Ms Margaux Ducker

Profession: Paramedic

Registration Number: PA30365

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 05/11/2018 End: 17:00 09/11/2018

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

Whilst working as a paramedic for Yorkshire Ambulance Service NHS Trust:

1) You attended to Patient A on 27 November 2016 and you:
a) Did not transfer Patient A to Sheffield Northern General Hospital (SNGH)
b) Did not adequately complete the Patient Care Record documentation
c) When asked by Person B whether you would transfer patient A to SNGH you stated: “it will be another crew because we have finished now” or words to that effect
d) Did not administer pain relief to Patient A
e) Told Patient A that the Hospital would administer pain relief because you “did not have the time” or words to that effect
f) Did not call the Primary Percutaneous Coronary Invention (PPCI) Unit at SNGH to discuss Patient A’s condition and observations
g) Left Patient A unattended for a period of time whilst you went to the ambulance to return the monitoring equipment and / or make a phone call

h) Did not attempt again to gain intravenous access to Patient A
i) did not record a second blood pressure check for Patient A
j) Spent between 17:31 and 18:35 handing over Patient A

2) The matters described in paragraph 1 constitute misconduct and / or lack of competence.

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

Finding

Preliminary Matters


Application to amend the particulars


1. Mr Millin, on behalf of the HCPC, made an application to amend the allegation. The application was not opposed by Mr Short, on behalf of Miss Ducker. The proposed amendments are as follows:

 1. Particular 1(a) replace “transfer” with “transport”

 2. Particular 1(b) add the following after “documentation”: “in that you did not record:

  i. the pain score;
  ii. your consideration in relation to cannulation;
  iii. your consideration in relation to administering drugs;
  iv. our conversation with Rotherham General Hospital

3. Particular 1(h) insert before “attempt” the words “make any or any sufficient” and delete “again”

4. Particular 1(i) insert after “record” the words “and or carry out”

5. Particular 1 (j) delete the original wording and replace with “Did not ‘clear’ from the scene within a reasonable time”.

2. The Legal Assessor advised that amendments can be made as long as no injustice is caused.

3. The Panel accepted the advice of the Legal Assessor and was satisfied that the proposed amendments did not cause injustice as they simply clarified the HCPC case. Accordingly, the Panel agreed to the amendments.


Background


4. The Registrant was employed by Yorkshire Ambulance Service (YAS) as a Paramedic. She completed her paramedic qualification in 2008 but had previously worked for YAS as an Emergency Medical Technician. The Registrant resigned from her role in 2017 having worked for the YAS for approximately 12 years.

5. The Registrant’s work included working on double-crewed ambulances and responding to 999 calls. As a qualified Paramedic she had responsibility for other non-paramedic members of staff with whom she worked.

6. On 27 November 2016 the Registrant was crewing an ambulance together with an Emergency Care Assistant, and they were called to attend Patient A.

7. Patient A was a 67 year old female who had been unwell for a number of days, and on or around 27 November 2016 she had developed a chest pain which led her husband to call 111, the NHS non-emergency number. The 111 service decided that an ambulance was required and a call was passed to the ambulance service.

8. When the Registrant and her colleague arrived at Patient A’s address an ECG was taken which confirmed that Patient A was having a myocardial infarction (heart attack) and she was taken in the ambulance to Rotherham General Hospital (RGH). Patient A was subsequently transferred by a different ambulance crew to the Primary Percutaneous Coronary Intervention Unit (PPCI) at Sheffield Northern General Hospital (SNGH).


9. When Patient A arrived at the PPCI unit staff there queried why she had not been brought there earlier. As a result, YAS subsequently carried out a Clinical Case Review of the handling of Patient A’s case. A formal disciplinary investigation was then commenced regarding the Registrant’s involvement with Patient A.

Decision on Facts

10. In reaching its decisions on the facts, the Panel considered both the oral and documentary evidence adduced in this case, together with the submissions made by Mr Millin and those by Mr Short.

11. The Panel heard and accepted the advice of the Legal Assessor.

12. The Panel was aware that the burden of proof rests on the HCPC, and that the standard of proof is the civil standard, namely the balance of probabilities. This means that the facts will be proved if the Panel is satisfied that it was more likely than not that the incidents occurred as alleged.

