Miss Kathryn Chignell

Profession: Paramedic

Registration Number: PA34348

Interim Order: Imposed on 08 Aug 2017

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 28/01/2019 End: 17:00 31/01/2019

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

(As amended)

While registered as a Paramedic and employed with South Western Ambulance Service, you:

1.  On or about 04 January 2016, in relation to Patient A did not:

(a) complete and / or record an adequate assessment of Patient A in that:

(i) you conducted and / or recorded only one set of observations;

(ii) you did not complete and / or record an Electro Cardiograph;

(b) provide adequate treatment to Patient A in that you did not provide adequate pain relief;

(c) complete a comprehensive and / or adequate Patient Clinical Record in that you did not record an adequate rationale as to why Patient A was not taken to the emergency department.

2.  On or about 24 April 2016, attended Patient B and did not:

(a) complete and / or record an adequate assessment of Patient B in that you:

(i) concluded that the patient was “unconclusive” in relation to the FAST test for stroke, rather than “positive”;

(ii) incorrectly circled “U” and “L” on the Patient Clinical Record, in relation to the FAST test for stroke;

(b) provide timely treatment to Patient B;

(c) request priority 1 back up;

3.  On or about 28 November 2016, attended an elderly patient, Patient C, who was unresponsive, and you did not provide adequate and / or timely treatment to the patient in that you did not provide the patient with oxygen;

4.  On dates between 13 and 17 December 2016, you:

(a) attended a seven-year-old patient, Patient D, and:

(i) you did not obtain an adequate history of the patient;

(ii) you had to be prompted regarding the correct pathway to be used;

(iii) you did not provide an adequate rationale for referring the patient to the out of hours service rather than conveying Patient D to Accident and Emergency.

(b)  attended an elderly patient, Patient E, with sepsis markers and:

(i) did not demonstrate adequate knowledge of sepsis markers;
 
(ii) did not demonstrate adequate knowledge of the procedure to be followed in relation to a patient with sepsis markers;

(iii) failed to notice Sodium Chloride had run into Patient E's arm tissue rather than through the vein.

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

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

Finding

Procedural Matters

Application to Amend the Allegation

1.  At the commencement of the hearing the Presenting Officer applied to amend the particulars of the allegations against the Registrant to ensure that it more accurately reflected the HCPC position. The Presenting Officer submitted that the changes did not materially alter the nature of the particularised allegation. The Registrant’s Representative confirmed that he had no objection to the proposed amendment to the allegation.

2.   The HCPC has issued guidance in relation to “Standard of Acceptance for Allegations” which sets out that allegations must be drafted in a clear and unambiguous way which enables the Registrant and anyone else reading them to understand what is being alleged. The allegations should be set out:

(a) briefly, concisely and in ordinary language which avoids the      unnecessary use of technical terms or jargon;
(b) in separate paragraphs, each dealing with a single element of the  allegation;
(c) with the facts in chronological order (unless there is good reason  to do otherwise);
(d) in the logical decision-making sequence of facts, statutory ground  and impairment.

3.   The Panel had regard to, and applied, advice from the Legal Assessor. It was satisfied that the amendment proposed by the Presenting Officer and agreed by the Registrant’s Representative ensured that the particulars of the allegation promoted the above requirements and did not unduly prejudice the Registrant. Accordingly, the application to amend the allegation was approved.

Proceeding in Private

4.  During the course of the hearing, the Registrant’s Representative applied to have part of the hearing conducted in private. The basis of his application was that there was information pertinent to the case in relation to the Registrant’s private life. It would therefore be appropriate for those parts of the hearing relating to such matters to be conducted in private. The Presenting Officer did not object to the application.

5.  The Panel received advice from the Legal Assessor, which it accepted. It had regard to the guidance note issued by the HCPTS entitled “Proceeding in Private”. Whilst conscious that there is a presumption that hearings will be conducted in public, the Panel was obliged to ensure that the interests of justice were served and the private life of the Registrant protected. It concluded that it would be inappropriate to refer to the health and private life of the Registrant in a public hearing. Accordingly, evidence in relation to the Registrant’s health and private life would be heard in private to protect her privacy, but all other matters would be heard in public.

Proceeding in Absence

6.  The hearing was not concluded within the original time allocated to it and instead concluded some months later. The Registrant was unable to attend when the hearing re-commenced on 28 January 2019 but her representative was in attendance and content to proceed with the case in the absence of the Registrant. The Presenting Officer believed that it was incumbent upon her to formally apply to proceed in the absence of the Registrant, which she considered to be voluntary.
7.   The Panel noted the provisions of the HCPTS practice note in respect of proceedings in absence and received advice from the Legal Assessor, which it applied. There had been no request for an adjournment received, nor any interest expressed by the Registrant in providing evidence via video or telephone link at that time, though the Registrant had already attended one day of the hearing by telephone link. The Panel was satisfied that it was appropriate for it to exercise its discretion to continue with the hearing in the absence of the Registrant. The extent of any disadvantage to the Registrant was limited as a consequence of her representative being in attendance and the public interest in proceeding outweighed any potential prejudice which may be suffered by the Registrant.
Background

8.   The Registrant is registered with the HCPC as a paramedic. At the time of the matters which are the subject of these proceedings, she was employed by South Western Ambulance Service Trust (the Trust). She commenced employment with the Trust on 18 December 2013, having operated as a paramedic in another region prior to that date.

9.       The Registrant was placed on “Restriction of Practice” (ROP) by the Trust on 15 March 2016 as a consequence of concerns raised about her treatment of a patient in January 2016, returning to unrestricted practice from 30 March 2016 following a satisfactory review.

10.   Following further concerns being raised about her practice in April 2016, the Registrant was again placed on restricted practice from 5 May 2016. During the period of that restriction of practice, further concerns were raised and the Registrant remained on restricted practice for the rest of her employment by the Trust. The Registrant was provided with support and training to help her meet the standards expected of her by the Trust, with the action plan being suspended for a period while the Registrant returned to work following a period of absence.

11.    Despite the action plan being extended by the Trust in December 2016,  the Trust concluded in January 2017 that the Registrant had not  sufficiently improved her practice and they therefore commenced formal  capability proceedings.

12.   The Trust referred their concerns regarding the Registrant to the HCPC. The HCPC provided a bundle of documents in support of the allegations in relation to the Registrant and called 5 witnesses to give evidence to the Panel. The Registrant was in attendance and represented. The Registrant gave evidence to the Panel and was cross examined by the Presenting Officer. She also answered questions from the Panel.    
Assessment of Witnesses

NW
13.   NW, a registered paramedic, was employed by the Trust as an  Operations Manager at the time the Registrant was employed. He did  not line-manage the Registrant but rather managed her managers. He  provided written and oral evidence to the Panel and answered questions  from the Presenting Officer, Registrant’s Representative and the Panel.  This witness gave his evidence carefully, taking time to think about the  questions asked of him. He drew attention to changes in policy  statement and was balanced in his evidence. He was consistent and  reliable and the Panel found him to be considered and credible. The Panel noted that he was, to a degree, removed from direct operational practice due to his seniority, a fact that he accepted.

