Mr Stephan A T Tucker
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Whilst registered as a paramedic, and during the course of your employment at South East Coast Ambulance Service NHS Foundation Trust you:
1. On or around 19 October 2016 added information to the Patient Report Form (PRF) for Patient A which was originally completed on or around 17 October 2016.
2. The matter set out in paragraph 1 was dishonest.
3. The matters set out at paragraphs 1 – 2 constitute misconduct and / or lack of competence.
4. By reason of your misconduct and / or lack of competence your fitness to practice is impaired.
1. The Registrant was, at the time of the events giving rise to the Allegation, employed as a Clinical Team Leader with the South East Coast Ambulance Service NHS Foundation Trust (“the Trust”). On the morning of 17 October 2016, the Registrant attended a patient who was complaining of breathing problems, together with Ambulance Technician, witness TR. The patient was abusive towards the crew and refused conveyance to hospital. The crew left her at the scene. At the time of attending the patient, the Registrant filled out a form known as the “PRF”. The patient was subsequently conveyed to hospital by a different ambulance crew, but, unfortunately she died. On 19 October 2016 the Registrant, having been made aware that the patient had died, learned that her death was likely to be the subject of an internal investigation. He requested a copy of the PRF to assist him in writing a statement about his involvement with the patient. It is alleged that on that date, the Registrant added information to the PRF which was originally completed on 17 October 2016 and it is further alleged that he did so dishonestly.
Decision on Facts
2. The Panel heard live evidence from a number of HCPC witnesses: JC, Operating Unit Manager with the Trust, CD, Operating Unit Manager with the Trust, RR, Operations Manager (previously titled Clinical Centre Manager), DW, Acting Make Ready Centre Manager for the Make Ready Team of the Trust, and TR, Technician for the Trust. The Panel also read the hearing bundle submitted on behalf of the HCPC.
3. The Panel heard live evidence from the Registrant, and read the bundle submitted on his behalf, which included numerous character references.
4. The Panel was of the view that in general JC, CD, RR and TR were genuine and credible witnesses. The Panel was of the view that while RR found it difficult to remember certain matters, she was open about when she could not remember, and tried her best to give her evidence to the best of her recollection. With regard to DW, the Panel was of the view that there was a particular aspect of his evidence which was not clear or logical, and this aspect is dealt with later in this decision in respect of Particular 2.
5. The Panel formed the view that the Registrant tried his best to assist the Panel in giving his evidence and did so in a balanced manner.
6. The Panel accepted the advice of the Legal Assessor who reminded it that the burden of proof rests entirely on the HCPC and that the standard is the civil standard. The Legal Assessor reminded the Panel that the Registrant is of good character, and that this should be considered by the Panel when considering his credibility and his propensity to act as alleged. The Panel took into account the Registrant’s good character as advised by the Legal Assessor.
7. The Panel was satisfied from the evidence of JC, CD, and RR that the Registrant was employed by the Trust as a registered Paramedic, a matter which is not disputed by the Registrant.
8. The evidence of RR was that she gave the PRF to the Registrant so that he could use it to assist him in writing a statement about his involvement with the patient. RR stated that there was data missing from the PRF that had not been filled in when she handed it to him, namely the mental capacity box had not been checked and timed, the drug dosages were not filled in, drug codes were not entered, and the crew condition code (used to categorise types of incidents for audit) was also missing. RR stated that after the Registrant returned the PRF to her, she noticed that the missing items had been added. RR stated that she went to see CD who agreed that the missing items had been added.
9. The evidence of CD was that on 19 October 2016 the Registrant showed her the PRF and asked her if he had filled it out correctly. CD’s evidence was that she had seen it previously after she had been informed that the patient had died. She informed the Registrant that he had not completed the mental capacity assessment section nor filled in the drug dosages. Later that day, CD states that RR spotted that changes had been made to the form and came to speak to her for advice.
10. It became clear during hearing the HCPC evidence that the PRF had not had the crew condition code or drug codes added, and these boxes remained uncompleted. Indeed, Ms Ryan on behalf of the HCPC confined her case on Particular 1 to the addition of the tick in the mental capacity box, the addition of the time of that assessment, and the drug dosages.
