Mr Gabor Tekeres

Profession: Paramedic

Registration Number: PA38438

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 21/01/2019 End: 17:00 29/01/2019

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

Panel: Conduct and Competence Committee
Outcome: Struck off

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Allegation

Whilst registered as a Paramedic and employed by North West Ambulance Service, you:

1. Between 26 and 29 September 2015:

a) did not adopt correct manual handling techniques in relation to one or more of the following patients:

i. Patient C

ii. Patient D;

iii. Patient E;

b) took photographs at a road traffic collision on your personal mobile;

c) in incident number 14839537:

i) insisted that an 80 year old patient who had collapsed stand up by getting onto her hands and knees;

ii) failed to conduct appropriate observations;

d) in incident number 1480811, did not pre-alert the hospital for the arrival of a patient who was FAST positive indicating a potential stroke;

2. Drove an ambulance vehicle at high speed and/or overtook vehicles when not on an emergency response and/or without good cause on or around:

a) 3 December 2015;

b) 16 April 2016;

c) 7 June 2016.

3. In or around October 2015, in relation to Patient A, you:

a) shouted at the patient;

4. On or around 8 January 2016, in relation to Patient A, you:

a) cannulated the patient without wearing gloves;

b) put the cannula in your mouth;

5. In or around April 2016:

a) responded to three incidents and transported the patients to a hospital single manned and without requesting back up;

b) in treating a patient who was suffering a cardiac arrest, you:

i. did not put an O.P. airway in place;

ii. began to assist the patient's breathing with a Bag Valve Mask (BVM) but did not turn on the oxygen;

iii. attempted to intubate the patient incorrectly;

iv. attempted to put an IGel in place incorrectly.

6. On or around 31 January 2017, you did not achieve a pass in the following clinical assessments:

a) Advanced Life Support Assessment;

b) Trauma Assessment;

c) Consultation Assessment;

d) Advanced Life Support (Asthma) Assessment

7. The matters set out at particulars 1a), c), d), e), 4 and 5b) amount to misconduct and/or lack of competence.

8. The matters set out at particulars 1b), 2, 3 and 5a) amount to misconduct.

9. The matters set out at particulars 6a) - d) amount to lack of competence.

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

Finding

Preliminary Matters

Proceeding in the Absence of the Registrant

1. At the outset of the proceedings the Registrant was neither present nor represented

2. Ms Sharpe, on behalf of the HCPC, invited the Panel to proceed in the absence of the Registrant.

3. She submitted first that the Panel was entitled to proceed in the absence of the Registrant because there was good evidence that he had been served with notice of the proceedings in accordance with the Health Professions Council (Conduct and Competence) (Procedure) Rules 2003 ("the Rules"). She submitted secondly that the Panel should exercise its discretion to proceed in the absence of the Registrant because all the evidence indicated that he had effectively disengaged from the HCPC proceedings and voluntarily absented himself.

4. Ms Sharpe drew the Panel’s attention to the following email correspondence between the HCPC and the Registrant:

a) an email dated 11 December 2018 from the Registrant to the HCPC, in which the Registrant said that he was “still in Hungary for family reasons …(and) would not be able to return to the UK in the near future”;

b) an email dated 13 December 2018 from the HCPC to the Registrant, reminding him of the date of the hearing and offering him the opportunity to attend by video link or telephone;

c) an email dated 18 January 2019 from the Registrant to the  HCPC enclosing some documents, referred to below and saying, “I would not be able to attend on the final hearing”.

5. Ms Sharpe also drew the Panel’s attention to 2 certificates obtained in Hungary on 15 January 2019, in “Advanced Life Support” and “Advanced Airway Technique, Rapid Sequence Intubation”, sent with the Registrant’s email of 18 January 2018 and to representations he had made in an email dated 12 March 2017 and a letter from the Northwest Ambulance Service dated 28 December 2016.

6. The Panel received the advice of the Legal Assessor, which it followed and incorporated in its determination set out below.

7. Accordingly, the Panel approached the question in two stages. First, it considered whether it was entitled to proceed in the absence of the Registrant. Secondly, it considered whether, in all the circumstances, it should exercise its discretion to do so.