AJ
14.   AJ was employed by the Trust. At the time of the incidents which formed the basis of the allegation he was a student paramedic, and he has since qualified as a paramedic. The Panel found him to be a credible, consistent and reliable witness. The witness readily identified his own failings in respect of the incident. He had good recollection of the incident in question, which he had reported to the Trust.

AN
15.   AN was employed by the Trust as a Learning Development Officer at the time of the incidents which were the subject of the allegation. He was responsible for supporting and appraising the performance of the Registrant while she was restricted in her practice. The Panel found AN to be robust and balanced in his evidence, and they considered him to be knowledgeable, considered, consistent and credible. The nature of his role meant that he maintained regular frontline engagement and supervision and therefore where his evidence conflicted with that of NW, the Panel preferred the evidence of AN, given his proximity to operational matters.

PB
16.   PB was a paramedic placement assessor assigned to the Registrant once she was on restricted practice. He fed back his opinion of the Registrant’s performance to AN. He had knowledge of the Registrant prior to the ROP coming into effect and was therefore well placed to comment on her performance before the restrictions of practice and thereafter. The Panel found PB to be knowledgeable and credible. He was honest about errors that had been made and was not overly critical of the Registrant.

CN
17.  CN was a paramedic mentor employed by the Trust and assigned to supervise the Registrant during the restrictions on her practice for two shifts. She had not undertaken this role previously and was unaware of the assessment form others had completed - she was merely asked to supervise the Registrant and feed back to management any issues, which she did verbally. Some weeks later, she was asked to confirm her concerns in writing, which she did via an email. The Panel found her to be honest, credible and consistent in her attempts to assist the Panel. 

The Registrant
18.  The Panel considered that the Registrant was broadly credible when giving evidence, however there were some occasions where she struggled to recall details, in all likelihood, as a consequence of both the passage of time and the issues she had dealt with in the past few years. It concluded that on some occasions the information she provided was simply not correct. For example, the Registrant asserted that, in respect of Patient B, she had called the control room to see where the “back-up” was and asked them not to divert it. However she could offer no explanation for her call not appearing on the extremely detailed automated incident log in respect of Patient B. She attempted to assist the Panel, sometimes to her detriment, insofar as it believed that on occasion she spoke of what she thought she would have done in the circumstances rather than what she actually did. The Panel was surprised that she was able to recall some matters in depth but was unable to recall anything in relation to other issues. The Panel noted that the Registrant’s recollection of events appeared to improve over time which the Panel was not satisfied was the best evidence before it, particularly in relation to matters contested.  In general terms, where her evidence conflicted with that of other witnesses, the Panel did not prefer her evidence.


Decision on Facts

19.  The Panel proceeded to consider each particular in turn, taking account of the documentary and oral evidence available to it, the submissions of the Presenting Officer and Registrant’s Representative and the legal advice provided by the Legal Assessor. In determining whether an allegation is “well founded” or “proved”, the Panel is required to decide firstly whether the HCPC, which has the burden of persuasion in relation to the facts alleged, has discharged that burden.

Patient A

20.  Patient A was an elderly female complaining of “chest / abdominal pain” at her home address. The Registrant attended the property, pursuant to a 999 call, and recorded that Patient A had a history of diverticulitis and angina. She assessed Patient A and recorded her professional impression that Patient A had a flareup of diverticulitis or “? IBS”, (Irritable Bowel Syndrome). When the patient said she was unable to attend the General Practitioner’s (GP) surgery, the Registrant consulted with the GP by telephone and arranged for the GP to make a home visit later that day. After consulting with the patient’s GP, the Registrant decided that Patient A should be left at home to await the GP visit. The GP visited later that day and diagnosed Patient A as suffering from gastroenteritis. A further 999 call was received later that afternoon and an ambulance crew attended Patient A. Patient A died later that day. The Panel noted that the Trust’s investigation report cited the cause of death as notified by the coroner, as ischaemic heart disease, chronic obstructive pulmonary disease, and hypertension.

21.  The Panel noted that the HCPC Standards of Conduct, Performance and Ethics requires regulated professionals to keep full, clear and accurate records for everyone they care for, treat or provide other services to. It had been provided with a copy of the Trust policy for the recording of patient care which gives effect to the HCPC standards and noted the method of recording care for the Trust was via a Patient Care Record (PCR). 

22.  Having carefully considered the documentary and oral evidence in relation to Patient A, the Panel concluded, on the balance of probabilities, that the Registrant considered Patient A’s symptoms to be related to a flare-up of pre-existing diverticulitis, or IBS, and treated her accordingly.


Particular 1(a)(i) - On or about 04 January 2016, in relation to Patient A [you] did not complete and / or record an adequate assessment of Patient A in that you conducted and / or recorded only one set of observations – Found Proved

23.  At the outset of the hearing the Registrant’s Representative confirmed to the Panel that the Registrant accepted she had only undertaken one set of observations on Patient A. She also accepted in her evidence that the failure to do more than one set of observations breached Trust policy at that time and rendered her assessment of Patient A inadequate. The Panel found that only one set of observations was taken and this rendered the assessment inadequate. Further, the Panel noted that the Registrant accepted that she had identified the patient was hypothermic and that she should have checked that the patient had warmed up prior to leaving her. Accordingly, this particular was proved. 


Particular 1(a)(ii) - On or about 04 January 2016, in relation to Patient A [you] did not complete and / or record an adequate assessment of Patient A in that you did not complete and / or record an Electro Cardiograph (ECG) – Found Proved

24.   The Panel noted that in the Registrant’s statement dated 14 February 2016, the only reference to an ECG was ‘no ECG recorded’. This was the most contemporaneous evidence available to it other than the PCR. The Registrant discussed the incident further with witness AN on 22 March 2016, when she is recorded as explaining ‘she thought she had conducted a 3 Lead ECG’.

25.  The oral evidence provided by the Registrant to the Panel was that she was 99.9% certain she had done a 3 Lead ECG, but not certain at all that she had done a 12 Lead ECG. The Panel noted that this is an example where the Registrant’s memory improved over time. The Registrant accepted that she had not recorded that an ECG had been performed on the PCR and therefore had not recorded an adequate assessment of Patient A.

26.  Given the Registrant’s detailed completion of the PCR in relation to some aspects of the assessment of Patient A, it is the Panel’s view that if she had performed an ECG she would have recorded it on the PCR in the relevant section and attached a copy of the ECG to the PCR. The absence of both suggested to the Panel that no ECG was performed. It was satisfied it was more likely than not that no ECG was performed. The Panel found that the Registrant believed that the patient was experiencing a flare-up of her pre-existing diverticulitis, or IBS and responded accordingly.  

