Mr Mark McKenzie

Profession: Paramedic

Registration Number: PA22586

Hearing Type: Final Hearing

Date and Time of hearing: 09:00 01/05/2018 End: 16:00 04/05/2018

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

Panel: Conduct and Competence Committee
Outcome: Caution

Please note that the decision can take up to 5 working days to be uploaded onto the HCPTS website. Please contact one of our Hearings Team Managers via tsteam@hcpts-uk.org or +44 (0)808 164 3084 if you require any further information.

 

Allegation

 

Allegtion ( as amended)

 

During the course of your employment as a Paramedic with North West Ambulance Service:

 

1. On or around 19 February 2016, you did not undertake an appropriate examination and/or assessment of Patient A, in that you:


a. dismissed the possibility of a spinal injury from a significant fall, despite:


i. being informed by the Mental Health Resettlement Worker of Patient A’s history and mental health which included previous suicidal ideation;


ii. being informed by the Mental Health Resettlement Worker that Patient A had told her he had jumped from a second floor window;


iii. being informed by Patient A that he had jumped from the second floor window, landed on the floor, got up and walked back upstairs, or words to that effect;


iv. Patient A complaining of buttock pain;


v. Identifying fresh lacerations on Patient A’s feet;


vi. Recording that Patient A had a heart rate of 138 beats per minute;


vii. Patient A’s difficulty focusing on a basic task of walking down the stairs, despite having a Glasgow Coma Score of 15.


b. Did not ensure any adequate blood pressure measurement was undertaken and/or recorded for Patient A by either yourself or the Emergency Medical Technician;


c. Did not ensure an ECG was undertaken and/or recorded for Patient A by either yourself or the Emergency Medical Technician;


d. Did not immobilise Patient A; and


e. Did not conduct and/or record a second set of clinical observations despite being with Patient A for approximately 90 minutes.


2. Inappropriately based your examination and/or assessment on the:


a. lack of disturbance to the bushes and the bin bags below Patient A’s window;


b. self-mobilisation of Patient A; and


c. demeanour of Patient A.


3. Inappropriately delegated:


a. the completion of the PRF to the Emergency Medical Technician; and


b. the care of Patient A during transportation to the hospital to the Emergency Medical Technician.


4. The matters described in Paragraphs 1-3 constitute misconduct and/or lack of competence.


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

 

Finding

Preliminary matters:

1. Ms Sheridan made an application to amend the particulars of the allegation. Mrs McKenzie did not oppose the application. The HCPC had given notice to the Registrant of the proposed amendments by letter dated 2 August 2017. The Panel accepted the advice of the Legal Assessor. In the Panel’s judgment the proposed amendments served to clarify the particulars of the allegation without materially altering their substance. No unfairness would be caused to the Registrant by making the amendments. The application was therefore granted. The particulars as amended are set out above in the amended allegation.

Background:

2. The Registrant is a Paramedic and was at the material time employed by North West Ambulance Service (NWAS) as a Band 5 Paramedic in the East Manchester Sector.

3. On 19 February 2016, DH, a Resettlement Worker in the Review Team at Greater Manchester Mental Health Trust, visited Patient A at his home address as an assessment had been arranged to determine whether he would be suitable to be moved to a residential home. Upon her arrival, DH found Patient A distressed, in blood-stained sheets. On questioning , he reported that he had jumped out of the window earlier that morning. His feet were cut and he was complaining of buttock pain. Patient A had previously been known to contact the ambulance service to report suicidal ideations and was reported to have jumped out of his window on a previous occasion on or about 8 January 2016. 

4. DH called for an ambulance and was duly attended upon by the Registrant and an Emergency Medical Technician (EMT). She informed them of what Patient A had told her and that he had been seen by a neighbour to jump out of his window on a previous occasion. In spite of these disclosures, it is alleged that neither the Registrant nor the EMT carried out an appropriate examination or assessment of the patient’s condition. It is alleged that they caused the patient to walk down three flights of stairs to the ambulance, although he had difficulty in doing so and complained of pain.

5. Thereafter, Patient A was taken to hospital with the Registrant driving the ambulance and the EMT accompanying the patient in the back of the ambulance.