13. At the outset of the hearing the Registrant admitted Particulars 1(a), 1(b)(i) – (iv), 1(d), and 1(f).

14. The Panel heard oral evidence from three witnesses called on behalf of the HCPC: 

  1. CL, Sector Commander, YAS who carried out the disciplinary investigation;
  2. CP, Paramedic, YAS who was involved in the transfer of Patient A to the PPCI unit;
  3. RK, Paramedic, YAS who spoke to the Registrant on 27 November 2016.


15. The Panel found all the witnesses called by the HCPC to be straightforward, honest, credible and reliable.

16. The HCPC had intended to call LRJ, Emergency Care Assistant, YAS, who attended Patient A with the Registrant on 27 November 2016. However, she did not attend the hearing as expected. It was established that she had engaged with the HCPC and had been in contact last week to discuss travel arrangements. The HCPC made attempts to contact her by telephone and email but these were unsuccessful. Additionally, YAS were contacted but they were not able to contact LRJ who is currently on leave.


17. LRJ’s evidence was received as hearsay evidence. In deciding what weight to attach to this evidence the Panel bore in mind it had not been tested in cross-examination.

18. The Panel heard oral evidence from the Registrant. The Panel found her evidence to be confusing at times and contradictory in places and difficult to follow in many regards. It found some of her evidence to be lacking in credibility.

19. The Panel next went on to consider the allegation and made the following findings:


Particular 1(a) – Found Proved

20. The Registrant has admitted this particular, and it is clear from all the evidence that Patient A was initially taken to RGH. Patient A was subsequently transferred to SNGH but this was not done by the Registrant.

Particular 1(b)(i) - (iv)

21. Although the Registrant admitted these at the outset of the hearing it became apparent during her evidence that these admissions were equivocal.

The Panel has found Particular 1(b)(i) and 1(b)(iv) Not Proved

22. The Panel has seen the relevant Patient Care Record (PCR) completed by the Registrant and in the Pain score box the Registrant has marked the “UTR” box which indicates that she was unable to record a pain score. The Panel considers this to be an adequate record.

23. In relation to the conversation with RGH the PCR records “ASHICE” which the Registrant told the Panel is an acronym for the information she conveyed by telephone to RGH. The Panel considers this to be an adequate record in that the communication with the hospital was documented.

The Panel has found Particular 1(b)(ii) and 1(b)(iii) Proved

24. The PCR does not record this information at all.

Particular 1(c) – Found Not Proved

25. In her statement dated April 2018, made for the HCPC, LRJ states that at RGH when Patient A’s husband asked if they were going to take the Patient to SNGH the Registrant replied that “we had finished our shift and somebody else would be transferring Patient A .” This is slightly different wording to that used by LRJ in her interview during the YAS investigation. LRJ does not mention this conversation at all in her most contemporaneous statement made on 21 December 2016.

26. The Registrant denies using these words at all.

27. Taking into account that LRJ could not be cross examined and the inconsistencies in her statements the Panel could not be satisfied to the required standard that the words were used as alleged.

Particular 1(d) – Found Proved

28. The Registrant has admitted this particular.

29. The Panel accepts that the Registrant could not administer Morphine as she had been unable to insert a cannula. However, other pain relief options were available such as Entonox and/or GTN and no attempt was made to administer these and the Registrant’s rationale for not administering these was not recorded on the PCR.

Particular 1(e) – Found Proved

30. In his HCPC statement CP stated that on 27 November 2016 he was working on a double crewed ambulance when he was sent to RGH to transfer Patient A to SNGH. CP said that whilst en route to SNGH he asked Patient A if she had been given any pain relief and Patient A replied “the paramedic that took me to Rotherham General Hospital said that she would get the nursing staff at the hospital to give me some as she didn’t have the time.”

31. CP told the Panel that when Patient A said this she appeared comfortable, alert and knew where she was. CP said he was 100% sure that the patient said this, and he was surprised by her comment.

32. The Registrant denies saying this and states she that she said something along the lines of she was unable to give anything but the hospital will be able to help.

33. The Panel preferred the clear evidence of CP.

Particular 1(f) – Found Proved

34. The Registrant has admitted this particular and now accepts she should have done. She has recorded on the PCR that her initial impression was the patient was suffering a STeMI (ST segment elevation myocardial infarction) and therefore she should have followed the “Yorkshire PPCI Referral Pathway for Acute STeMI” which required her to call the nearest Cardiac Centre which was at SNGH.

Particular 1(g) – Found Proved

35. The Registrant has admitted this particular. The Registrant and LRJ left Patient A while they returned some equipment to the ambulance. The Registrant then made a telephone call to RGH which she did not want the patient to overhear as this may have caused further distress. In the meantime LJR had returned to the Patient. The Panel is satisfied that the patient was left unattended for only a short period of time.