27.   Both AN and NW were of the opinion that in the particular circumstances of Patient A (presenting with chest pain and a history of angina), an assessment without an ECG would be inadequate.

28.  The Panel found, on the basis of the evidence of witness AN, that a 12 Lead ECG ought to have been performed by the Registrant in the circumstances. The Panel was not persuaded that the Registrant did perform a 3 Lead ECG. Even if the Panel had preferred the Registrant’s oral evidence that she did perform a 3 Lead ECG, she accepted that a 12 Lead ECG would have been appropriate, and in any event, she did not record it on the PCR. Overall the Panel found that the Registrant did not complete or record an adequate assessment of Patient A. This particular was therefore proved.

 
Particular 1(b) - On or about 04 January 2016, in relation to Patient A [you] did not provide adequate treatment to Patient A in that you did not provide adequate pain relief – Found Not Proved

29.  The HCPC has the burden of proving the allegation against the Registrant. Witness AN was clear in his evidence to the Panel that discharging Patient A at home to await a visit from a GP while she was complaining of pain with a score of 8 out of 10 was inappropriate and inadequate. Both AN and NW however agreed that it was possible that the patient could not have been given any other pain relief in the circumstances (i.e. due to vomiting and having already taken pain relief).

30.   The Registrant observed the patient as having abdominal tenderness but no guarding or rigidity and recorded the pain as being in waves. Her observations were consistent with her view that Patient A was suffering from an abdominal complaint. She noted the analgesic history and when the next relief would be available to the patient. She discussed the patient with the GP. The GP visited and prescribed an anti-emetic but no further pain relief. The Panel found that given that the GP did not administer further pain relief, it would be difficult to criticise the Registrant in this respect.

31.  The Panel was not satisfied that the HCPC had proved this particular, given that the Registrant had given advice on when the patient could take more pain relief and had arranged a visit from her GP. It therefore found this particular not proved.


Particular 1(c) - On or about 04 January 2016, in relation to Patient A [you] did not complete a comprehensive and / or adequate Patient Clinical Record in that you did not record an adequate rationale as to why Patient A was not taken to the emergency department – Found Not Proved

32.   The Registrant’s Representative conceded at the commencement of the hearing that the Registrant accepted that she did not complete a comprehensive PCR in respect of Patient A in that she did not record her rationale for not conveying the patient to hospital. The Registrant confirmed in her oral evidence that the PCR as a whole was an inadequate record of the care provided to Patient A as, she stated, in addition to the failure to record the rationale for not taking the patient to the emergency department, it did not document:

 (a)  Patient A’s refusal to go to hospital;
 (b)  the extent of Patient A’s cooperation in respect of observations;
 (c)  the conversation the Registrant had with the GP;
 (d)  the detail of the worsening advice provided.
  
33.  However, the allegation is that the PCR was inadequate due to a failure by the Registrant to record a rationale for why the patient should not be conveyed to hospital. The Panel noted that the Registrant had completed the PCR in detail in a manner consistent with the Panel’s finding that she believed that Patient A was experiencing a flare-up of pre-existing diverticulitis, or IBS. The Registrant’s treatment plan – that the patient should remain at home and be seen by the GP - was also consistent with her assessment of the patient and in these circumstances, there was no requirement or expectation upon her to justify non-conveyance in the PCR. There was no evidence before the Panel that a registrant is expected to record every possible treatment option that they have considered and discounted on a PCR. The Panel noted that the GP was also content to leave the patient at home, both during the phone call from the Registrant, and after his own visit some time later. The Panel did not find this particular to have been proved on the balance of probabilities.


Patient B

34.  Patient B was an elderly female in a care home. The ambulance service had been contacted by the care home as Patient B was not speaking and had slumped to one side.


Particular 2(a)(i) – On or about 24 April 2016 [you] attended Patient B and did not complete and / or record an adequate assessment of Patient B in that you concluded that the patient was “unconclusive” in relation to the FAST test for stroke, rather than “positive” - Found Proved

35.  The Registrant accepted from the outset that she had recorded Patient B as FAST ‘unconclusive’ and accepted that this was not correct as “U” stood for “Unable to assess”, therefore this particular was proved.


Particular 2(a)(ii) - On or about 24 April 2016 [you] attended Patient B and did
not complete and / or record an adequate assessment of Patient B in that you
incorrectly circled “U” and “L” on the Patient Clinical Record, in relation to the FAST test for stroke – Found Proved

36.  It was accepted by the Registrant from the outset of the hearing that she had circled “U” and “L” incorrectly on the PCR in relation to the FAST test for a stroke. She mistakenly believed that “U” stood for “unconclusive”, when in fact, it stands for unable to assess. The Panel was given evidence that it is inappropriate to select both “U” and “L” simultaneously and therefore this renders the PCR unclear in this respect. The Panel was satisfied that this particular was proved.

Particular 2(b) - On or about 24 April 2016 [you] attended Patient B and did not provide timely treatment to Patient B -– Found Not Proved

37.  Prior to closing her case, the Presenting Officer informed the Panel that, following the evidence provided during the hearing, the HCPC offered no evidence in relation to this particular and it was therefore not proved.


Particular 2(c) - On or about 24 April 2016 [you] attended Patient B and did not request priority 1 back up – Found Proved

38.  At the commencement of the hearing, the Registrant’s Representative stated that this particular was denied as the Registrant had upgraded the request for back up to Priority 1 during her attendance at the scene. However, in evidence, the Registrant stated that she contacted the control hub to ask where the back up was, and told them not to divert the crew assigned to convey Patient B. She conceded that while she intended this call to inform the hub that the response should now be Priority 1 (i.e. crew only to be diverted from attending Patient B if responding to a cardiac arrest), she did not mention Priority 1 specifically. The Panel noted the extensive nature of the automated incident log, which contained no evidence of her request, and considered it unlikely that a radio contact from the on-scene paramedic would not be recorded. The Panel found, on the basis of the evidence before it, that no such request had in fact been made. Even if the Panel were wrong in that conclusion, the Panel found that the Registrant’s instruction fell short of a clear and unambiguous request for a Priority 1 back up.

39.  The Panel also had regard to the evidence of AJ, who stated that when he arrived on the scene, the Registrant did not appear to appreciate the urgency of the situation – which was consistent with her not requesting Priority 1 back up. The Panel was satisfied that this particular had been proved.


Patient C

40.  Patient C was an elderly female who had been reported as being slumped on a commode, and presented as unresponsive, cyanosed and breathing erratically.


Particular 3 - On or about 28 November 2016 [you] attended an elderly patient, Patient C, who was unresponsive, and you did not provide adequate and / or timely treatment to the patient in that you did not provide the patient with oxygen - Found Proved

41.  It was accepted by the Registrant at the outset and throughout her evidence that she did not provide Patient C with oxygen sufficiently quickly. Witness PB’s evidence was that Patient C was cyanosed and required oxygen. He explained that he left to get a chair from the ambulance, and that the Registrant should have given oxygen to Patient C while he was away. The evidence was that the Registrant only provided oxygen to Patient C once PB returned and when she was prompted to do so. The Registrant did not dispute this evidence. The Panel found that there was a delay in the administration of oxygen to Patient C. The Panel was satisfied that this particular was proved.