6. DH was of the view that the assessment, treatment and subsequent handling of the patient by the Registrant and the EMT was inadequate and inappropriate. She reported her concerns to her manager, who thereafter forwarded her complaint to NWAS.

7. It is alleged that Patient A was subsequently diagnosed with a fractured spine and pelvis, although, regrettably, no medical evidence was obtained by NWAS, or subsequently by the HCPC, to that effect.

8. The complaint by DH resulted in a disciplinary investigation conducted by  CP, an Advanced Paramedic and designated lead investigator for the Greater Manchester Area of NWAS.

9. Following its investigation, NWAS made a referral in relation to these matters to the HCPC, resulting in the current proceedings against the Registrant.

10. It is the HCPC’s case that the Registrant failed to undertake an appropriate assessment or examination of Patient A in that he dismissed the possibility of a spinal injury in spite of the presenting circumstances particularised at allegation 1(a)(i)-(vii).

11. It is further alleged that the Registrant failed to ensure that an ECG, blood pressure measurement or second set of observations were taken from Patient A and that he failed to oversee the completion by the EMT of the Patient Report Form (PRF) on the day of the incident.

12. In addition, it is alleged that the Registrant inappropriately delegated the care of Patient A to the EMT during transportation to the hospital.

13. At the outset of the hearing Mrs McKenzie admitted the following particulars 1b, 1d and 1e on behalf of the Registrant.

14. The HCPC presented a Core Bundle totalling 47 pages and an Exhibits Bundle totalling 160 pages, containing documents generated by CP’s investigation, including statements made on 6 April 2016 by the Registrant and the EMT respectively. The HCPC called DB and CP to give evidence in support of the allegation. In addition, Ms Sheridan provided the Panel with a file note relating to attempts by Kingsley Napley, on behalf of the HCPC, to secure the attendance of the EMT as a witness.

15. The Registrant submitted a bundle of documents containing his response to the allegation, his reflections on the incident and various certificates, references and testimonials. In addition, the Registrant provided a supportive statement from the EMT. Neither the Registrant nor the EMT attended the hearing to give evidence.

16. The relevant statutory grounds to be decided upon by the Panel in this case are misconduct and/or lack of competence.

17. In alleging misconduct, the HCPC placed reliance on the 2016 edition of the HCPC Standards of conduct, performance and ethics.

18. In alleging lack of competence, the HCPC placed reliance on the 2016 edition of the HCPC Standards of proficiency for Paramedics in England.

Burden and standard of proof

19. The Panel was mindful that the burden of proof is on the HCPC and that the civil standard of proof applies, so the particulars of the allegation must be proved on the balance of probabilities. The Panel took into account submissions by Ms Sheridan on behalf of the HCPC, and Mrs Mckenzie on behalf of the Registrant. The Panel accepted the advice of the Legal Assessor.

The witnesses

20. The Panel considered DH to be honest, credible, consistent and fair as a witness. She gave her account of the incident to the best of her ability and acknowledged when her memory of events failed her. The Panel accepted her evidence in all material respects.

21. The Panel considered CP to be an honest, fair and balanced witness. His evidence was measured, thoughtful and authoritative. He appeared to have no bias or preconceptions against the Registrant. The Panel accepted his evidence.

The Panel’s findings of fact

22. On the basis of all the evidence from the witnesses and contained in the documents provided, the Panel made the following findings of fact.

1. On or around 19 February 2016, you did not undertake an appropriate examination and/or assessment of Patient A, in that you:

a. dismissed the possibility of a spinal injury from a significant fall, despite:

i. being informed by the Mental Health Resettlement Worker of Patient A’s history and mental health which included previous suicidal ideation;

ii. being informed by the Mental Health Resettlement Worker that Patient A had told her he had jumped from a second floor window;

iii. being informed by Patient A that he had jumped from the second floor window, landed on the floor, got up and walked back upstairs, or words to that effect;

iv. Patient A complaining of buttock pain;

v. Identifying fresh lacerations on Patient A’s feet;

vi. Recording that Patient A had a heart rate of 138 beats per minute;

vii. Patient A’s difficulty focusing on a basic task of walking down the stairs, despite having a Glasgow Coma Score of 15.
                                                                    Proved


23. In relation to particulars 1a i and 1a ii above, the Panel accepted the evidence of DH that she informed the Registrant that Patient A told her that he had jumped out of the window of his second floor flat that morning, that on a previous occasion he had been seen by a neighbour to jump out of his window and that he had a history of mental health problems including suicidal ideation. The Registrant confirmed in his statement dated 6 April 2016 that he had been provided with this information by DH at the time.