11. The Registrant admitted this Particular, and in his evidence he accepted that on 19 October 2016 he ticked the mental capacity box, added the time of the mental assessment and added the drug dosages.
12. On the basis of the evidence and the Registrant’s evidence, the Panel found on the balance of probabilities that the Registrant added to the PRF on 19 October 2016 by ticking the mental capacity box, the addition of the time of that mental capacity assessment, and the drug dosages.
13. The Panel therefore found this Particular proved.
14. The Panel considered the Allegation and was of the view that it was not particularised in that it did not specifically state why the act of adding information was alleged to be dishonest. Nevertheless, Ms Ryan provided particularisation in her submissions by stating that dishonesty was alleged on the basis that the Registrant knew that the PRF would be scrutinised at a later stage due to the death of the patient, and that he wanted to prevent criticism of himself or his actions. This was the case which was put to the Registrant by Ms Ryan during his cross examination.
15. The Panel considered the evidence surrounding the circumstances and context in which the Registrant added to the form, as well as the evidence about his state of mind at the time.
16. The Panel first considered the effect of the additions made.
17. The PRF contains a significant amount of information which was handwritten by the Registrant in a free text box on 17 October 2016. In that section, the Registrant’s contemporaneous written notes show that the patient gave some history in that she is specifically referred to as having stated that her breathing had worsened and that she could not breathe. He also recorded that the patient stated that she considered that the Paramedic crew were treating her like a five-year-old. The Registrant also noted that she was able to speak in full sentences. As a result, the Panel was satisfied that there was evidence contained within the PRF which indicated that the Registrant had in fact assessed the patient’s mental capacity at the time. It is of note that the fact that a mental capacity assessment was carried out was confirmed by TR who was in attendance with the Registrant, and the Panel accepted TR’s evidence of how this was done.
18. The Panel considered the evidence of JC who questioned whether the the Registrant had made an accurate assessment of the patient’s mental capacity. It also considered the evidence of CD, who stated that it was not clear from the form whether the patient had mental capacity, for example she may have been hypoxic which could have caused her to lose her mental capacity. The Panel considered this evidence but was unconvinced that it was of much assistance in the consideration of whether the Registrant had a dishonest motive in ticking the box on 19 October 2016. This is because while an investigation into the patient’s capacity might be relevant at a future Serious Incident Review (SIR), as confirmed by CD, the question of whether she in fact had mental capacity would not be particularly assisted by the tick box in the PRF itself. The fact that a mental capacity assessment was carried out is reflected by what is contained in the free text box which, it is agreed, was filled out contemporaneously, as already referred to above. The tick in the box would simply confirm what was already clear from the form, namely, that an assessment was made. The accuracy or otherwise of that assessment is not a question for this Panel. In addition, the Panel was satisfied that it is more likely than not that whether the patient did indeed have capacity would need to be investigated by further means such as direct questioning and the consideration of statements taken by the ambulance crews.
19. The Panel also accepted the Registrant’s evidence that the drugs given to the patient, the names of which had already been completed on the PRF at the scene, were standard doses given by Paramedics at the time in question. This was also confirmed by CD in her oral evidence.
20. The Panel therefore was satisfied that adding the dosages two days later did not significantly change the content of the PRF by adding anything new which was not already implicitly contained in the form.
21. As such, the Panel decided that the Registrant was providing clarification rather than adding anything new to the PRF.
22. In addition, CD, who confirmed that at the time she was acting into the position of the Registrant’s manager, stated that the effect of the missing information from the PRF was not so serious that it would be likely to lead to disciplinary action against the Registrant by his employer. She confirmed that there had been a move away from an emphasis on discipline to a more supportive learning environment at the Trust. In her view, it would have been treated as a learning point for the Registrant. The Registrant, in his evidence, confirmed that this was also his understanding, and that in the Serious Incident Review which was likely to result as a result due to the patient’s death, he would expect the Trust’s Professional Standards Department to highlight such omissions as a source of learning for him.
23. Certain conversations which occurred on 19 October 2016 were relevant to the question of dishonesty and the Panel found it necessary to resolve some of the disputes between the parties with regard to these when coming to its decision on dishonesty.