Particular 1(h) – Found Not Proved

36. The Panel has accepted the Registrant’s evidence that although she attempted to locate a vein to allow her to cannulate she was unable to do so, and that she did not want to “start digging for one” as this would distress the patient. The Panel also accepts that Patient A told the Registrant that it was not unusual for there to be a difficulty in locating a vein which would cause further distress to the patient. The Panel considers her attempt was sufficient.

Particular 1(i) – Found Proved

37. The Registrant has admitted that although she carried out a second blood pressure check she did not record it. The Panel accepted the Registrant’s explanation that she had taken a manual blood pressure reading in the ambulance and written the result on her glove which she later disposed of. The Panel has found the particular proved on the basis of not recording.

Particular 1(j) – Found Proved

38. Mr Millin explained that the scene refers to the hospital and that there is no criticism relating to the time spent at Patient A’s house.

39. The Registrant arrived at RGH at 17.31 but did not “clear” until 18.35. The Panel accepts CL’s evidence about the expected turn around times at hospital and that even in the circumstances of this case, this time was excessive. Although the Registrant told the Panel that she was waiting to transfer Patient A to SNGH, she did not inform ambulance control of this.

Decision on Grounds

40. The Panel does not consider the facts amount to lack of competence as they relate to a single incident and there is no evidence to suggest that the Registrant lacked the necessary paramedic skills.

41. The Panel does not consider Particular 1(g) to amount to serious misconduct; the Registrant’s actions were misguided in leaving a seriously ill patient unattended, even for a very brief period, but they do not reach the threshold of serious misconduct.

42. The Panel is satisfied that the Registrant’s behaviour in the other proved particulars amounts to serious misconduct and the Panel is satisfied that her conduct as described in those particulars fell well below the standards expected of a registered paramedic.

43. Her behaviour had the potential to put Patient A at serious risk of harm and breached the following standard of the HCPC’s Standards of conduct, performance and ethics:

2.5 You must work in partnership with colleagues, sharing your skills, knowledge and experience where appropriate, for the benefit of service users and carers.

2.6 You must share relevant information, where appropriate, with
colleagues involved in the care, treatment or other services  provided to a service user.

6.1 You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.

9.1 You must make sure that your conduct justifies the public’s trust   and confidence in you and your profession.

10.1 You must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to.

10.2 You must complete all records promptly and as soon as possible after providing care, treatment or other services.

Decision on Impairment

44. The Panel went on to consider whether the Registrant’s fitness to practise is impaired by reason of her misconduct and referred to the HCPC Practice Note “Finding that Fitness to Practise is Impaired”.  The Panel accepted the advice of the Legal Assessor.

45. The Panel considered that although the misconduct is capable of remediation the Registrant has only taken limited steps towards remediation. She undertook a day of training and undertook some supervision at YAS following its investigation but since leaving YAS in 2017 she has not been working as a frontline paramedic. Although the allegation relates to one incident only, the Panel cannot rule out a limited risk of repetition of similar behaviour and consequently a risk to patients.

46. The Panel is concerned that the Registrant has demonstrated a lack of insight into her misconduct. It is clear that she regrets her actions and omissions, but she does not seem to fully appreciate their potential serious impact on Patient A. She does not yet have full insight of the impact of her actions on the reputation of the profession.

47. The Panel has no doubt that a member of the public would be shocked to learn how the Registrant behaved and it has decided that a finding of impairment is required to declare and uphold proper standards of conduct and behaviour and maintain confidence in the profession and the HCPC.

48. Accordingly, the Panel has concluded that the Registrant’s fitness to practise is impaired by reason of her misconduct.

Sanction

49. In coming to its own, independent decision as to sanction, the Panel took into account all the evidence and the submissions made.

50. In deciding what sanction to impose, if any, the Panel has reminded itself that the purpose of sanctions is not to be punitive but to protect patients and the public interest, although there may be a punitive effect.  The Panel has also taken into account the principle of proportionality, balancing the interests of the public with those of the Registrant. It has taken into account the HCPC’s Indicative Sanctions Policy. The Panel accepted the advice of the Legal Assessor.