24. In relation to particular 1a iii, the EMT in his statement dated 6 April 2016 confirmed that the patient had “kept repeating that he had jumped out the window”. This information was also recorded by the EMT in the PRF as follows: ”says jumped out of 2nd floor window, says landed on floor, got up and walked back upstairs”.

25. With regard to particulars 1a iv and 1a v, DH gave evidence that the patient complained of buttock pain and had fresh lacerations on his feet. This information was also confirmed in the PRF and recorded in the statements of the Registrant and EMT dated 6 April 2016.

26. With regard to particular 1a vi, the PRF recorded that the patient had a heart rate of 138 beats per minute, which, according to CP, was double the normal rate, of which possible indicators could include significant bleeding or shock. He stated that he would have expected a Paramedic to have investigated this further.

27. With regard to particular 1a vii, the PRF recorded that he had a Glasgow Coma Score of 15. CP gave evidence that, although this was a normal reading, the patient had difficulty in walking downstairs. This apparent discrepancy, combined with the information about his reported significant fall, could have been indicative of his having suffered an injury, requiring examination and assessment.

28. The Panel accepted the evidence of CP that, in light of all the factors referred to in particulars 1a i-vii above, the Registrant should have been alerted to the possibility that Patient A had sustained a significant injury which required appropriate examination and assessment. In fact, it is clear from all the evidence that the Registrant did not believe that the patient had jumped from the window and dismissed the possibility that the patient had sustained a spinal injury. It follows that particular 1a is proved in is entirety.

1b Did not ensure any adequate blood pressure measurement was undertaken and/or recorded for Patient A by either yourself or the Emergency Medical Technician;            

                                                                  Proved

29. The Registrant admitted this particular. The only blood pressure assessment recorded on the PRF was a systolic measure of 90 plus. This was established by the presence of the patient’s radial pulse. The Panel accepted the evidence of CP that a full blood pressure measurement should also have been taken and recorded. The Panel found particular 1b proved on the basis of CP’s evidence and the Registrant’s admission.

1c Did not ensure an ECG was undertaken and/or recorded for Patient A by either yourself or the Emergency Medical Technician;

                                                              Not proved

30. CP in his evidence acknowledged that Patient A’s PRF recorded that an ECG was undertaken. Accordingly, particular 1c is not proved.


1d Did not immobilise Patient A;
                                                               Proved

31. This particular was admitted by Mrs McKenzie on behalf of the Registrant and is found proved on the evidence.

1e Did not conduct and/or record a second set of clinical observations despite being with Patient A for approximately 90 minutes.        

                                                              Proved
32. This particular was admitted on behalf of the Registrant and is found proved on the evidence.

3 Inappropriately based your examination and/or assessment on the:

a.lack of disturbance to the bushes and the bin bags below Patient A’s window;

b. self-mobilisation; and

c. demeanour of Patient A
                                                             Proved

33. It was apparent from the statement of the Registrant dated 6 April 2016 that he dismissed the possibility that the Registrant had jumped out of the second floor window and suffered any significant injury. He did so based on his own observations of the apparent lack of disturbance to the bushes and bin bags below the patient’s window, the fact that the patient had been able to climb back up the stairs after his reported fall and his observation of the patient’s demeanour and self-mobilisation. The Panel accepted the evidence of CP that the Registrant’s failure to place any reliance on the Registrant’s assertion that he had jumped from the window, his reported mental health history and suicidal ideation, his complaint of buttock pain, significantly raised heart beat and difficulty in walking downstairs, all combined to lead to the conclusion that the cursory examination and assessment of the patient by the EMT was inadequate and inappropriate.  Particular 2 is therefore proved in its entirety.

3. Inappropriately delegated:

a. the completion of the PRF to the Emergency Medical Technician; and

                                                                Proved


b. the care of Patient A during transportation to the hospital to the Emergency Medical Technician.