24. CD gave evidence that the while she was in the open plan office talking to another colleague, and after the Registrant had shown her the form asking for her advice as to what was missing, DW had said jokingly “Oh is the carbon copy there?” or words to that effect, and CD thought that he had also said jokingly “Just fill it in” but she could not remember exactly. CD’s evidence was that she stood up, looked at DW in a disapproving way, and he stopped talking.
25. DW’s evidence was that he did not say “Just fill it in”. His oral evidence was that he jokingly asked “Is the carbon copy there”. Under cross examination, he denied that he meant, by means of the joke, to suggest to the Registrant that he fill in the missing parts on the PRF. DW stated that the joke was in respect of the patient not having the carbon copy.
26. The Registrant’s evidence was that DW said “Just fill it in now” and that DW was not laughing when he said these words. The Registrant’s evidence was that he did not take it to be a joke, but rather a colleague suggesting that he add the information. The Panel considered the evidence of the Registrant that CD rolled her eyes and turned her back on the Registrant, which indicated to him that she was aware of the meaning of DW’s suggestion but that she did not want to know, and that she was effectively turning a blind eye. The Registrant accepted in evidence that he may have misinterpreted her actions, but stated that this is what he thought she was communicating to him at the time. In her evidence, CD stated that she gave a disapproving look but she did not remember whether she rolled her eyes.
27. The Panel found on the balance of probabilities that DW did say “just fill it in” on the basis firstly, of CD’s evidence that he said “something like fill it in” and laughed and secondly, such a comment by DW is also consistent with CD’s evidence that she stood up and looked at DW in a disapproving way resulting in him stopping talking. Thirdly the Registrant’s evidence is that DW said “Just fill it in” and this is supported by CD’s evidence. The Panel was not persuaded by DW’s evidence that his joking question about whether the carbon copy was still there was nothing to do with a suggestion to the Registrant to fill in the form. The Panel found this unlikely, and considered that, on this point, DW was being defensive. The Panel was satisfied on the balance of probabilities for the reasons above that DW said “Just fill it in” or words to that effect. Having considered the Registrant’s evidence about his interpretation of CD’s response, following her hearing DW’s suggestion, joking or otherwise, in effect to fill in the gaps on the PRF, the Panel accepts his understanding at the time that he had the tacit consent of CD, even if she did not in fact consent. The Panel is fortified in its conclusion by the fact that the Registrant carried out the additions whilst still in the open plan office, without attempting to conceal them, and he gave the amended PRF to RR who had herself given him the unamended version not long before. The Panel was not satisfied that there was any wish to mislead his managers.
28. After the Registrant had filled in the gaps on the PRF, it was agreed by the parties that there was a further exchange between the Registrant and RR. The content of that exchange was disputed. Both parties’ evidence was that RR entered the room and, having seen the Registrant with the PRF, said words to the effect of “you’re not going to change that are you?”. The Registrant’s evidence was that he said “I won’t change any more” and handed RR the PRF. RR’s evidence was that the Registrant said “no” and handed RR the PRF. In an internal investigation document, RR had recorded that the Registrant had said “No, I was just looking at what it would have been.” RR candidly admitted that her recollection of the conversation some two years after the event was unclear but was adamant that the thrust of the Registrant’s answer (at least as she had understood it) was that he had not amended the form. The Panel found RR’s evidence to be credible on this point and supported by her comment that, given her position as Audit Lead within the department, she would certainly have reacted and probed further had she heard the Registrant admitting that he had amended the PRF. Despite accepting RR’s evidence on this point as to what she understood the Registrant to be saying, the Panel did not believe that this fundamentally altered its view of the Registrant’s honesty, and considered that the surrounding circumstances supported its finding that his intention was to be open and honest about his actions.