Service of Notice of the proceedings

8. The Panel received evidence in the form of a notice dated 18 September 2018 and a certificate of service, signed by Adam Hern, which showed that notice of the proceedings had been sent by first class post on 18 September 2018 to the address held by the HCPC in the “Paramedic part of the HCPC Register”

9. The Panel had regard to Rule 3 of the Rules, which provides that the sending of a notice under the Rules can be effected by sending it to the Registrant’s address as it appears in the Register. It also had regard to Rule 6, which provides that a Registrant is entitled to 28 days’ notice of the hearing. It also had regard to Rule 11 which provides that "where the health professional is neither present nor represented at a hearing, the committee may nevertheless proceed with the hearing if it is satisfied that all reasonable steps have been taken to serve the notice of the hearing under Rule 6 (1) on the health professional.”

10. Finally, the Panel had regard to the guidance given to Panels by the Court of Appeal in GMC v Adeogba [2016] EWCA Civ 162, that in deciding whether reasonable steps had been taken to serve a Registrant when notice had been posted to his registered address, the Panel should bear in mind that the Registrant was under an obligation to maintain an up-to-date address on the regulator’s register and that the duty of the HCPC “is very simple. It is to communicate with the practitioner at the address he has provided; neither more nor less.”

11. In these circumstances, the Panel was satisfied that the HCPC had taken all reasonable steps to serve notice of the proceedings on the Registrant by posting a notice to the address held by the HCPC on the appropriate register.

Exercising the Panel’s discretion whether to proceed in the absence of the Registrant

12. The Panel then considered whether it should exercise its discretion to proceed in the Registrant’s absence.

13. The Panel had regard to the guidance given in the Practice Note, “Proceeding in the absence of the Registrant" dated 22 March 2017 and to the decision of the House of Lords in R v Jones [2002] UKHL 5 and the further guidance given to Panels by the Court of Appeal in GMC v Adeogba (above).  It bore in mind that the discretion to proceed in the absence of the Registrant should be exercised with great care.

14. It looked at the nature and circumstances of the Registrant’s absence and in particular whether his absence was deliberate and voluntary so that it amounted to a waiver of his right to appear. 

15. The Panel had regard to the correspondence between the Registrant and the HCPC and came to the conclusion that the Registrant knew of the hearing date.  Although, he said in his email of 18 January 2019, "I would not be able to attend on the final hearing” he gave no reason for this, much less a medical or other good reason.  In those circumstances, the Panel was satisfied that the Registrant had voluntarily absented himself from the hearing.

16. It also considered whether an adjournment was likely to result in the Registrant attending at a later date, the likely length of any such adjournment and whether there was any indication that the Registrant wished to be represented. The Panel was satisfied that there is no evidence that an adjournment would secure the Registrant’s attendance or that he would wish to be represented at any hearing. In particular, the Registrant had not responded to the option to attend via phone or video link. The Panel noted that the Registrant had not sought an adjournment in any correspondence or given any indication of when he would attend a hearing.

17. The Panel also noted that the Registrant had not cooperated with listing arrangements and in particular had given no indication that he intended to attend a hearing.  Nor had he supplied the sort of written representations that indicated he wanted to dispute the HCPC case.

18. The Panel considered whether proceeding in the absence of the Registrant would cause prejudice to him. It accepted that a Registrant will inevitably suffer prejudice by not being able to present his/her case, although that will be mitigated to an extent in this case by the material sent in by the Registrant to which Ms Sharpe drew the Panel’s attention.

19. Nevertheless, the Panel balanced prejudice to the Registrant against the public interest in allowing the HCPC to fulfill its duty to protect the public.  The Panel bore in mind the guidance given by the Court of Appeal in Adeogba: “It would run entirely counter to the protection, promotion and maintenance of the health and safety of the public if a practitioner could effectively frustrate the process and challenge a refusal to adjourn when that practitioner had deliberately failed to engage in the process.”

20. When assessing the public interest the Panel had regard to the fact that the HCPC had secured the attendance of 5 witnesses who were either in attendance or were about to attend during the next 4 days. The Panel noted that these witnesses were already required to recall events that occurred, in some cases, over 3 years ago.  Any further delay would inevitably have a detrimental effect upon them and the quality of their evidence. The Allegation raised serious concerns about public safety and there was a strong public interest in dealing with this case without further delay.

21. Having regard to all these matters, the Panel was satisfied that it should exercise its discretion to proceed in the absence of the Registrant. All the evidence pointed to the Registrant having largely disengaged from the regulatory process and voluntarily absented himself, while there was a strong public interest in proceeding with the case so that it will be concluded within a reasonable time.

Application to amend the Allegation

22. After deciding to proceed in the absence of the Registrant, the Panel heard an application by Ms Sharpe, on behalf of the HCPC to amend a number of Particulars of the Allegation in the terms set out in the body of this decision.