Patient D

42.  This patient was a seven year old female who had collapsed at home. She presented as lethargic, pale and unable to walk. She became unresponsive while the Registrant was in attendance. Witness CN was supervising the Registrant for this shift on 14 December 2016 and was later asked by AN to provide feedback on the Registrant’s performance during the shift, which she did verbally in the first instance, then confirmed via an email to AN on 9 January 2017.

43.  The Registrant’s evidence was that she had no memory of seeing Patient D. As a result, the evidence she gave in relation to Patient D was based upon her opinion of the documentation available to the Panel and the evidence provided by CN. Accordingly, where a dispute arose, the evidence of CN was preferred.


Particular 4(a)(i) - On dates between 13 and 17 December 2016, you attended a seven-year-old patient, Patient D, and you did not obtain an adequate history of the patient - Found Proved

44.  Whilst clinically supervising the Registrant during the taking of Patient D’s history, CN believed that an inadequate history of the patient was being taken by the Registrant. The email she sent to AN of 9 January 2017 reflected her concerns. In oral evidence CN informed the Panel that the Registrant’s questions in respect of Patient D were very limited and did not include basic questions. CN said it appeared to her that the Registrant did not know what to ask and that some of the Registrant’s questions were irrelevant. CN stated that she and a colleague asked questions of the patient and the parents to gain a full history as the Registrant had not done so.

45.  The Panel found the testimony and documentary evidence provided by CN to be consistent and persuasive and noted that it was unchallenged by the Registrant. It was satisfied that the particular had been proved on the balance of probabilities.


Particular 4(a)(ii) - On dates between 13 and 17 December 2016 you attended a seven-year-old patient, Patient D, and you had to be prompted regarding the correct pathway to be used - Found Proved

46.   Witness CN’s evidence was that the only appropriate pathway for Patient D was conveyance to Accident and Emergency. She stated that the Registrant was unable to identify the appropriate pathway for the management of Patient D. She stated that the Registrant suggested contacting the Out of Hours service despite Patient D being pale and lethargic with a high temperature, having previously collapsed and been unresponsive, being unable to walk unassisted and collapsing in a short unresponsive episode while the Registrant was at the scene. CN’s evidence, contemporaneously confirmed in her email of 9 January 2017, was that the Registrant needed prompting on the right pathway to take. Patient D was subsequently conveyed to Accident and Emergency and “kept in majors due to her poor appearance and collapse”.

47.   CN also stated that she believed that when the Registrant suggested referring Patient D to the Out of Hours Service, she meant this as a pathway choice (i.e. treatment plan), not just contacting them for information. It was common ground between the parties that pathways exist to assist decision making in relation to patients, and that it would not be inappropriate for a paramedic to consult with another professional, such as a doctor in the Out of Hours Service, prior to determining which pathway to follow. CN confirmed that she classed “pass” and “refer” as ‘calling’ the Out of Hours Service.

48.   The Registrant stated that she may have suggested contacting the Out of Hours Service to obtain more history in relation to Patient D however she could not recall her thought processes. She believed she must have suggested contacting the Out of Hours Service to obtain more information on Patient D’s medical history prior to taking her to hospital rather than as a treatment choice.

49.  The Panel preferred, and accepted, the evidence of CN in relation to Patient D and found this particular proved.


Particular 4(a)(iii) - On dates between 13 and 17 December 2016 you attended a seven-year-old patient, Patient D [and] you did not provide an adequate rationale for referring the patient to the out of hours service rather than conveying Patient D to Accident and Emergency - Found Proved

50.   As set out in respect of particulars 4(a)(i) and 4(a)(ii), the Registrant was unable to recall Patient D and therefore unable to challenge witness CN’s evidence that the Registrant did not provide an adequate rationale for referring the patient to the Out of Hours Service rather than Accident and Emergency. The Registrant said that, with the benefit of hindsight and following reflection on the incident, she believed that suggesting this would have been due to a desire to obtain further medical history information. The Panel preferred the evidence of CN in this regard and accordingly found this particular proved.


Patient E

51.  Patient E was an elderly female who lived alone with a care package in place. The ambulance service had been contacted as a consequence of a deterioration in her health and Patient E was attended by the Registrant, who was again supervised by witness CN. CN expressed her concerns about the Registrant’s treatment of Patient E to AN orally on his request, confirmed within the same email of 9 January 2017 referred to in respect of Patient D. 


Particular 4(b)(i) - On dates between 13 and 17 December 2016 you attended an elderly patient, Patient E, with sepsis markers and did not demonstrate adequate knowledge of sepsis markers - Found Proved

52.  Witness CN addressed this particular in her statement and in her oral evidence. The basis for CN’s belief that the Registrant did not have adequate knowledge of sepsis markers appeared to be that the Registrant did not communicate what she was thinking to CN as the “job” progressed and did not respond when CN asked her what she was thinking. It was CN that raised the prospect of sepsis and facilitated a discussion between herself, the Registrant and the student CN was mentoring. It was CN’s view that the Registrant always agreed with her during any discussion of patient related issues and contributed little in the way of clinical input.

53.   CN confirmed that she did not specifically feed back to the Registrant in relation to her knowledge of sepsis markers as at the end of the shift there was an issue with Patient E’s cannula being misplaced. The only discussion in respect of sepsis had therefore been whilst attending the patient and the only contemporaneous document in relation to this discussion was the email of 9 January 2017, sent by CN to AN some weeks later. CN confirmed that the electronic PCR calculated a NEWS (National Early Warning System) score and, where the same resulted in a score above 3, prompted the person completing the EPCR (i.e. the Registrant) to ‘consider sepsis’. CN believed that the Registrant ‘seemed unsure of the sepsis markers and procedure’.

54.   The Registrant denied having an inadequate knowledge of sepsis markers, but could not offer an explanation why another supervisor (AO) identified a similar concern that she ‘lacked awareness to sepsis markers’ during the period 5 January 2017 to 13 January 2017. The Panel noted that AO had not provided a statement or given evidence under oath and therefore attached less weight to that comment but found it consistent with CN’s evidence.

55.  On the balance of probabilities, the Panel was satisfied that, despite the EPCR producing a NEWS score and prompting consideration of sepsis, the Registrant did not demonstrate an adequate understanding of sepsis markers. Accordingly, this particular was proved.