29. The Panel accepts the Registrant’s evidence that he had no intention to mislead any potential SIR, and took into account the consensus between CD and the Registrant that the Registrant would not have been in serious trouble with his employer if his omissions were highlighted at the SIR. The Panel accepts the Registrant’s evidence that his motivation in adding information to the PRF was because he wanted it to be completely filled in. The Panel finds that there was a genuine lapse of judgement by the Registrant on this occasion. While the Registrant accepted that that there was an unwritten rule that PRFs should not be altered after the incident in question, the lack of a formal or written policy about how to amend PRFs contributed, in the Panel’s finding, to his lack of judgment. CD herself, stated “I can’t say I know what to do” when asked about the correct procedure for adding to a PRF. In all the circumstances, the Panel accepts that this was a lapse of judgment by the Registrant, believing he had the tacit consent of his manager, and his motivation was to make sure the form was complete and correct. There is of course no suggestion that the additions represented false information. Having found that this was his state of mind at the time, the Panel considered that, when applying the objective standard of ordinary decent people, the Registrant’s actions in adding to the PRF were not dishonest.
30. The Panel therefore found this Particular not proved.
Decision on Grounds
31. The Panel then considered whether the facts found proved constitute misconduct or lack of competence. It was aware that there is no burden of proof at this stage and that the questions of misconduct or lack of competence are a matter for its own professional judgment. The Panel was aware that a breach of professional standards such as those contained in the HCPC Standards of conduct, performance and ethics (“the Standards”) was not necessarily in itself determinative of whether there was misconduct.
32. Ms Ryan submitted that the matter contained in Particular 1 constitutes misconduct rather than a lack of competence. She referred to the HCPC witness evidence that a PRF should not be altered, on the basis that a PRF is a contemporaneous document, and that if it is changed after the event, there is no way of knowing about treatment administered at the time when the patient was being attended to. Mr Marsland agreed that this is not a lack of competence case. Mr Marsland recognised that changing a PRF after the event deprived it of its contemporaneous quality, but submitted that the actions were neither serious nor deplorable in the eyes of fellow practitioners. The Panel accepted the advice of the Legal Assessor who referred to the case of Roylance v GMC (No. 2)  1 AC 311 and Shaw v General Osteopathic Council  EWHC 2721. The Panel also accepted the advice of the Legal Assessor that this case should more properly be considered a case of misconduct rather than lack of competence.
33. The HCPC witnesses JC, CD and RR all confirmed that there is an unwritten rule that PRFs should never be altered as they should be a contemporaneous document. CD stated that it is a legal document, and that she did not know the procedure for adding information to a PRF. RR stated that she had never before in her career dealt with an incident of a PRF which had been added to. The Registrant has always accepted that he knew he should not have added to the PRF.
34. The Panel was of the view that the Registrant breached the following standards of the HCPC Standards of conduct, performance and ethics 2016:
“10 Keep records of our work
Keep accurate records
10.1 You must keep full, clear and accurate records for everyone your 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.”
35. The Panel was of the view that, in itself, the act of correcting omissions to a PRF might not, in every case, be sufficiently serious to constitute misconduct. However, due to the particular circumstances surrounding this case, namely the death of the patient involved and the high likelihood of a SIR that would look at the PRF in detail, meant that it was of the utmost importance to be clear from looking at the PRF what was filled in contemporaneously at the time the patient was treated. The Panel therefore decided that in the particular circumstances of the case, and in light of the significance and scrutiny which was likely to be given to the PRF, as the Registrant well knew, the Registrant’s actions fell seriously short of the standards expected of him and thus were sufficiently serious to constitute misconduct.
Decision on Impairment
35. The Panel took into account the submissions of Ms Ryan that the Registrant’s fitness to practise is currently impaired on the basis of the public component, namely the need to uphold public confidence in the profession and to uphold proper standards. Mr Marsland agreed that the public component including confidence in the profession is the most relevant potential ground for impairment, but submitted that the Registrant is not impaired on either the personal or the public component.
36. The Panel accepted the advice of the Legal Assessor who referred to CHRE v (1) NMC (2) Grant  EWHC 927. The Panel took into account the HCPTS Practice Note entitled “Finding that Fitness to Practise is ‘Impaired’” which states, amongst other matters, that in determining whether fitness to practise is impaired, panels must take account of a range of issues which, in essence, comprise two components:
i. the personal component which includes insight, the risk of repetition, whether the matters raised are remediable and whether there has been remediation by the Registrant.
ii. the public component which includes the need to protect service users, maintain confidence in the profession, and declare and uphold proper standards of conduct and behaviour.
