Mr Michael J Wise

Profession: Paramedic

Registration Number: PA10263

Interim Order: Imposed on 29 Jun 2016

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 12/11/2018 End: 17:00 23/11/2018

Location: Health and Care Professions Council, 405 Kennington Road, London, SE11 4PT

Panel: Conduct and Competence Committee
Outcome: Struck off

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Allegation

 

 

 

 

 

 



 

Whilst registered as a Paramedic you:

 

 

1. Submitted your curriculum vitae to an agency, in which you indicated you were an independent prescriber when this was not the case.

 

 

2. Between 29 March and 3 April 2016 whilst working through an agency at SEQOL Urgent Care Centre:

 
 

a. Stated you were a qualified prescriber and;


 

b. Took possession of a prescription pad;

 

 

c. Used a prescription pad to prescribe medication when you were not authorised to;

 

 

3. Between 29 March and 4 April 2016 whilst working through an agency at SEQOL Urgent Care Centre:

 
 

a. You issued medication to patients in circumstances where there was no Patient Group Direction (PGD) authorising you to do so;

 

b. You issued approximately 18 patients with incorrect and/or inappropriate medication;

 

c. You issued approximately 9 patients with the incorrect dose of medication:

 

d. You did not follow PGDs and issued approximately 10 patients with medication for the incorrect or inappropriate duration.

 

4. You did not follow the correct procedure in the administration of Tramadol to Patient O, in that:

 

a. there was no prescription form recorded in respect of the Tramadol administered;

 
 

b. when signing the controlled drugs book in relation to the Tramadol, you sought the counter-signature of a driver who was not authorised to sign.

 

5. Between 29 March and 4 April 2016 whilst working through an agency at SEQOL Urgent Care Centre:

 

a) you did not complete adequate clinical records, in that:

 
 

i. You did not consistently record in patients clinical notes that medication had been prescribed and/or supplied;

 

 

ii. You did not consistently record in patients clinical notes the duration of medication provided;

 

 

iii. You did not consistently record in patients clinical notes the dosage of medication provided;

 

 

iv. You did not consistently record in patients clinical notes undertaking tests and/or the results;

 

v. You did not record adequate details of your clinical encounter with Patient DD.

 
 

b) You did not consistently undertake and/or record:

 
 

i. adequate history taking;

 
 

ii. adequate patient examination;

 
 

iii. adequate observations;

 
 

iv. providing adequate safety netting advice.

 

 

6. Whilst working through an agency at Care UK:

 

 

a. On or around 10 October 2015 you gave Tramadol from your own prescribed medication to Colleague A for his own personal use;

 

 

b. On or around 13 October 2015:

 

i. you took a call from Person A and you advised Person A to administer Patient A with its sibling's medication;

 

ii. You did not remain on the telephone line to Person A following the administration of Salbutamol medication until the ambulance arrived.

 

 

7. Your actions described in paragraph 1 and/or paragraph 2 were dishonest.

 
 

8. Your actions described in paragraphs 1-7 amount to misconduct and/or lack of competence.

 
 

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

 

 

 

 

 

Finding

Preliminary Matters

Service

1. Notice of the hearing was sent to the Registrant by a letter sent on 30 July 2018 by special delivery post and by email. The Panel had sight of a signed Proof of Service certificate confirming the sending of the notice on 30 July 2018 to the Registrant’s address held by the HCPC.  The Panel was satisfied that service had been made in accordance with the HCPC (Conduct and Competence Committee)(Procedure) Rules 2003 (“the Rules”).


Proceeding in Absenc


2. Ms Manning-Rees on behalf of the HCPC submitted that the Panel should exercise its discretion to proceed in the Registrant’s absence.

3. The Panel considered the submissions on behalf of the HCPC.  It accepted the advice of the Legal Assessor. The Panel referred to the HCPTS Practice Note on proceeding in absence and to the guidance a hearing panel should consider provided by the cases of R v Jones (Anthony) [2004] 1 AC 1HL  and GMC v Adeogba and GMC v Visvardis [2016] EWCA Civ 162.  Applying that guidance, the Panel was careful to remember that its discretion to proceed in absence is not unfettered and must be exercised with the utmost caution and with the fairness of the hearing at the forefront of its mind.
 
4. The Notice of Hearing dated 30 July 2018 informed the Registrant of the date and details of the Conduct and Competence Committee hearing, and of his right to attend and be represented.  The Registrant was also advised of the Panel’s power to proceed with the hearing in his absence if he did not attend and of how he could apply for an adjournment of the hearing. He was informed of the sanctions available to the Panel, should it find his fitness to practise to be currently impaired.

5. The Registrant had not responded to the Notice of Hearing of 30 July 2018, and had not communicated with the HCPC. There was no information before the Panel suggesting that he had sought to instruct a representative. No request for an adjournment had been received, nor was there any indication that the Registrant wished to attend the hearing but for some reason was unable to. The Panel noted that the case had been adjourned on a previous occasion (not as a result of the Registrant’s actions) when the Registrant had also not been present.

6. Taking all the above circumstances into account, the Panel concluded that the Registrant had disengaged from the HCPC process.  It was therefore unlikely in all the circumstances that an adjournment would secure the Registrant’s attendance on a future date. The Panel took the view that the Registrant had voluntarily waived his right to attend and adjourning the hearing would serve little purpose. 

7. The Panel was also mindful that it must also consider fairness to the HCPC, whose case was ready to proceed today. This was the second listing of the hearing.  The HCPC’s witnesses were ready to proceed.  The Panel took account of the public interest in the expeditious resolution of disciplinary allegations and the impact of cost and delay caused by an adjournment upon other cases. Following the guidance in Adeogba, given that there was no good reason to adjourn the hearing, the Panel decided it was in the public interest to proceed in the Registrant’s absence. 