                                                                Proved


34. In his statement dated 6 April 2016 the Registrant admitted that the EMT completed the PRF and that he himself had neither viewed the PRF nor countersigned it. The Panel accepted the evidence of CP that the Registrant, as the qualified Paramedic, was responsible for ensuring that the PRF was properly completed, even if it was the EMT who filled in the details on the form. However, the Panel noted that the practice of not counter-signing the PRF by the attending Paramedic was relatively widespread in NWAS at the time. The Registrant admitted that, as the lead clinician, it was his responsibility that the form was completed adequately and he accepted that it was not. In circumstances where there was cause for concern that Patient A had sustained a spinal injury, following a significant fall, it was inappropriate for the Registrant to delegate the full completion of the PRF to the EMT and a dereliction of his responsibility not to check what the EMT had written. Particular 3a is therefore proved.

35. With regard to particular 3b, the Panel accepted the evidence of CP that, in circumstances where there were reasons to believe that Patient A had sustained a significant fall, and where no proper examination or assessment had been undertaken to rule out that the patient had suffered a spinal injury, it was inappropriate for the Registrant to entrust the care of the patient to the EMT during transportation to the hospital. It was entirely possible that the patient’s condition could deteriorate during that period and it was the Registrant, as the qualified Paramedic, who should have taken charge of the Patient A’s care. Particular 3b is therefore proved.

Statutory Grounds:

36. The Panel went on to consider whether the facts found proved, or any of them, amounted to misconduct and/or lack of competence, as alleged in particular 4. The Panel took into account the submissions of Ms Sheridan for the HCPC and Mrs McKenzie for the Registrant.The Panel accepted the advice of the Legal Assessor.

37. The Panel was mindful that this is a matter for the Panel’s professional judgement, there being no standard or burden of proof.

38. The Panel first considered whether the facts found proved, or any of them, constituted lack of competence. The Panel was not satisfied that there was a fair sample of work to consider. In any event, the Registrant was an experienced Paramedic of many years’ standing. He knew what was required of him in these circumstances. In the Panel’s judgement, his failures in all these respects could not be attributed to a lack of competence.

39. The Panel went on to consider whether the facts found proved, or any of them, constituted misconduct. The Panel took into account that misconduct was defined in Roylance v General Medical Council (no 2) [2001] 1 AC 311 as:

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 medical practitioner in the particular circumstances”.

40. It is clear from case law that misconduct must be sufficiently serious that it can be properly described as misconduct going to fitness to practise.

41. The Registrant was at the time an experienced Paramedic, having at the time of the allegation been employed by North West Ambulance Service for thirteen years and as a Paramedic for nine of those years.

42. The facts found proved related to basic standards of conduct and performance required of all Paramedics.

43. The Panel found the Registrant to be in breach of the following paragraphs of HCPC’s Standards of conduct, performance and ethics (2016):

• Paragraph 1: “You must promote and protect the interests of service users and carers

• Paragraph 1.2: You must work in partnership with service users and carers, involving them, where appropriate, in decisions about the care, treatment or other services to be provided

• Paragraph 2.2: You must listen to service users and carers and take account of their needs and wishes

• Paragraph 4.1: You must only delegate work to someone who has the knowledge, skills and experience needed to carry out safely and effectively

• Paragraph 4.2: You must continue to provide appropriate supervision and support to those you delegate work to

• Paragraph 6.1: You must take all reasonable steps to reduce the risk of harm to service users …… as far as possible

• Paragraph 6.2: You must not do anything, or allow someone else to do anything, which could put the health or safety of a service user ….. at unacceptable risk.

44. The Panel’s findings of misconduct relate to all the facts found proved.

Decision on Impairment:

45. The Panel carefully considered the submissions of Ms Sheridan on behalf of the HCPC and Mrs McKenzie on behalf of the Registrant.

46. The Panel accepted the advice of the Legal Assessor and considered the HCPTS Practice Note on Finding that Fitness to Practise is “Impaired”.

47. In determining whether the Registrant’s fitness to practise is impaired, the Panel took into account both the “personal” and “public” components of impairment. The “personal” component relates to the Registrant’s own practice as a Paramedic, including any evidence of insight and remorse and efforts towards remediation. The “public” component includes the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession and the Regulator.