37. The Panel was aware that impairment is a matter for its own independent judgment and that public protection and the wider public interest should be considered.
38. The Panel was of the view that the reflective piece which the Registrant had written early on and close to the event was not sufficiently deep or insightful and was somewhat focused on the consequences of the Registrant’s actions upon him personally, However, having heard the Registrant give evidence, the Panel was of the view that he did not seek to minimise what had happened, nor to pass blame to others, and that his insight into why he acted as he did, and why it was wrong, was now far more developed. The Panel was of the view that the Registrant now has sufficient insight into why he made an error of judgment as well as insight into the impact of it on the wider reputation and confidence in the profession.
39. In terms of remediation, the Panel considered the Registrant’s meaningful oral reflection. The Panel also took into account the Registrant’s numerous testimonials, including from his current line manager, which attest to his integrity, his insight into his misconduct and his abilities as a paramedic. The Panel also took into account that the Registrant has remained with the same employer, albeit having been demoted to a different role, and has continued to work for some two years as a paramedic, including mentoring junior staff, since the incident in question without any further concerns. The Panel also took into account that this was an isolated incident in a career spanning almost 20 years.
40. The Panel took into account the questions formulated by Dame Janet Smith in the Fifth Shipman report, as set out in the case of Grant and which ask whether the practitioner:
“a. has in the past acted and/ or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and/ or
b. has in the past brought and/ or is liable in the future to bring the…profession into disrepute” and/ or
c. has in the past breached and/ or is liable in the future to breach one of the fundamental tenets of the…profession; and/ or
d. has in the past acted dishonestly and/ or is liable to act dishonestly in the future.”
41. In considering these questions, the Panel decided that the Registrant had not in the past acted so as to put a patient at unwarranted risk of harm, nor were there grounds to determine that he is liable to do so in the future.
42. The Panel considered whether the Registrant had in the past brought the profession into disrepute by his actions, but concluded that he had not because the additions he made to the PRF were an accurate reflection of what he did at the scene, and had been discovered by his manager very soon after he had made them, and the matter was dealt with by an internal investigation. In light of the insight and remediation shown by the Registrant, the Panel was satisfied that the risk of repetition was negligible and therefore the Registrant is not liable to bring the profession into disrepute in the future.
43. The Panel was of the view that the Registrant had breached fundamental tenets of the profession, as set out in the Panel’s decision on misconduct. However, again, in light of the insight and remediation shown by the Registrant, the Panel was satisfied that the risk of repetition is negligible, and therefore the Registrant is not liable to breach fundamental tenets in the future.
44. The last question relates to dishonesty which is no longer an issue in this case and the Panel disregarded it.
45. The Panel could find no reason to find impairment on the basis of the personal component.
46. The Panel went on to consider the public component. The role of a Paramedic incorporates a responsibility to maintain high professional standards which are necessary for public confidence in the professional exercising that role. The Panel had in mind that this was a lapse of judgment, that there was no intention to mislead, and no inaccurate information or information which was other than clarificatory was added. However, the Registrant nevertheless breached a fundamental and crucial principle of the profession, namely that PRFs must be completed contemporaneously. The role of a Paramedic involves responding to difficult emergency situations in which important decisions are made in relation to vulnerable patients. It is therefore crucial that PRFs are always accurate in the sense that all the information contained within them was completed contemporaneously at the time of attendance with the patient. If further additions are made, in the manner made by the Registrant, there is no way of knowing that they were made later. While of course further information may, in principle be added by a Paramedic if necessary, it must always be made clear that such information was added at a later date.
47. While no harm or risk of harm to the patient was caused by the Registrant’s actions, his conduct in adding information to the PRF two days after attending the patient breached an important principle fundamental to the role of a Paramedic. It is the breach of this important tenet of the profession that, in the Panel’s view, has an adverse impact upon confidence in the profession. In the Panel’s view, a reasonable member of the public, informed of all the facts and circumstances of the case, would be concerned by the Registrant’s conduct and would have his or her confidence in the profession undermined.