Application to amend the allegation


8. Ms Manning-Rees applied to amend the particulars of allegations 2(a), (b) and (c), and 6(a) and 6(b)(i).

The proposed amendments were as indicated in bold type below:

2. Between 29 March and 3 4 April 2016 whilst working through an agency at SEQOL Urgent Care Centre:

a. Told one or more colleagues that you Stated you were a qualified prescriber and;

b. Took possession of a prescription pad; non-prescription supply forms

c. and used these a prescription pad to supply prescribe medication when you were not authorised to do so.

6. Whilst working through an agency at Care UK:

a. O In or around 10 October 2015 you gave Tramadol from your own prescribed medication to Colleague A Tramadol for her his own personal use;

b. On or around 13 October 2015:

i. you took a call from Person A and you advised Person A to administer Patient A with its their sibling's Salbutamol medication;

ii. You did not remain on the telephone line to Person A following the administration of Salbutamol medication until the ambulance arrived.

9. The Panel accepted the advice of the Legal Assessor. It was satisfied that the Registrant had been given notice of the proposed amendments and had not objected to them. The Panel considered that the amendments were not substantive in nature. They provided clarification of the wording of the allegations.  The Panel was satisfied that no unfairness or prejudice was caused to the Registrant by the amendments sought and the Panel accepted the application to amend the allegations in the form proposed.

Documents

10. The Panel received the HCPC hearing bundle, numbered pages 1-430, the written opening submissions on behalf of the HCPC and a document setting out the particulars of the allegations in a matrix format.  

11. No written submissions or documents had been received from the Registrant for the purpose of the hearing. In the HCPC bundle were two communications from the Registrant provided to the HCPC at an earlier stage of the investigation.


Background

12. The Registrant is a registered Paramedic. From June 2015, he was employed through an agency, Merco, at Care UK as a Clinical Adviser (111).  This was a temporary position and he worked on an ad hoc basis. The role required a person with a nursing or Paramedic background. 

13. During this employment, the Registrant is alleged to have given the medication Tramadol to another member of staff, a Health Adviser (GC). 

14. In October 2015, it is further alleged that the Registrant provided inappropriate advice to the mother of a child, Patient A.  The 31 month old child was assessed by the Registrant as having breathing problems. The Registrant initially allocated the case as ‘Green 2’, meaning that an ambulance would respond in 30 minutes and travel in blue light conditions.  He then upgraded this to a ‘Red 2’, which is used when the situation is life threatening and the ambulance will then respond in eight minutes.  The Registrant was heard contacting the Control Centre at South West Ambulance Trust (SWAT) who informed him that the ambulance was 22 miles away.  The Registrant then called Patient A’s mother back and advised her to give Patient A 10 puffs of his sister’s Salbutamol. These issues were subsequently raised with the Agency, Merco.

15. Further allegations relate to the Registrant’s period of temporary employment as an Emergency Care Practitioner (ECP) Paramedic with SEQOL.  SEQOL at that time managed and operated the Urgent Care Centre service.

16. The Registrant was employed through a local recruitment agency, Locus Meds, and worked six consecutive night shifts at the Urgent Care Centre from 29 March 2016 to 3 April 2016. He was responsible for assessing, diagnosing and treating walk-in service users of all ages. 

17. At the beginning of April 2016, a concern was raised with SL, Matron, regarding a prescription which had been completed by the Registrant. This prompted SEQOL to undertake a review of all the Registrant’s cases.  He had seen 49 patients.  The clinical records were examined by a group of senior staff and concerns were identified in relation to a number of cases.

18. It also came to light that the Registrant had informed colleagues at SEQOL that he was qualified as a non-medical prescriber.  He informed Dr PD, Clinical Director, and RP, Nurse Practitioner, that he had undertaken a pilot prescribing course for paramedics.  He was also heard to say that he was dual qualified as a nurse and paramedic and had undertaken the nursing prescribing qualification.  Prior to commencing his role at SEQOL the Registrant also provided a CV to the agency stating that he held a prescriber qualification. 

19. The concerns were referred to the HCPC by RG of SEQOL on 18 April 2016. 

Evidence

RG

20. RG is a Registered Nurse and was employed by SEQOL as a Business Partner based at the material time at the Urgent Care Centre. RG never met the Registrant in person. Shortly after the time when the Registrant had worked four shifts as a temporary ECP in the Urgent Care Centre in March and April 2016, she became aware of concerns raised by other staff as to whether he was in fact a non-medical prescriber.  RG participated with other senior staff in a preliminary investigation.  All the records and prescriptions that the Registrant had written were reviewed by the group and concerns were found in relation to a significant proportion of them.

21. RG said that the Registrant had told other staff that he was a non-medical prescriber, saying that he had been part of a pilot scheme for paramedic prescribers.  RG explained that the issue was significant as non-medical prescribers were not bound by Patient Group Directions (“PGD”s), whereas people not qualified as prescribers would be. 

22. RG also gave evidence in support of particular 4 in respect of Patient O. She had investigated this matter. She confirmed that no prescription had been completed for the Tramadol given to Patient O, and that the counter signature in the Controlled Drugs Book was that of a driver, responsible for transporting GPs on home visits, rather than by another registered health professional.  RG stated she was aware this had been the practice in the past, but on taking up her role in the Urgent Care Centre, she had made it clear that this was not permitted practice by putting a laminated notice on the front of the Controlled Drugs book. 