Particular 4(b)(ii) -  On dates between 13 and 17 December 2016 you attended an elderly patient, Patient E, with sepsis markers and did not demonstrate adequate knowledge of the procedure to be followed in relation to a patient with sepsis markers – Found Proved

56.   On occasions where sepsis had been identified as a potential issue, such as with Patient E, it was the opinion of CN that the Registrant did not have an adequate knowledge of the procedure to be followed, as set out in the Trust clinical guideline ‘Sepsis including Meningococcal Septicaemia’. The Panel preferred CN’s assessment of the Registrant’s understanding in this respect to that of the Registrant, given that CN had found it necessary to include this as a concern in her email to AN. Further, the Panel noted that she was not the only supervisor to raise concerns in relation to the Registrant’s knowledge and handling of patients potentially being at risk of sepsis. The Panel found that the Registrant did not demonstrate adequate knowledge of the relevant procedure to be followed. This particular was therefore found proved. 


Particular 4(b)(iii) - On dates between 13 and 17 December 2016 you attended
an elderly patient, Patient E, with sepsis markers and failed to notice Sodium
Chloride had run into Patient E's arm tissue rather than through the vein - Found Proved

57.   This particular had been amended by the Presenting Officer at the commencement of the hearing, and the Registrant’s Representative had indicated that the particular, as amended, was accepted by the Registrant.

58. The Panel was satisfied that the cannula had been misplaced and that the Registrant had not noticed this until such time as a substantial volume of liquid had entered the arm tissue. The Registrant gave evidence that the cannula had been in situ when she connected the last sodium chloride infusion at 01.51 but accepted that she should have spotted the subsequent misplacement prior to arrival at the hospital at 02.15. The particular was therefore found proved.


Statutory Grounds
59.  The Presenting Officer invited the Panel to consider whether the statutory ground of misconduct and / or lack of competence applied in the light of the facts found proven. She stated that for the ground of lack of competence to be made out, the Panel would need to be satisfied that they had been provided with a fair sample of the Registrant’s work and that it demonstrated an unacceptably low standard of performance for the post that the Registrant was undertaking. The Panel was reminded that the Registrant had been subject to ROP for one year and despite robust support and supervision, the employing Trust continued to have concerns about her ability to practise autonomously in respect of the management of time-critical patients.

60.  It was the HCPC’s submission that there was considerable support for the statutory ground of lack of competence given that the sample provided to the Panel covered five patients, with time-critical conditions, over a prolonged period of time. The Presenting Officer also reminded the Panel that a sufficiently serious isolated incident can amount to lack of competence. She asserted that in respect of Patient A, the Registrant had made a number of basic errors and accepted that she had contravened Trust policy in respect of the number of observations to be undertaken. The Registrant had accepted that, on reflection, it was obvious that Patient B was having a stroke but could not help the Panel as to why she had not identified this at the time. In respect of Patient C, it was clear that she was hypoxic and that the Registrant did not provide timely treatment, whilst with Patient D – a visibly unwell child – the Panel had identified that the Registrant’s history taking was inadequate and that she needed to be prompted as to the correct pathway. For Patient E, the Registrant had failed to identify sepsis markers, and failed to identify a misplaced cannula.

61.  The Presenting Officer submitted that the Registrant had made fundamental errors on more than one occasion and had breached a number of the HCPC Standards of Proficiency for Paramedics (2014) as well as a number of the HCPC Standards of Conduct, Performance and Ethics applicable at the relevant time.

62.  The Registrant’s Representative submitted that the case law suggested that moral blameworthiness or recklessness was required to find misconduct, and that was not present in this case, even though there may be serious issues to consider. Lack of competence must be judged on a fair sample of the Registrant’s work, which he did not consider had been presented to the Panel. He addressed the Panel on the authorities he considered relevant to this matter, highlighting that:
 -  mere negligence does not amount to misconduct but negligence which is serious can be misconduct;
 - a single act is less likely to cross the threshold than multiple acts, but could do so;
  -  professional performance must be unacceptably low and demonstrated by a fair sample of work;
 - a single instance of negligent treatment, unless very serious, would not amount to misconduct;
 -  misconduct is not lack of competence;
 -  dissimilar instances should not be aggregated to make a case of serious deficiency.

63.   There were a number of instances while the Registrant was under a ROP when, for some patients, there were departures from the standards required. The Registrant’s Representative cautioned the Panel against aggregating dissimilar issues to form a fair sample of work. He reminded the Panel that there were positive reviews of the Registrant’s work, including that witness AN had concluded in November 2016 that the ROP could be lifted, although before that happened, there had been a further performance issue which reignited concerns. If the HCPC were correct to say that there was a fair sample of work and not an aggregation of dissimilar issues, it was submitted that the Panel should consider matters in the round.


Decision on Grounds

64.   Having determined the facts and found some particulars proved, the Panel was required to judge whether the facts found proved amounted to a statutory ground as advanced by the HCPC. Whilst this would usually be considered following submissions from representatives on grounds and impairment, in this case the Registrant’s Representative had requested that the Panel determine grounds prior to receiving submissions on impairment. 

65.  The Panel noted that both parties agreed that the two grounds which may relate to this case are those of misconduct or lack of competence, and that it was required to provide a decision in sufficient detail for readers to understand why the facts do or do not amount to the ground(s) alleged. Aside from misconduct and lack of competence, the statutory grounds of impairment set out within the Health and Social Work Professions Order 2001 at article 22(1) had not been alleged by the HCPC (i.e. criminal conviction or caution, physical or mental health, or a finding of impairment by a regulatory body) and had not therefore been considered by the Panel. It determined the issue of grounds only in relation to the particulars that were found proved. No further consideration was given to the particulars that were found not proved. 

66.  The Panel was aware that determining the issue of misconduct and / or lack of competence was a matter for its own judgement. In considering the grounds, the Panel took into account the oral submissions of the Presenting Officer and those of the Registrant’s Representative.

67.  It accepted and applied the Legal Assessor’s advice, noting in particular that the relevant authorities were:

- Roylance v General Medical Council [1999], which advanced the   premise that:

“Misconduct is a word of general effect, involving some act or omission which falls short of what would be proper in the circumstances. The standard of propriety may often be found by reference to the rules and standards ordinarily required to be followed by a .... practitioner in the particular circumstances. The misconduct is qualified in two respects. First it is qualified by the word ‘professional’ which links the misconduct to the profession ....Secondly, the misconduct is qualified by the word ‘serious’. It is not any professional misconduct which will qualify. The professional misconduct must be serious”.

- Holton v General Medical Council [2006] - the High Court held that in assessing lack of competence, the standard to be applied was that applicable to the post to which the registrant had been appointed and the work they were carrying out – i.e. an experienced paramedic.

- Calhaem v General Medical Council [2007] -  in which case law was assessed the Court concluded that five principles were relevant to the issue of conduct:

(1) Mere negligence does not constitute misconduct, however negligent acts or omissions which are particularly serious may amount to misconduct.

(2) A single negligent act or omission is less likely to amount to misconduct than multiple acts or omissions but in some circumstances a single act or omission, if grave, could be misconduct.