23. She submitted that the proposed amendments did not materially alter the Allegation that the Registrant faced and that the amendments were in the interests of justice because they ensured that the amended Particulars better reflected the evidence.

24. She also submitted that the amendments could be made without prejudice to the Registrant, not least because he had been notified of all but one of the proposed amendments by a letter dated 5 July 2018.

25. The only proposed amendment which had not been notified to the Registrant in advance was the proposed amendment to Particular 1(a)(iii) to amend the end date from 29 September 2015 to 11 April 2016 to accord with the evidence of LF1, that the Particular of the Allegation relating to Patient E took place on 11 April 2016.

26. The Panel heard the advice of the Legal Assessor, which it accepted and incorporated into its decision.

27. The Panel applied the test of whether each proposed amendment was in the interests of justice and whether it could be made without prejudice to the Registrant. The Panel decided it could, because the amended Particulars better reflected the evidence and, with the single exception set out above, notice of the HCPC’s intention to apply to amend the Allegation had been served on the Registrant on 5 July 2018 with a copy of the proposed amendments giving him ample time to respond if he had any objection.

28. With regard to the proposed amendment of the stem of Particular 1, the Panel was satisfied that the amendment only affected the date of the case relating to Patient E.  In all other respects the Allegation was the same and the Registrant had received ample notice of the issues that he faced.

29. Accordingly, the Panel allowed the proposed amendments.

Background

30. Mr Gabor Tekeres (“the Registrant”) was employed as a Band 5 Paramedic by the North West Ambulance Service (“NWAS”) between January 2015 and 23rd February 2017.

31. The Registrant was recruited in Hungary, where he had worked as a Paramedic, mainly in a hospital environment.

32. After a period of relocation and two weeks’ induction training, the Registrant started work with the NWAS in June 2015 as a relief (or reserve) Paramedic. This meant that he was expected to work over three ambulance stations namely Distington, Egremont and Flimby, would not have a fixed shift pattern and was expected to accept shifts at short notice to cover rota gaps.

33. Concerns were raised by a number of his colleagues from an early stage, relating to both clinical performance and conduct. The Allegation arises out of those concerns and covers much of the 20 months that the Registrant actively worked for NWAS.

Decision on Facts

34. The Panel read witness statements and heard oral evidence from five witnesses who worked with the Registrant, between June 2015 and January 2017. The Panel also accepted and read the witness statement of LF2, who did not attend to give oral evidence. It also read a significant body of documentation. The Panel will deal with the evidence of each witness and the relevant documentation when it sets out its decision in respect of each Particular of the Allegation.

35. The Panel heard submissions from Ms Sharpe who drew the Panel’s attention to the evidence which she said supported each Particular of the Allegation. She reminded the Panel of the burden and standard of proof. She reminded the Panel of the relevant law and dealt fairly with the way the Panel should approach the various forms of evidence before it.

36. The Panel also heard the advice of the Legal Assessor, which it accepted and followed in this decision.  In particular, it bore in mind that the burden of proving each Particular of the Allegation rests upon the HCPC.  The standard of proof is the balance of probabilities, that is to say that a fact is proved only if it is found to be more likely than not to be true. It also reminded itself that it should draw no adverse inference against the Registrant because he had not attended the hearing.

37. Before turning to the Allegation, the Panel needs to say something about the overall picture during the period covered by the Allegation and the way it approached the documentation.

38. In order to understand the overall situation, the Panel relied upon the evidence of CH1, who worked for NWAS as a Senior Paramedic throughout the time the Registrant worked for NWAS. He was one of two Senior Paramedics managing 60 Paramedics across three ambulance stations.   He wrote a statement dated 15/3/2018, gave oral evidence and produced a number of documents.

39. The Panel found him to be a helpful, balanced and entirely straightforward witness.  He remembered a considerable amount of detail and was always ready to accept there were details he could not recall.  He also made every effort to be fair to the Registrant.  He explained on more than one occasion that he felt the Registrant was not familiar with UK ambulance work and may not, initially at least, have had all the training he needed.  Unless otherwise stated, the Panel accepted his account entirely.

40. He told the Panel that the induction training the Registrant received at the start, was the same as he would have received if he'd simply moved from one ambulance area to another. In his view, this was not enough for somebody moving from another country.

41. He supervised the Registrant on his first two shifts in June 2015 and alerted senior management to concerns that he had, and took on responsibility for much of the additional training and support initially provided. He provided evidence of the wide range of corrective training and support he had given and the Panel noted that this had included elementary aspects of infection prevention control, such as not inserting a cannula without wearing gloves, nor putting the cannula in his mouth. As a result of his position, he became something of a focal point for other ambulance staff raising concerns.  The result was that, although he had relatively little direct contact with the Registrant between August 2015 and November 2016, he was aware of concerns about him and how they were being dealt with.