SL

23. SL is a Registered Nurse who at the material time was employed as a Clinical Matron in Urgent Care and was responsible for the overall clinical management and running of the service.  She was on annual leave during the period when the Registrant worked on the period of consecutive night shifts at the Urgent Care Centre and did not work with him or meet him. She said she would have been aware if she had been present that, as a Paramedic, the Registrant could not at that time in 2016, have been a non-medical prescriber. 

24. SL was one of the senior staff involved in the preliminary investigation regarding the records made by the Registrant prior to the referral to the HCPC. Subsequently, at the time of the HCPC’s investigation, she undertook a detailed review of the relevant records and set out her findings in her witness statement. 

25. In evidence, SL confirmed the content of her witness statement which considered the relevant records in relation to 49 patients in respect of whom she identified concerns and went through a number of cases of the patients in detail in her evidence in order to explain the records and her findings.

26. SL’s concerns, in addition to the Registrant undertaking prescribing when he was not entitled to do so, related to his prescribing of Inappropriate medication, or incorrect dosage and duration, for the conditions of the patients concerned. 

27. SL also referred to the records completed by the Registrant. The online record he was required to complete on seeing a patient in the Urgent Care Centre was called the Consultation Information Sheet.  SL explained that many of the records completed by the Registrant during his six night shifts were inadequate in relation to the information about the patient’s presenting condition, observations, examination, assessment, diagnosis and treatment planning. 

28. SL stated that she had been extremely concerned by the findings, particularly in relation to unauthorised prescribing of medication to children.

SG

29. SG is a Registered Nurse who in 2016 was employed by SEQOL as a Senior Nurse Practitioner and Team Leader at the Urgent Care Centre.  SG worked with the Registrant during two of the nights shifts he worked. She did not work with him on his first shift and so was not aware of his induction, but she stated that when she worked with him, he seemed to know his way around the unit and did not raise any issue with her about not having had an induction.  SG explained that she and the Registrant worked in adjoining rooms and she was available to answer any questions, but he did not raise any. 

30. SG stated that she was surprised when she became aware that the Registrant said he was a non-medical prescriber, as this was unusual for a Paramedic and she was aware that a number of paramedic colleagues were keen to be able to prescribe.  The Registrant told SG he had been part of a trial for Paramedics to prescribe, but that it had been expensive and had been discontinued. SG did not initially question this, as she assumed the SEQOL would have checked the relevant paperwork.  She said she became concerned when she heard other staff saying that the Registrant had told them he was dual qualified as a Registered Nurse and Paramedic.  She said the inconsistencies in what he was saying began to ring alarm bells and she raised her concerns with SL and RG

31. In relation to PGD’s, SG stated that these could be used by staff who were not able to prescribe, subject to their having undergone the relevant training and signed each PGD in confirmation. The PGD’s were available in a folder in the Urgent Care Centre and on the intranet.  However, SG said that a qualified prescriber would not be required to use the PGDs. 

32. SG explained that records in the Urgent Care Centre are kept on the electronic system System 1 and are made contemporaneously at the time of seeing the patient. She said that although nursing and paramedic professionals make records in a slightly different format, they should contain essentially the same information.

Dr PD

33. PD confirmed he was employed by SEQOL as Clinical Director of Urgent Care at the time when the Registrant worked at the Urgent Care Centre.  PD confirmed that he worked on more than one shift with the Registrant during his temporary employment at SEQOL, but could not recall how many or the dates.  A note he wrote which was exhibited in the HCPC bundle confirmed he had worked on the Registrant’s first night shift. PD stated he was not involved in the Registrant’s induction. 

34. PD recalled that during shifts, the Registrant approached him with questions about patients on a couple of occasions. He concluded that the Registrant had carried out the appropriate assessments prior to approaching him, in relation to blood pressure, temperature and pulse.  The extent of the Registrant’s questions did not cause him to have concerns about the Registrant.

35. PD recalled the Registrant discussing pay and places he had previously worked.  He stated that on one occasion, he heard the Registrant say that before becoming a Paramedic he had trained as a nurse and that he had undertaken a prescriber course in London. 

36. PD was involved with other senior staff in the later review of the Registrant’s patient notes and prescriptions. The records were divided up between the reviewing colleagues and he may have reviewed about 20%.  The records he reviewed did not cause him any concerns.  He was aware there were some concerns about the non-clinical nature of the language used, the brevity and the spelling.  PD confirmed that after the review, those records which had caused concern to the reviewing group were divided up for follow up with the patients.  He was not able to make contact with the patients he was asked to follow up.

37. In relation to the review undertaken by the staff group, PD said there was no process of moderation of the findings.  The staff involved were all of an experienced, senior level, but came from different professional backgrounds and as such may have had different professional views at to the adequacy or otherwise of the records. 

38. PD recalled that in relation to counter signing the supply of controlled drugs, it had been acceptable practice for a driver to countersign if no health care professional was available.  He could not recall when this practice was stopped and said that it could still have been continuing at the time when the Registrant was employed. He had not seen the Registrant prescribing any medication or in possession of a purple prescription pad.  

RP

39. RP was employed at the relevant time as a Band 6 Nurse Practitioner at SEQOL. She confirmed that she was not qualified as a non-medical prescriber at the time in 2016, but now is, having undertaken the V300 prescribing course. 