51. The Panel has identified the following aggravating factor:

  • The risk of harm to a potentially vulnerable patient

52.The Panel has identified the following mitigating factors:

  • Single incident
  • Engagement with HCPC and YAS
  • Several admissions made from the outset
  • Positive references and testimonials including one from her current employer where she undertakes disability assessments in line with guidance
  • 20 year career as a registered health professional
  • Undertook some training and supervision at YAS following the incident

53. In view of the nature of the matters that gave rise to the finding of impairment it would not be appropriate to arrange mediation or to conclude the case without taking any action as this would not sufficiently address the potential ongoing risk to the public or address the wider public interest.

54. The Panel then considered a caution order. The Indicative Sanctions Policy states:

“A caution order is an appropriate sanction for cases, where the lapse is isolated, limited or relatively minor in nature, there is a low risk of recurrence, the registrant has shown insight and taken appropriate remedial action.”

55. As the Panel has already identified that the Registrant has only taken limited steps towards remediation and that she does not yet have full insight, it does not consider that a Caution Order would provide sufficient protection for the public.

56. The Panel then considered a Conditions of Practice Order. The Indicative Sanctions Policy states:

“Conditions of practice will be most appropriate where a failure or deficiency is capable of being remedied and where the Panel is satisfied that allowing the registrant to remain in practice, albeit subject to conditions, poses no risk of harm or future harm.”

57. The Panel has concluded that this is such a case and that workable conditions can be formulated which will be sufficient to protect the public and also to reassure the public that the Registrant will be able to demonstrate that she has addressed the deficiencies in her practice.

58. Mr Short has indicated that the Registrant is willing to comply with conditions and that the imposition of conditions would not mean that she would be unable to continue her current employment.

59. The Panel determined that an Order of Suspension would be disproportionate and unnecessary given the limited risk to the public identified by the Panel and the Registrant’s willingness to comply with a Conditions of Practice Order. The Panel has also considered the public interest in allowing an otherwise competent practitioner to remain in practice, albeit subject to conditions.

60. The Panel has determined that a Conditions of Practice Order for a period of nine months will allow sufficient time for the Registrant to remediate the identified deficiencies in her practice and to mark the wider public interest.

61. The Panel reviewing this Order maybe assisted by the Registrant attending the review hearing and providing details of her education and development undertaken since this hearing.

Application for an Interim Order:

1. Following the announcement of the sanction Mr Millin applied for an Interim Conditions of Practice Order. Mr Short did not oppose the making of an interim order.

Decision on Interim Order:

2. The Panel has already decided that a Conditions of Practice Order is required to protect the public. Accordingly, the Panel is satisfied that an Interim Conditions of Practice Order is necessary for the protection of the public.

3. The Panel has concluded that the appropriate length of this Interim Order is to be 18 months to allow for the disposal of any appeal. It has concluded that the following condition is the only one necessary on an interim basis:

  • You must not carry out emergency response paramedic work, including event cover, unless directly supervised by a registered health care professional

4. This order will expire: (if no appeal is made against the Panel’s decision and Order) upon the expiry of the period during which such an appeal could be made; or (if an appeal is made against the Panel’s decision and Order) upon the final determination of that appeal, subject to a maximum period of 18 months.

Order

ORDER:

The Registrar is directed to annotate the HCPC Register to show that, for a period of nine months from the date that this Order takes effect (“the Operative Date”), you, Margaux Ducker, must comply with the following conditions of practice:

1. You must not carry out emergency response paramedic work, including event cover, unless directly supervised by a registered health care professional

2. You must obtain a report from your Line Manager or your Clinical Supervisor to be sent to the HCPC before the review which reports on the following:

a) The quality of your professional working relationships with colleagues and service users

b) Your compliance with protocols and guidelines and documentation

3. You must provide to the HCPC prior to the review hearing of this Order a reflective account that looks at clinical assessment, communication and clinical judgement

4. You must provide to the HCPC prior to the review hearing of this Order a written account of the learning you have obtained as a result of this incident including care pathways, analgesia and the management of critically unwell patients.

5. You must promptly inform the HCPC if you cease to be employed by your current employer or take up any other or further employment.

6. You must promptly inform the HCPC of any disciplinary or capability proceedings taken against you by your employer.

7. 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).

8. You will be responsible for meeting any and all costs associated with complying with these conditions.

Notes

This Order will be reviewed by the Committee before its expiry, no later than 6 September 2019.

Hearing History

History of Hearings for Ms Margaux Ducker

Date Panel Hearing type Outcomes / Status
05/11/2018 Conduct and Competence Committee Final Hearing Conditions of Practice