in July 2017.

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

4. 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

The order imposed today will apply from 14 August 2018.

This order will be reviewed again before its expiry on 14 February 2019.

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 Hearing has not yet been held
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