40. RP met the Registrant on his first night working at the Urgent Care Centre and provided his induction.  She did not work that shift with him, and thought she had worked on a day shift and was about to go off duty.  She stated that the Registrant told her he was a nurse and ECP. When she is told the person is a nurse, she would usually then ask if the person is a prescriber. RP said that the Registrant informed her that he was a prescriber and was one of the first people to do the nurse prescribing course on a pilot scheme in London and that he was dual qualified. 

41. When asked about the Registrant’s statement claiming he had not received an adequate induction, she said she believed she had inducted him safely.  She did not see the Registrant take or use any prescription pads. As she understood he was a prescriber, she did not discuss the PGDs with him, as he would not need to use them, but she showed him the folder and where to access them on the intranet.  

GC

42. GC gave evidence, in relation to allegation 6a, in private.

MW

43. MW’s evidence related to particular 6.  She is a registered Paramedic.  At the relevant time, MW was employed by Care UK as the National Head of 111 Clinical Services. MW explained that 111 Clinical Services is the non-emergency contact line for service users to access care in the lower acuity healthcare arena.

44. The Registrant was employed with Care UK as a Clinical Adviser (111) from June 2015 on an ad hoc basis through a recruitment agency called Merco.  The role was for a Paramedic or Nurse and was a non-prescribing role.

45. As a Clinical Adviser, the Registrant would respond to telephone calls referred to him by a Health Advisor. MW explained that Paramedic Clinical Advisers must work within the Joint Royal College Ambulance Liaison Committee (JRCALC) Guidelines. 

46. MW never worked directly with the Registrant. She was made aware of the incident referred to in Particular 6(a) involving witness GC. She confirmed that it is not acceptable for a clinician to give prescribed medication to persons who are not prescribed it. She explained that Tramadol is categorised with other higher level drugs such as morphine. A concern arising from doing so would be that the Registrant would not have cross-referenced the medication which GC was already taking.

47. MW became aware of concerns about the incident which is the subject of Particular 6(b) regarding advice the Registrant gave to Person A during a 111 call during his shift on 13 October 2015. The Panel was played a recording of the calls during this incident. 

48. The initial call in question was from the mother of a 31 month old child who contacted the 111 service because her child was experiencing breathing problems. MW said the call indicated that the child was in severe respiratory distress. The Registrant initially requested a ‘Green 2’, a 30 minute ambulance call.  He subsequently revised this to a ‘Red 2’, which is used when a situation is life threatening and the ambulance will respond in 8 minutes.

49. The Registrant was heard to call Person A back for a second time.   In the course of dealing with the call, the Registrant was heard to state that he was stepping outside the JRCALC guidelines. He advised Person A to give the child ten puffs of his sibling’s Salbutamol. MW explained that Salbutamol is an inhaler used by asthmatics.

50. MW confirmed that it was not permissible for the Registrant to step outside the JRCALC guidelines unless he had sought prior authorisation from the Medical Director on duty. This was the case even where the situation is life threatening. The Registrant on the night in question did not consult the Medical Director in advance of advising the mother to give Salbutamol. He contacted the supervisor afterwards to state what he had done.  

51. MW stated that having initiated the 8 minute ambulance request, and having telephoned Person A to give advice regarding the taking of Salbutamol, the Registrant should have remained on the call with Person A to provide support while she awaited the ambulance. The Registrant did not do so and terminated the call, as confirmed by the recording of the call. MW said that Person A’s condition could have deteriorated as a result of his advice and he would not have known if he had not stayed on the call.

Witness statement of BN

52. The witness statement related to enquiries made by BN of the HCPC with the Nursing & Midwifery Council (“NMC”) which confirmed that the Registrant is not a nurse registered with the NMC. 

Paramedic prescribers

53. The Panel had sight of recent legislation regarding Paramedics acting as non-medical prescribers.  Although some health professions including nurses have been able to act as prescribers for some years, these have not included the paramedic profession. 

54. Changes were made by the (Human Medicines Regulations 2012) by virtue of a statutory instrument entitled The Human Medicines (Amendments) Regulations 2018, S.3(2)(a), which permitted paramedics to become independent prescribers for the first time. 

Thus Paramedics were by law not able to qualify as non-medical prescribers until April 2018. 

Legal Advice on facts and grounds

55. The Panel received and accepted advice from the Legal Assessor.  The Panel was reminded that the burden of proof was upon the HCPC which brings the allegations. It was not for the Registrant to prove his innocence.  This remained the case where the Registrant did not attend the hearing.

• The standard of proof in HCPC proceedings is the civil standard, on the balance of probabilities, meaning that before finding a fact proved the Panel must be satisfied it is more likely than not that it occurred.

• Dishonesty was alleged in respect of particulars 1 and 2.   In relation to the allegation of dishonesty, the Panel was reminded of the test set out in the case of Ivey (Appellant) v Genting Casinos (UK) Ltd. t/a Crockfords (Respondent) [2017] UKSC 67, where Lord Hughes, giving judgment, stated as follows:
 
“…The fact finding tribunal must first ascertain (subjectively) the actual state of the individual’s knowledge or belief as to the facts.  The reasonableness or otherwise of his belief is a matter of evidence (often in practice determinative) going to whether the held the belief, but it is not an additional requirement that his belief must be reasonable; the question is whether it is genuinely held.  When once his actual state of mind as to knowledge or belief as to facts is established, the question whether his conduct was honest or dishonest is to be determined by the fact-finder by applying the (objective) standards of ordinary decent people. There is no requirement that the defendant must appreciate that what he has done is, by those standards, dishonest.”