(3) Deficient professional performance is different to negligence and misconduct. It connotes a standard of professional performance which is unacceptably low and which, save in exceptional circumstances, has been demonstrated by reference to a fair sample of the doctors work.

(4) A single instance of negligent treatment, unless very serious indeed, would be unlikely to constitute deficient professional performance.

(5) It is neither necessary nor appropriate to extend the interpretation of deficient professional performance in order to encompass matters which constitute misconduct.

This case also explained the respects in which deficient professional performance differed from misconduct.

- Spencer v General Osteopathic Council [2012] – which confirmed that no single instance of negligence or unacceptable care would be sufficient to found a conclusion of professional incompetence. Hence, for both purposes a breach of the code of practice is a starting point and is relevant, but cannot be definitive or indeed even raise a presumption that “professional incompetence” or “unacceptable professional conduct” is made out. It drew attention to the issue of “moral opprobrium” being a factor in finding misconduct. Moral opprobrium in common parlance is defined as “public disgrace or ill fame that follows from conduct considered grossly wrong or vicious” and the Panel therefore had regard to this when determining whether the facts proved amount to misconduct.

- Shaw v General Osteopathic Council [2015] - considered conduct which was finely balanced and confirmed the issue of moral opprobrium being a factor of misconduct.

68.   The Panel also had regard to relevant guidance issued by both the HCPC and the HCPTS. The Panel was aware that lack of competence can be distinguished from misconduct in that it indicates an inability to work at the required level and connotes a standard of professional performance which is unacceptably low, demonstrated by reference to a fair sample of a registrant’s work. The Panel was aware that breach of the professional standards alone does not necessarily constitute misconduct.

69.   The Panel noted that all five of the HCPC witnesses confirmed that there were some aspects of the Registrant’s practice that were acceptable and that some improvements had been noted during the restriction of practice periods. Notwithstanding this, NW, AN, PB and CN, registered paramedics, remained concerned about the Registrant’s basic understanding and ability to apply fundamental principles of practice when faced with a time-critical patient.

70. The Panel was satisfied that it had been presented with a fair sample of the Registrant’s work and therefore felt able to determine the level of competence shown by the Registrant when operating as an experienced paramedic. The sample of work provided to the Panel covered almost one year of the Registrant’s practice and five patients of differing ages who were critically ill and required timely assessment and intervention.

71.   The Panel found the Registrant’s assessment and management in respect of Patients A to E demonstrated an unacceptable level of performance far below the standards of proficiency of registered paramedics. The Registrant repeatedly failed to meet the standards expected of her in relation to the management of the patients she was attending. The actions the Registrant was required to take were fundamental to her area of practice and could not be described as limited in nature or momentary failures. Although the Registrant appeared to have been able to practise autonomously to a certain extent, there were repeated occasions when attending time-critical patients that she did not demonstrate competence in her knowledge, understanding, assessment and management.

72. The Panel considered the HCPC Standards of Proficiency for Paramedics (2014 edition) and considered that the following standards had been breached by the Registrant:

3. Be able to maintain fitness to practise
3.3 understand... the need to keep skills and knowledge up to date...
4. Be able to practise as an autonomous professional, exercising  their own professional judgement
4.1 be able to assess a professional situation, determine the nature and severity of the problem and call upon the required knowledge and experience to deal with the problem
4.2 be able to make reasoned decisions to initiate, continue, modify or cease treatment or the use of techniques or procedures, and record the decisions and reasoning appropriately
4.4 recognise that they are personally responsible for and must be able to justify their decisions
4.8 be able to make a decision about the most appropriate care pathway for a patient and refer patients appropriately
10. Be able to maintain records appropriately
10.1 be able to keep accurate, comprehensive and comprehensible records in accordance with applicable legislation, protocols and guidelines

73.  The Panel was satisfied that the Registrant demonstrated a lack of competence in relation to all of the particulars found proved with the exception of 4(b)(iii).

74. It was the view of the Panel that particular 4(b)(iii) was an oversight on behalf of the Registrant within a particular context and one which, on its own, did not reach the threshold of seriousness such as to amount to misconduct.


Decision on Impairment 
 75.   The Presenting Officer submitted that the Registrant is currently impaired and referred the Panel to the evidence of the Registrant, relevant case law and the test for impairment. The Registrant’s Representative submitted that while the Registrant was of the view that she was not currently impaired, the Panel may want evidence of current reflection, current practice and testimonials. He submitted that the Panel should take account of the fact that she has undertaken voluntary learning relevant to the identified deficiencies in her practice despite the challenges in her personal life. He pointed out the timing of that learning did not impact upon the relevance of the same.

76.  The Panel took account of the documentation provided by the Registrant which included reflective pieces written in 2016 on Patient Care Reports and Time Critical Patients, e-learning certificates and details of her achievements on a life coaching diploma. The Registrant also gave evidence under affirmation in relation to impairment, and answered questions from the Presenting Officer and the Panel. The Panel was therefore able to explore with her:
(a) the degree of insight shown;
(b) the steps she had taken to maintain her competence to practise;
(c) her current work situation;
(d) her current personal circumstances.

The Registrant explained to the Panel that upon leaving the Trust, she took up employment as a Personal Independent Payment Assessor for the Department for Work and Pensions, which engaged her paramedic registration. Subsequently, she worked for a period of time as a Personal Care Assistant and more recently had been working for Royal Mail. She explained that she had been unable to secure further work as a registered paramedic due to the pending regulatory proceedings. She explained the timing and rationale in relation to the training and development she had undertaken, and the benefit she had gained from the life coaching course which she believed had improved her confidence.

77.  The Panel noted the submissions from the Presenting Officer and the  Registrant’s Representative on the issue of impairment and also took  account of the evidence of the Registrant. It also received and relied upon advice from the Legal Assessor.

78. The Panel noted that to assist with determining whether fitness to practise is impaired where there is a finding of lack of competence, the HCPTS has published a practice note for the guidance of panels and to assist those appearing before them. This document confirms that panels are required to consider for each allegation:
 (a)  whether the facts set out in the allegation are proved;
 (b)  whether these facts amount to the statutory ground set out in the      allegation (e.g. lack of competence); and
 (c) in consequence, whether the registrant’s fitness to practise is impaired.

79.  The Panel reminded itself that the test of impairment is expressed in the present tense in relation to the need to protect the public against the acts and omissions of those who are not fit to practise, but this cannot be achieved without taking account of the way a person has acted or failed to act in the past. When assessing the likelihood of recurrence of harm, panels must take account of the degree of harm caused by the Registrant and the Registrant’s culpability for that harm, recognising that the harm could have been greater or less than the harm which was intended or reasonably foreseeable. Panels may also take account of character evidence. 