48. The Registrant had a previously unblemished career with NWAS as a Paramedic for nine years prior to the incident in question.  After the incident, his employer apparently had sufficient confidence in him to permit him to work unsupervised until October 2016, including working alone as a sole respondent. In addition, CP confirmed that he had received no other complaints about the Registrant either prior to or since the incident of February 2016. The Panel noted the positive testimonials in support of the Registrant.

49. The Panel accepted the Registrant’s explanation that he was distracted by his awareness of, and concern for, Patient A’s mental health from paying proper regard to the possibility that he had sustained a significant injury. This resulted in his failure to ensure that an appropriate examination and assessment of the patient’s physical condition was carried out.

50. The Registrant had provided reflections on the incident, in which he acknowledged his failures and set out what he should have done and what, in retrospect, he would do differently should he be faced with similar circumstances in the future. The Panel considered that the Registrant had acquired sufficient insight and that the risk of repetition was minimal. It follows, in the Panel’s judgment, the Registrant’s fitness to practise is not currently impaired in relation to the “personal” element.

51. However, with regard to the “public” element of impairment, the Panel took into account the following guidance contained in the HCPTS Practice Note :

“It is important for Panels to recognise that the need to address the ‘critically important public policy issues’ identified in Cohen – to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession – means that they cannot adopt a simplistic view and conclude that fitness to practise is not impaired because, since the allegation arose, the Registrant has corrected matters or ‘learned his or her lesson.”

52. The Panel considered that that the misconduct in this case was of such a serious nature, and the potential consequences to Patient A so grave, as to require some mark to be placed on the Registrant’s registration in order to send a message to the profession and to reassure the public that such a falling short from professional standards cannot be tolerated. Failure to making a finding of current impairment would, in the Panel’s judgment, undermine public confidence in the profession and in the Regulator.

53. In all the circumstances, the Panel found that the Registrant’s fitness to practise is currently impaired by reason of his misconduct in relation to the “public” component.

Decision on Sanction

54. The Panel took into account the Registrant’s statement, the submissions of Ms Sheridan on behalf of the HCPC and the submissions of Mrs McKenzie for the Registrant.

55. The Panel adopted the HCPTS Indicative Sanctions Policy and accepted the advice of the Legal Assessor. The Panel was mindful that the purpose of a sanction is not to punish the Registrant but to protect the public and the wider public interest of upholding proper standards and maintaining the reputation of the profession. The Panel applied the principle of proportionality, balancing the interests of the Registrant with those of the public, and considered the available sanctions in ascending order.

56. The aggravating factors in this case are that:

• The Registrant paid insufficient heed to the information provided by the Mental Health  worker, DH, about Patient A’s condition

• The Registrant’s misconduct had the potential to cause serious harm to the patient

57. The mitigating factors are that:

• The Registrant’s misconduct resulted from his placing too much emphasis on the mental health aspect of Patient A’s condition as opposed to his physical condition.

• The Registrant’s delegation of tasks to the EMT, whilst inappropriate, arose from his trust in the EMT based on a previous six years’ successful working relationship

• The Registrant had been employed by NWAS as a Paramedic for 9 years without any previous problems. There was evidence before the Panel that he had a good work record including successful mentoring of student Paramedics

• After the material incident, the Registrant continued to practise as a Paramedic for approximately 9 months, on occasion as a sole responder, without any concerns arising

• The Registrant had reflected on his failures of practice and how he would improve his response should similar circumstances arise in the future

58. Given the number of basic failures in practice demonstrated by the allegation in this case, and the potential for serious harm to the patient, the Panel concluded that the case was too serious to take no further action.

59. The Panel considered that in circumstances where the Registrant’s misconduct was an isolated lapse, where there was a low risk of recurrence, where the Registrant had shown insight and addressed the need to remediate his practice, a Caution Order for a period of two years was the appropriate and proportionate sanction to reflect the seriousness of the Registrant’s misconduct without preventing him from returning to practice.

 

Order

Order: That the Registrar is directed to annotate the register entry of Mark McKenzie with a caution, which is to remain on the register for a period of two years from the date this order comes into effect.

Notes

No notes available

Hearing History

History of Hearings for Mr Mark McKenzie

Date Panel Hearing type Outcomes / Status
01/05/2018 Conduct and Competence Committee Final Hearing Caution