Decision on Facts

Witnesses

56. The Panel first considered the credibility of the witnesses who had given oral evidence. 

57. The Panel found all the witnesses who had worked at SEQOL, RG, SL, SG, PD, and RP, to be credible and reliable witnesses. They were all senior and experienced health professional practitioners. They did their best to assist the Panel in answering questions, gave balanced evidence and were willing to acknowledge if they were unable to remember or had been incorrect in any respect.

58. The Panel found GC, the Care UK 111 Health Adviser, to be credible, straightforward and frank in her evidence.

59. The Panel found MW to be a credible and helpful witness. She had held a senior role at Care UK (111) and was very experienced as a Paramedic and in the procedures and operation of Care UK (111).

60. The Panel had received written witness statement from BN of the HCPC and CS of Kingsley Napley. The Panel accepted these hearsay statements and was able to accord weight to them as they related to matters of fact. 

The Registrant

61. There had been no submissions regarding the allegations from the Registrant for the purposes of this hearing. The Panel treated the allegations as denied and remained mindful throughout that the burden of proof is upon the HCPC.

62. The Panel had sight of two communications which were undated, but which it understood had been submitted by the Registrant at an earlier stage of the HCPC investigation. In the Registrant’s absence, questions were asked of the relevant witnesses by the Panel, the Presenting Officer and the Legal Assessor about issues raised in the communications, such as the Registrant’s claim that he had not received an adequate induction on commencing at the Urgent Care Centre, and that he had not been shown the PGDs.  Based on the evidence of the witnesses, the Panel did not find this to be established and it gave little weight to these claims.  The Panel did however note that in one of his communications, the Registrant claimed to be entitled to prescribe and stated he had been qualified to do so for 13 years. 

Findings of fact

Particular 1 - proved

67. The Panel had sight of the curriculum vitae which was produced by the witness SL. The Panel accepted her evidence that this was the CV the Registrant provided to Locum Meds and which was submitted by the agency to SEQOL when the Registrant joined the organisation.  SL said she reviewed the CV when she returned from leave. The Panel noted that it clearly stated on the second page that the Registrant was an Independent Prescriber and stated on the fifth page that he had undertaken an “ECP Prescribers Course” in 2004/6. 

68. The Panel noted the position regarding Paramedics as non-medical prescribers and that this was only permitted as a result of a change in legislation in April 2018.

69. The Panel was satisfied that the Registrant was not, and could not have been, an independent prescriber at the date of the allegations in this matter.
 
Particular 2(a) - proved

70. The Panel heard and accepted the evidence of several members of staff from SEQOL that the Registrant informed them that he was a prescriber. RG stated she was aware that the Registrant had informed several staff that he was a prescriber.  SL said that concerns had been reported to her by other staff. SG stated in her evidence that the Registrant informed her directly that he was a non-medical prescriber.  He told RP that he had undertaken a non-medical prescribers course and that he was one of the first people to undertake the nurse prescribing course on a pilot scheme in London. PD heard the Registrant say during a conversation that he had undertaken a prescriber course in London. 

71. The Panel considered the evidence of SEQOL staff that the Registrant claimed to be dual qualified and to have undertaken a nurse prescriber course.  It appeared he made inconsistent statements to different staff.  The Panel took into account the evidence of BN which produced confirmation from the Nursing and Midwifery Council that the Registrant is not on the NMC Register.  It noted that the Registrant’s detailed 5 page CV only referred to registration with the HCPC as a Paramedic and made no reference to being qualified as a nurse or registered with the NMC. 

72. The Panel also took account of the Registrant’s own communication to the HCPC in which he claimed that he was a prescriber and had been for 13 years.

Particular 2(b) - proved

73. The Panel concluded that no witness had given evidence of directly seeing the Registrant take possession of non-prescription supply forms (known as “purple pads”).  However, the Panel was satisfied that given that the Registrant had seen patients whilst working on night shifts and completed their records and had provided prescriptions linked to patients, it could properly draw an inference that the Registrant had been in possession of the forms and had used them to supply medication which he was not authorised to supply because he was not an authorised non-medical prescriber. 


Particular 3 (a), (b), (c) and (d) - proved

74. The Panel considered the evidence of SL.  She is a senior and experienced registered nurse.  She worked as the Clinical Matron at the Urgent Care Centre from June 2015 until October 2016, and thus at the time the Registrant worked there. She reviewed the records of 49 patients seen by the Registrant over the six night shifts that he worked.  She set out the concerns she identified in these records in her witness statement.  The Panel had found her to be a credible and experienced witness and accepted her evidence. 

75. However, the Panel also carefully reviewed all the exhibited patient records to satisfy itself that the issues identified by SL were correct and supported by the patient documentation. The documentation for each patient consisted of the Consultation Information Sheet and a copy of the relevant medication supply form and in some cases, a relevant extract from the British National Formulary concerning the medication in question. 

76. Having reviewed the documents, the Panel accepted in respect of 3(a) that there were 24 instances in which the Registrant had issued medication to the patients where there was no PGD authorising him to do so.

77. In respect of 3(b), the Panel found 20 instances where the Registrant issued patients with incorrect and/or inappropriate medication.

78. In respect of 3(c), the Panel found 21 instances where the Registrant had issued patients with the incorrect dose of medication.

79. In respect of 3(d), the Panel found 24 instances where the records indicated that the Registrant had not followed PGDs and issued patients with medication for the incorrect or inappropriate duration. 


Particular 4(a) - proved

80. The Panel accepted the evidence of RG, who had investigated the patient records at the time and found that no prescription had been completed for Tramadol.