80.  The Panel found a number of particulars proved which amounted to the statutory ground of lack of competence. It was mindful that a finding of impairment does not automatically follow a finding on that ground. The Panel could properly conclude the act or omission was an isolated error and the chance of repetition in the future is remote. They also noted the guidance in the case of Cohen v General Medical Council [2008] that it must be highly relevant when determining impairment that the conduct leading to the allegation is easily remediable, has been remedied and is highly unlikely to be repeated.

81.  The Registrant provided no testimonials from colleagues in relation to her practice. However, she provided details of two 2-hour e-learning courses which she considered had “refreshed” her knowledge in the areas of weakness identified (i.e. identification of stroke and sepsis).

82. The Registrant did not accept that she jeopardised patient safety in her management of Patients A, B, D and E but acknowledged that all assessments could have been improved. She informed the Panel that the courses had “refreshed” her knowledge and “brought it to the forefront of her mind”.  She informed the Panel that she did not wish to return to the role of a frontline paramedic as a consequence of physical limitations due to an injury, however she believed that without that physical limitation, she was capable of returning to frontline practice.

83.  The Panel considered the Registrant’s current fitness to practise firstly  from the personal perspective and then from the wider public  perspective. It was concerned that the Registrant did not appear to understand the gravity of the findings it had made in relation to her competence. The Panel was sympathetic to her personal circumstances, however the issues which arose in relation to Patient A and B pre-dated the issues which arose as a consequence of those circumstances. The Panel appreciated that the processes consequent to the death of Patient A, including the imposition of a Restriction of Practice, would be stressful for the Registrant and difficult to deal with, but her reaction to that was what was of relevance. At most the Registrant conceded that the stress of being observed all the time might have had an impact on her performance. She told the Panel that she believed her colleagues isolated her once she was on ROP and that she was “targeted” by her employer.

84.  In the Panel’s view, the Registrant demonstrated limited insight into her standard of practice between 2016 and the end of her employment with the Trust in March 2017. She informed the Panel that she had reflected on her practice throughout the ROP process and since, and provided two reflective pieces to the Panel. Those reflective pieces were however produced in 2016 as part of the ROP process. No further reflection had been provided to the Panel in relation to the issues that arose in respect of Patients C to E. On two separate occasions when giving evidence in relation to impairment the Registrant confirmed that she considered her knowledge, at that time, to have been “good”.  

85.  In the Panel’s view, the two e-learning courses the Registrant had undertaken were rudimentary, and generic, and completed in isolation from her peers. The Panel did not consider that this learning addressed the fundamental issues it had identified in relation to her lack of competence. The Panel considered that the areas of practice where a lack of competence had been found were capable, in themselves, of remediation. However, without appropriate insight, the effectiveness of remediation would be limited. It concluded that in the light of Registrant’s lack of insight and remediation, there was a real risk of the shortcomings being repeated and therefore it found the Registrant to be impaired on the personal aspect of the test for impairment.

86.  In considering the public component of impairment, the Panel had regard to the important public policy issues which include the need to maintain  confidence in the profession and declare and uphold proper standards  of conduct and behaviour. It considered that members of the public and members of the profession would be concerned to learn that a paramedic had been found to lack competence in relation to several patients with serious presenting symptoms over a sustained period of time. It determined that public and professional trust and confidence in the profession, professional standards, and the regulator would be undermined if a finding of impairment was not made. The Panel concluded that the Registrant’s fitness to practise is currently impaired on the basis of both the personal and public component.

Sanction

87.  Having delivered the above findings, the Panel invited the parties to address it as to sanction. 

88.   The Presenting Officer referred the Panel to the Indicative Sanctions Policy (ISP) adopted by the HCPC. She reminded the Panel that the purpose of imposing a sanction was not to punish the Registrant but to ensure that the public was protected, promote public confidence in the profession and provide a deterrent to other registrants. The Panel should address the sanctions in ascending order and identify the most appropriate and proportionate means of addressing the concerns identified. She submitted that it would be inappropriate to take no action and that, in applying the ISP, the criteria for a Caution Order were not met in this case. If the Panel was to formulate conditions, it would have to not be so wide as to amount to a suspension by default or reducing the Registrant to the status of a support worker. If realistic and achievable conditions could not be formulated, the Panel would need to consider a Suspension Order to protect the public.

89.   The Registrant’s Representative confirmed to the Panel that he concurred with the Presenting Officer’s assessment of the approach it should adopt when considering what, if any, sanction was appropriate in this case. He noted that, in the light of the Panel’s findings, it may relatively quickly determine that the sanctions of no further action, mediation and a Caution Order may not be appropriate in this case. The ISP provided that a Conditions of Practice Order could be appropriate when the behaviour which was the subject of the allegation was capable of being remedied by the Registrant. He recognised that the Panel had been critical of the Registrant’s lack of insight and submitted that she did demonstrate nascent insight.  

90.   He reminded the Panel that the Trust had been considering lifting the ROP in respect of the Registrant and allowing her to return to autonomous work, demonstrating that the Registrant was capable of correcting her practice prior to events in her personal life affecting her confidence and her performance again. The Registrant was literally and figuratively in a new place now and there was no reason to think that she would not be able to maintain an appropriate level of performance. He stated that she does not deny wrongdoing and the Panel had not found any dishonest or breach of trust. He also submitted that the Registrant could be trusted to make a determined effort to resolve the issues and that suspension in the circumstances of this case would be disproportionate.

91.   The Panel was able to raise questions with the representatives in relation to the issue of sanction and received confirmation from the HCPC that the Registrant had fully complied with the terms of the Interim Conditions of Practice Order imposed in August 2017.

92.  When considering what, if any, sanction was appropriate in this case, the Panel was mindful that each case must be determined on its own merits. The HCPC has adopted a policy in respect of indicative sanctions to aid panels to make fair, consistent and transparent decisions. It was also aware of the need to give clear and cogent reasons for its decision, particularly if departing from the policy. It received and applied advice from the Legal Assessor in relation to the determination on sanction. 

93.    The Panel was conscious that the purpose of fitness to practise proceedings is not to punish but to:

(a)  protect the public;
(b)  maintain public confidence in the regulatory process;
(c)  protect the reputation of the profession concerned;
(d)  act as a deterrent to other registrants.

94.    Article 29 of the Health and Social Work Professions Order 2001 provides that the sanctions available to a panel to protect the public are:

(a) Mediation;
(b) Caution
(c) Conditions of Practice;
(d) Suspension;

Striking off is not however available in this matter as the statutory ground found was lack of competence. It was also open to the Panel to take no further action.

95.  When determining the appropriate level of sanction, panels must be proportionate so that the sanction:

(a) is appropriate in the circumstances;
(b) secures the protection of the public;
(c) takes account of the wider public interest;
(d) is the least restrictive means of securing public protection;
(e) is proportionate and strikes a proper balance between the rights of the Registrant and the protection of the public.