48. For the reasons set out above, in the Panel’s view, it would also undermine confidence in the regulator if no finding of current impairment were made by the Panel. As such, the Panel was of the view that the need to uphold proper professional standards and maintain public confidence in the profession, and also the regulator, would be undermined if a finding of impairment were not made in the particular circumstances of this case.
49. The Panel therefore found the Registrant’s current fitness to practise to be impaired on the basis of wider public interest.
Decision on Sanction
50. The Panel heard the submissions of Ms Ryan that sanction is a matter for the Panel’s own judgment, and that its purpose is to uphold the public interest and that it must be proportionate.
51. Mr Marsland submitted that it would be appropriate to impose no further action in this case, and referred to the paragraph of the Indicative Sanctions Policy (ISP) which dealt with such an outcome. In the alternative, if the Panel did not agree, he submitted that a Caution Order for a minimum period of one year would be the appropriate sanction.
52. The Panel took into account all of the oral and documentary evidence, read the HCPC’s Indicative Sanctions Policy (ISP), and accepted the advice of the Legal Assessor. The Panel was aware that the aim of sanction is not to be punitive. Rather, the aim is to protect the public and the public interest. Sanction is a matter for the independent judgment of the Panel. The Panel took into account the principle of proportionality in coming to its decision on sanction.
53. The Panel identified the following mitigating factors:
i. isolated incident;
ii. sufficient insight shown by the Registrant;
iii. no harm caused to the public;
iv. negligible risk of repetition;
v. early admissions to his employer and in the regulatory proceedings;
vi. character references attesting to his skills as a Paramedic;
vii. lack of a written policy on changing PRFs.
54. The Panel identified the following aggravating factors:
i. the Registrant was in a senior position as a team leader at the time;
ii. the PRF in question related to a patient who had died and there was likely to be an internal investigation which examined the PRF.
55. The Panel was of the view that mediation was not appropriate in that its purpose would be to address unresolved differences between the Registrant and his employer, and there is no suggestion of the existence of such differences.
56. The Panel considered taking no further action. The Panel took into account para. 8 of the ISP which states:
“Even if a Panel has determined that fitness to practise is impaired, it is not obliged to impose a sanction. This is likely to be an exceptional outcome but, for example, may be appropriate in cases where a finding of impairment has been reached on the wider public interest grounds identified above but where the registrant has insight, has already taken remedial action and there is no risk of repetition.”
57. The Panel took into account its findings at the impairment stage that the Registrant had not placed a patient at risk by his actions, nor was he liable to do so in the future. He has been found impaired in order to uphold the wider public interest which includes maintaining public confidence in the profession. The Registrant has sufficient insight, has remediated his actions and the risk of repetition is negligible. He has also and continued to work to an exemplary standard for almost two years for the same employer, and he is held in high regard as a Paramedic, as demonstrated by a significant number of testimonials.
58. On the basis of all of these circumstances, the Panel was not satisfied that it is necessary, in order to uphold the wider public interest, to impose a sanction in this case. It is the Panel’s view that the case falls squarely within para. 8 of the ISP and as such is an exceptional case.
59. As a result, the Panel decided that it would be appropriate and proportionate to impose no further action in this case.
60. The Panel did consider a Caution Order and took into account paragraph 28 of the ISP which states as follows:
“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. A caution order should also be considered in cases where the nature of the allegation means that meaningful practice restrictions cannot be imposed but where the registrant has shown insight, the conduct concerned is out of character, the risk of repetition is low and thus suspension from practice would be disproportionate. A caution order is unlikely to be appropriate in cases where the registrant lacks insight .”
61. The Panel was of the view that a Caution Order would be disproportionate given all the circumstances of this case. The Registrant has already suffered significant repercussions to his career as a result of disciplinary action taken by his employer and in the Panel’s view it would serve no useful purpose to impose a caution order in this case. The Panel was of the view that Conditions of Practice or Suspension would be disproportionate and punitive.
62. The Panel therefore decided to take no further action.
No Further Action
A Final Hearing was held in London 1-4 October 2018. The Panel decided to take no further action and the Registrant may practise unrestricted.
History of Hearings for Mr Stephan A T Tucker
|Date||Panel||Hearing type||Outcomes / Status|
|01/10/2018||Conduct and Competence Committee||Final Hearing||No further action|