Particular 4(b) - not proved

81. The Panel considered there was a lack of clarity as to when the practice of the signing the Controlled Drugs book by a driver as a witness was stopped.  It was clear from all the witnesses that at one time this had been accepted practice at the Urgent Care Centre and that at some point the practice had been stopped. The Panel considered the evidence as to the date was unclear and it was not able to be satisfied to the required standard that the practice was no longer permitted at the point when the Registrant worked there. The Panel found this particular not proved.

Particular 5(a) - proved

82. The Panel accepted the evidence of SL who had conducted a detailed examination of the records.  The Panel also reviewed the relevant records of the patients.  The Panel accepted the evidence of SL as to adequacy and applied its own judgment according to the standard expected of a reasonable Paramedic.  It was careful not to judge the standard of record-keeping against a “gold standard”.  The Panel accepted that the form of record keeping may vary slightly between different health professionals, but considered the essential contents will be consistent. The Panel was satisfied that the clinical records completed by the Registrant in the relevant instances identified by SL indicated basic inadequacies of record keeping.

83. In respect of (i) there were 34 instances where the Registrant had not consistently recorded that medication had been prescribed and/or supplied;

84. In respect of (ii) there were 33 instances where the Registrant had not consistently recorded the duration of medication provided

85. In respect of (iii) there were 29 instances where the Registrant had not consistently recorded the dosage of medication provided

86. In respect of (iv) there were 15 instances where the Registrant had not consistently recorded undertaking tests and/or the results.

87. Giving the word “consistently” its natural meaning of “on every occasion”, the Panel was satisfied particulars (i) to (iv) were established. 

88. In respect of (v) the Registrant did not record details of his clinical encounter with Patient DD and the Panel found this proved.

Particular 5(b) - proved

89. Ms Manning-Rees accepted in her submissions that this particular could only be considered on the basis of not recording, rather than not “undertaking”.  The Panel concurred and found there was no evidence as to whether or not the Registrant had undertaken the actions at (i) to (iv). 

90. On the basis of the evidence of SL and its own examination of the patient records, and applying the term “consistently” as it had done under 5(a) above, the Panel was satisfied that the Registrant consistently did not:

(i) record adequate history-taking ( evidenced in 41 cases);

(ii) record adequate patient examinations (evidenced in 38 cases);

(iii) record adequate observations (evidenced in 29 cases);

(iv) provide adequate safety netting advice (evidenced in 15 cases).

Particular 6(a) - proved

91. Particular 6 concerned the period when the Registrant was employed as a temporary Clinical Adviser at Care UK.  The Panel accepted the evidence of GC and found proved that the Registrant had given her Tramadol. This was not prescribed and appeared to be from the Registrant’s personal supply. 

92. The Panel was also mindful of the evidence of MW, who had confirmed that it is not acceptable for a clinician to give prescribed medication to persons who are not prescribed it. She explained that Tramadol is categorised with other higher level drugs such as morphine.  A concern arising from doing so would be that the Registrant would not have cross-referenced the medication which GC was already taking.

Particular 6(b)(i) -proved

93. The Panel heard evidence from MW and a recording of the 111 call the Registrant had with Person A on 13 October 2015. The recording clearly supported the allegation that the Registrant advised Person A to administer Salbutamol prescribed for Patient A’s sibling to Patient A and the Panel was satisfied that the facts were proved. 

Particular 6(b)(ii) – proved

94. The Panel heard the recording of the second call when the Registrant called Person A back and told her an ambulance had now been requested on an 8 minute call. He advised Person A to administer Salbutamol to Patient A. He told her to wait for the ambulance and then terminated the call.  MW confirmed that in these circumstances, the call should have been kept open and the Clinical Advisor should have remained on the line to support the service user until the ambulance arrived. The Panel was satisfied the facts were proved.

Particular 7 - proved

95. The Panel considered whether the Registrant’s actions in respect of Particulars 1 and 2 were dishonest. It applied the test in Ivey (Appellant) v Genting Casinos (UK) Ltd. t/a Crockfords (Respondent) [2017] UKSC 67.

96. The Panel concluded that the Registrant had deliberately sought to pass himself off as a qualified non-medical prescriber in his curriculum vitae which he put forward to obtain employment, in conversations with his colleagues and by his actions.  The Registrant must have been fully aware he was not qualified to, and was not able to, be a non-medical Paramedic prescriber at this time in 2016.  The Panel concluded that he was deliberately dishonest in representing himself as a prescriber and acting as one.  The Panel was in no doubt that this conduct was dishonest by the objective standards of ordinary decent people and that in this case, although it is not a requirement of the Ivey test, the Registrant would have appreciated that what he had done was, by those standards, dishonest.

97. The Registrant had misled patients and health professional colleagues.  He had gone on to prescribe medication to patients and in so doing, acted beyond his qualification and in contravention of the legislation and the HCPC standards.


Decision on Grounds - misconduct and/or lack of competence

98. The Panel considered the submissions of Ms Manning-Rees on behalf of the HCPC.  It received and accepted the advice of the Legal Assessor.  The Panel bore in mind that these were matters for its own judgment and took account of the guidance from the case law relating to the meanings of misconduct and or lack of competence, both of which were alleged as alternatives in this case.  It bore in mind the guidance of Lord Clyde in Roylance v GMC [No 2] 2000 1 AC 311 and also reminded itself that not every falling short of the expected standard amounts to misconduct: the falling short must be serious and may be considered deplorable by other professionals. Lack of competence is distinct from misconduct and, as per the case of Calhaem v GMC [2007] EWHC 2606, connotes a standard of professional performance which is unacceptably low and which can usually be demonstrated by reference to a fair sample of a practitioner’s work. 