96.    The Panel found that the matter had the following aggravating features:

• at the outset of the proceedings the Registrant denied most of the particulars either entirely or in part;

• the Registrant had limited insight into her failings and the potential consequences of them;
 
• there had been limited training and development undertaken by the Registrant to address the issues identified in respect of her competence;

• there were aspects of the Registrant’s evidence that the Panel did not find credible;

• the Registrant’s failings related to fundamental aspects of paramedic practice - assessment, knowledge, understanding and management - specifically related to time-critical patients.

97.    There were however also mitigating factors in existence in relation to the matter:

• some failings were accepted during the proceedings;

• the Registrant had an unblemished regulatory record prior to and since these events;

• it was accepted that the Registrant had experienced a range of difficult personal circumstances over a significant period of time which included the duration of her ROP and a long period after leaving the Trust;

• the Registrant had engaged fully with her regulator;
• she had complied fully with the Interim Conditions of Practice;

• she had taken steps to improve her understanding of personal issues which had, in her view, impacted upon her practice during the ROP.

98.    It was not appropriate for the Panel to take no action given the finding of a lack of competence. It noted that there was no outstanding dispute as the Registrant had left the employment of the Trust and therefore mediation was also an inappropriate sanction in this matter.

99.   The ISP identifies that a Caution Order may be an appropriate sanction for cases where:

- the lapse is isolated, limited or relatively minor in nature;
- there is a low risk of recurrence;
- meaningful practice restrictions cannot be imposed;
- the conduct is out of character;
- suspension from practice would be disproportionate.

100.   As this case involved serious failings in relation to a number of patients over a period of time, and a risk of repetition has been identified, the Panel concluded that a Caution Order is inappropriate.

101.   The Panel therefore moved on to consider whether a Conditions of Practice Order would be appropriate. The purpose of a Conditions of Practice Order is to restrict a registrant’s practice, require the registrant to take remedial action or impose a combination of both. Imposition of a Conditions of Practice Order means that the Panel is satisfied that the registrant is capable of practising safely and effectively beyond the conditions, the conditions being remedial or rehabilitative in nature. It noted that conditions will rarely be effective unless the Registrant is genuinely committed to resolving the issues to be addressed and can be trusted to make an effort to do so. The Policy points out that conditions of practice are unlikely to be suitable where, as in this case, the Registrant has lacked insight or engagement with the regulator.

102.  Notwithstanding the lack of insight demonstrated by the Registrant, the Panel was satisfied that she had complied with the Interim Conditions of Practice Order and that she had made some effort to access additional training with a view to addressing the deficiencies in her practice. Further, she had demonstrated an ability to improve her practice while on ROP. The Registrant had articulated an interest in returning to practice and demonstrated that she was open to further development. For these reasons, the Panel considered that it was appropriate to give the Registrant the opportunity to remediate her practice.

103.   Given the concerns it identified in relation to the risk of repetition and the potential risk to the public, the Panel considered that the Registrant could not return to unrestricted practice. A Conditions of Practice Order was necessary and proportionate for the protection of the public. Such an order was appropriate to declare and uphold proper standards and maintain confidence in the profession. 

104.   The Panel also considered whether a period of suspension would be appropriate, however it determined that, given the issue related to a lack of competence, a suspension would be disproportionate as realistic and workable conditions could be formulated which would protect the public and enable the Registrant to address her deficiencies while in practice.

105.  Having determined that a Conditions of Practice Order was the appropriate sanction, the Panel considered the period for which it would apply. The Registrant would need sufficient time to secure appropriate employment, develop further insight, and improve her knowledge and understanding so that she could demonstrate that the deficiencies in her practice had been addressed. It therefore concluded that it was appropriate and proportionate for the Registrant to be subject to the order for a period of twelve months.

106.   Striking off was not considered by the Panel given that a Striking-Off  Order may not be made in respect of an allegation relating to lack of  competence or health unless the registrant has been continuously  suspended, or subject to a Conditions of Practice Order, for a period of  two years at the date of the decision to strike off.

107. It may assist a future panel, when this order is reviewed, if the Registrant could provide:

- evidence of training and development she had undertaken relevant to the practice deficiencies identified;
- a reflective piece addressing the development of her insight into both the failings identified by the Panel in her practice and her progress in remediation;
- relevant professional testimonials;
- any other information that the Registrant considers to be relevant.

The Panel recognised that it cannot be prescriptive and its recommendations do not bind or fetter the discretion of a future panel considering this matter.

Order

The Registrar is directed to annotate the Register to show that, for a period of 12 months from the date that this order comes into effect (“the Operative Date”), you, Miss Kathryn Chignell, must comply with the following conditions of practice:

a) You must, when working in an emergency or unscheduled care environment [i.e. ambulances/emergency response vehicles, minor injury units, walk-in centres, urgent care centres etc.] confine yourself to working directly with an appropriate Health Care Professions Council (HCPC), Nursing and Midwifery Council (NMC) or General Medical Council (GMC) registered professional at all times;

b) You must not undertake the autonomous discharge of patients;

c) You must place yourself, and remain under, the supervision of a work place supervisor registered by the HCPC, NMC or GMC;

d) You must provide details of your work place supervisor to HCPC within 14 days of commencing employment. If your work place supervisor changes you must notify HCPC within 14 days of that change.

e) You must attend upon your work place supervisor as required and follow their advice and recommendations.

f) You must work with your supervisor to formulate a Personal Development Plan designed to address the deficiencies in your practice in respect of time-critical patients in the following areas: 

i. Assessment;
ii. Knowledge;
iii. Understanding; and
iv. Management.

g) Within 28 days of the appointment of the work place supervisor, you must forward a copy of the Personal Development Plan to the HCPC.

h) You must meet with your work place supervisor on a fortnightly basis to assess your progress towards the aims set out in your Personal Development Plan.

i) You must allow your workplace supervisor to provide reports to the HCPC that address your progress against the objectives set out in your Personal Development Plan. The first report must be provided within 2 months of the appointment of the workplace supervisor and thereafter every 3 months.

j) You must inform the HCPC in writing within 14 days if you cease to be employed by your current employer or take up any further registered employment;

k) You must inform the HCPC in writing within 14 days of any disciplinary proceedings taken against you by your employer.

l) You must inform the following parties that your registration is subject to these conditions:

i.  Any organisation or person employing or contracting with you to undertake or for whom you voluntarily undertake professional work;
ii.  Any agency you are registered with or apply to be registered with (at the time of the application); and
iii.  Any prospective employer (at the time of your application).

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

n) Any condition requiring you to provide any information to the HCPC is to be met by you sending the information to the offices of the HCPC, marked for the attention of the Director of Fitness to Practise or Head of Case Management.

Notes

This order will be reviewed again before its expiry on 28 February 2020.

Hearing History

History of Hearings for Miss Kathryn Chignell

Date Panel Hearing type Outcomes / Status
28/01/2019 Conduct and Competence Committee Final Hearing Conditions of Practice
10/09/2018 Conduct and Competence Committee Final Hearing Adjourned part heard