99. In respect of Particulars 1 and 2, the Panel had found dishonesty proved.  The Panel had concluded that the Registrant had deliberately sought to pass himself off as a qualified non-medical prescriber. He had misled patients and health professional colleagues.  He had gone on to prescribe medication to patients and in so doing acted beyond his qualification and in contravention of the legislation and the HCPC standards.  His actions in prescribing medication when he was not qualified to do so put patients at risk of harm.  The Registrant’s actions represented a very serious falling short of expected standards and the Panel found misconduct proved.

100. Particulars 3 and 4(a) concerned the Registrant issuing medication to patients which was incorrect, inappropriate or not authorised by a PGD. The Panel found these were serious and deliberate actions which put the patients concerned, of whom there were a significant number, at risk of harm.   The Panel was satisfied this was a serious falling short of standards and constituted misconduct. 

101. Particular 5 concerned a range of record-keeping failings. The inadequacy on the records was extensive and covered the records of a large number of patients seen by the Registrant over his six night shifts at SEQOL. The inadequacies related to all aspects of record-keeping,   The Panel considered that the record-keeping issues in Particulars 5(a)(i) to (iv) and 5(b)(i) to (iv) raised lack of competence concerns rather than misconduct. The Panel was satisfied it had seen a fair sample of the Registrant’s record-keeping and that this was overall of an unacceptably low standard of practice.  The Panel found lack of competence proved. 

102. In respect of Particular 5(v), the Panel found this particular amounted to misconduct. The Registrant failed to take action he should have taken and the Panel found this fell seriously short of the standard expected.  The absence of records which should have included details of the examination of the patient and the medication provided presented a risk to the ongoing health care of the patient concerned.

103. Particular 6(a) also concerned the inappropriate supply of medication, in this case to a colleague, GC, to whom he gave Tramadol, a prescription only, powerful pain relief medication, from his own supply.  It had not been prescribed for her and was given without reference to or knowledge of GC’s health history or other medication she was prescribed.  This was not in GC’s best interests and could have caused her harm. The Panel was satisfied this amounted to misconduct.

104. Particular 6(b) concerned the 111 call from Person A on 13 October 2015.  In respect of 6(b)(i), this was a further instance of prescribing medication which was not prescribed for the patient, in this case a 31 month old child. The Panel was concerned that, having received a full induction into the working protocols at Care UK (111), the Registrant took a conscious decision to act outside of the JRCALC guidelines. Although the Panel recognised that he may have believed child's situation was serious and urgent, there was, as described by MW, a process in place by which he should have obtained authorisation for his actions in advance, from the Medical Director on duty, but he chose not to do so.  Both this, and the Registrant’s actions in 6(b)(ii) represented a serious falling short of the required standards and the Panel found they constituted misconduct. 

105. In respect of Particular 7, as explained in relation to Particulars 1 and 2 above, the Panel found the Registrant’s actions to constitute dishonesty of a very serious nature and they clearly amounted to misconduct. 

106. The Panel considered the following standards were relevant:

HCPC Standards of Conduct, Performance and Ethics (2012)

Standard 1: You must act in the best interests of service users.

Standard 10: You must keep accurate records.

Standard 13: You must behave with honesty and integrity and make sure that your behaviour does not damage the public’s confidence in you or your profession.

HCPC Standards of Proficiency for Paramedics (2014)

Standard 1: be able to practise safely and effectively within their scope of practice.

Standard 2: be able to practise within the legal and ethical boundaries of their profession.

Standard 3: be able to maintain fitness to practise.

Standard 10: be able to maintain records appropriately.

Standard 15: understand the need to establish and maintain a safe practice environment.

Decision on Impairment 

107. The Panel next considered whether, by reason of the Registrant’s misconduct and lack of competence, his fitness to practise is currently impaired.

108. Ms Manning-Rees informed the Panel that the Registrant had previously been convicted in respect of two criminal offences: possession of a Class A drug on 5 April 2011; and for driving under the influence of alcohol on 7 April 2011.  He appeared before a panel of the Conduct and Competence Committee in connection with these convictions in 2012 and was suspended for 12 months.  Ms Manning-Rees submitted that in the light of its findings on facts and grounds, the Panel should find the fitness of the Registrant to be impaired in relation to both the public and private components of current impairment. 

109. No submissions regarding impairment had been received from the Registrant. 

110. In considering current impairment, the Panel accepted the advice of the Legal Assessor and had regard to the HCPTS Practice Note “Finding that Fitness to Practise is Impaired” of March 2017. The Panel kept in mind that not every finding of misconduct or lack of competence will necessarily result in a conclusion that fitness to practise is currently impaired. Impairment is a matter for the judgment of the Panel.
 
111. The information that the Registrant had received a previous conviction in 2011 for possession of a Class A drug indicated further concerns about the Registrant’s interaction with medication.   In consequence of these convictions, he had been the subject of previous disciplinary proceedings before the HCPC in 2012.
 
112. As the Registrant had not engaged in the hearing and had not put forward any submissions or information, there was no evidence before the Panel demonstrating any explanation, acceptance, insight or remorse on his part.

113. Whilst clinical failings in respect of record-keeping were potentially capable of remedy, the Panel was mindful that a finding of dishonesty is more difficult to remediate.   In any event, in this case the Registrant had made no submissions suggesting any attempts to remediate either the clinical failings or his dishonesty.  

114. The Panel considered that its findings of dishonesty in this case were serious.  The Registrant had shown a blatant disregard of the legal parameters of his permitted scope of practice as a registered Paramedic.  He had misled colleagues and patients.  His judgment was called seriously into question by his willingness to step outside of protocols in his places of work.

115. In relation to the personal component of impairment, the Registrant had put service users at risk of serious harm as a result of acting as a non-medical prescriber when he was not trained or authorised to do so. Furthermore, the evidence obtained from the patient records from relating to the Registrant’s time at the SEQOL Urgent Care Centre demonstrated actual poor and unsafe practice which had put patients at risk.

116. In the absence of any evidence to suggest the risk posed by the Registrant’s dishonesty and poor clinical practice had been addressed, the Panel considered there is a real risk of repetition which puts the public at risk of harm.

117. In considering the public component of impairment, the Panel concluded that public confidence in the Paramedic profession, and in the HCPC as its regulator, would be under-mined if a finding of impairment were not made where there had been such serious dis-honesty, a blatant contravention of the legal limitations of the scope of Paramedic practice and unlawful clinical prescribing practice. Service users and the public need to be able to have confidence that a health professional who prescribes medication is appropriately trained, qualified and legally permitted to prescribe competently.

118. The Panel found that the Registrant’s fitness to practise is currently impaired.  

Decision on Sanction

119. Ms Manning-Rees made submissions in the issue of sanction. Ms Manning-Rees did not propose a particular sanction in this matter, but referred the Panel to the HCPC Indicative Sanctions Policy. 

120. The Panel accepted the advice of the Legal Assessor.  The Panel was aware that the purpose of a sanction is not to be punitive, though a sanction may have a punitive effect. The Panel bore in mind that its primary function at this stage was to protect the public, while reaching a proportionate sanction, taking into account the wider public interest and the interests of the Registrant. The Panel referred to the HCPC Indicative Sanctions Policy and applied it to the Registrant’s case on its own facts and circumstances.


121. The starting point for the Panel was that the misconduct and lack of competence found proved were serious. There had been serious breaches of the HCPC Standards. Patients and the public were at risk of harm. 

122. The Panel considered mitigating and aggravating factors. 

123. No submissions or evidence had been put forward on behalf of the Registrant.  The Panel did not identify any mitigating factors in the case.

124. The Panel identified the following aggravating factors in this case:

• the allegations involved deliberate dishonesty and unlawful practice;
• patients had been placed at risk of harm as a result of the Registrant’s actions;
• the Registrant’s lack of engagement in the HCPC proceedings;
• the absence of insight, remorse or remediation on the part of the Registrant; 
• the Registrant’s previous criminal convictions from April 2011;
• the Registrant had been the subject of a previous HCPC disciplinary sanction a relatively short time before the events which are the subject of the present allegations.

125. In light of all of the circumstances, the Panel considered what sanction, if any, should be applied, and considered the sanctions in ascending order of seriousness.

Mediation

126. This was not possible or appropriate given the Registrant’s lack of engagement with the HCPC and further, the allegations proved were too serious.

No Further Action

127. A risk of harm to patients had been identified and the safety of the public and the wider public interest would not be protected if the Panel were to take no further action in a case of this seriousness.

Caution

128. A Caution Order would be insufficient to mark the seriousness of the Panel’s findings and to protect the public and maintain public confidence in the Paramedic profession.

Conditions of Practice Order

129. In applying the Indicative Sanctions Policy, the Panel considered the absence of engagement by the Registrant in this process, and his lack of acceptance or insight.  In these circumstances, the Panel could not have confidence that the Registrant would be committed to complying with a Conditions of Practice Order or could be trusted to do so.  The Panel noted the guidance in the policy was that where an allegation concerns dishonesty, conditions of practice are unlikely to be suitable.
 
130. Given the Registrant’s lack of engagement and the serious dishonesty findings, the Panel decided that a Conditions of Practice Order would not be effective or appropriate. 

Suspension

131. The Panel considered whether a period of suspension would be appropriate.  The Panel noted that the guidance in the Indicative Sanctions Policy indicates that suspension may be suitable where an allegation is of a serious nature but is unlikely to be repeated.  The Panel did not consider that to be the case and was satisfied there was a real risk of repetition. A period of suspension would involve an expectation that the Registrant would take steps to remediate his failings. This would require him to engage, to show full insight and to demonstrate there is no continuing risk of repetition of his behaviour.  Given his lack of engagement with this process and the difficulty of remediating dishonest behaviour, the Panel concluded that suspension would not provide the required public protection. 

Striking Off Order

132. The Panel was mindful of the guidance in the Indicative Sanctions Policy that striking off is a sanction of last resort for serious, deliberate or reckless acts involving abuse of trust including dishonesty.

133. The Panel could only conclude that there is no real prospect of the Registrant remedying his failings or engaging with the HCPC and therefore the appropriate order is removal from the HCPC register.

134. Given the serious nature and gravity of its findings, the Panel considered that any lesser sanction than striking off would not protect the public, nor would a lesser sanction ensure the maintenance of public confidence in the Paramedic profession and the regulatory process. 

135. The Panel was mindful of the personal impact this order may have upon the Registrant. However, it was satisfied that this is an appropriate and proportionate sanction in these circumstances. The need to protect the public and maintain confidence in the profession and the regulatory process outweighs the impact upon the Registrant.
 
136. In light of the above, the Panel was satisfied that a Striking Off Order is the appropriate and proportionate sanction in this case.

Order

Order: That the Registrar is directed to strike the name of Mr Michael J Wise from the Register with immediate effect.

Notes

 

 

 

Hearing History

History of Hearings for Mr Michael J Wise

Date Panel Hearing type Outcomes / Status
12/11/2018 Conduct and Competence Committee Final Hearing Struck off