42. He also received copies of emails from people who worked with the Registrant and raised issues with the management within NWAS.  Many of these were written by people who were not witnesses before the Panel and sometimes described incidents that do not form part of the Allegation. 

43. The Panel came to the conclusion that where the contents of the emails did not relate specifically to any Particular of the Allegation, then even if they related to a similar incident or generic information, they could not be used as evidence to support the evidence of the witnesses.

44. The Panel decided it should also have regard to these various emails in two ways. First, they demonstrated that the witnesses were entitled to pay attention to the Registrant’s performance, because there were widespread concerns. Secondly, they alerted the Panel to the need to be cautious in approaching the evidence of the witnesses in case their views had been coloured by what others had said about the Registrant.

45. Witness CH1 also produced a number of documents showing that there had been meetings between the Registrant and management. He told the Panel that he was able to produce these documents because they had been copied to him when they had been circulated after the meetings.

46. However, CH1 was not present at any of the meetings; only one person who attended the meetings gave evidence or even made a statement; the identity of the people who made the records of the meetings was not clear and, of particular importance, there was no evidence that the Registrant had seen or approved the records of the meetings.

47. The Panel approached the evidence of these meetings with particular caution. The Panel was satisfied it could safely draw two conclusions from the material before it.  First, a number of meetings took place between the Registrant and management of NWAS during 2016. Secondly, the Registrant can have had no doubt throughout 2016 that the management of NWAS had concerns about him, that he probably should have known all the details of the concerns but, if not, he had ample opportunity to find out.

48. Accordingly, before dealing with each Particular of the Allegation, set out below are the dates of the meetings which took place during 2016:

a) A meeting was held on 19th January 2016 to discuss specific concerns with the Registrant;

b) Following the meeting, an Action Plan was developed for the Registrant and put into place on 19th April 2016.  The Action Plan included a requirement for the Registrant to work with Senior Paramedics and to be observed; and have his work and record-keeping audited;

c) A review meeting was held in June 2016 to review the Registrant’s progress under the Action Plan;

d) A meeting took place on 4th July 2016 to discuss further concerns that had been raised about the Registrant. A letter summarising the outcome of this meeting and dated 5 July 2016 was sent to the Registrant;

e) The Registrant attended a further meeting in relation to his progress on 8th July 2016.

f) In October 2016, the Registrant attended an additional clinical induction training program, devised as a four-week induction course for newly-arrived internationally qualified Paramedics. The Registrant completed the course in late 2016;

49. With regard to the meeting on 4 July 2016, the Panel was assisted by the evidence of RS. She is a Paramedic who has been employed by NWAS since 2000. The Panel heard her give evidence and read her signed statement to the HCPC dated 16 February 2018.

50. She was also a straightforward and helpful witness. The Panel was satisfied that she too made every effort to be fair to the Registrant. In her written evidence she confirmed that she had been assigned to support the Registrant and had attended the meeting on 4 July 2016. She described how she had met the Registrant after the meeting and made sure he understood that the matters raised were serious and he had confirmed that he understood this and had no questions. She invited him to contact her if he had any questions.  He did not do so.

51. Because of her role, RS was aware of the level of support offered to the Registrant and told the Panel she had “never seen anyone given that level of support.  It was a large amount of support”.

52. Against this background, the Panel considered each Particular of the Allegation in turn.

1. Between 26 and 29 September 2015 and April 2016:

a) did not adopt correct manual handling techniques in relation to one or more of the following patients:

(i) Patient C – Found Proved

53. The Panel heard the evidence of BT and read her statement dated 15 February 2018, which she adopted as her evidence. It also read an email and attached statement she sent to PH, an Advanced Paramedic, on 7 October 2015 and the NWAS Manual Handling Procedures that she exhibited.

54. BT was a Grade 1 Emergency Medical Technician (EMT) who had worked for NWAS for 23 years in a number of roles and as an EMT since 2010. She was also experienced at driving ambulances in emergency conditions.

55. The Panel found her to be a reliable and balanced witness and accepted the account she gave to the Panel, which was consistent with the account she had given to PH in October 2015. Unless stated otherwise, the Panel accepted her account entirely.

56. She described working two 12 hour shifts with the Registrant on 26 and 29 September 2015. On the first shift, she attended with the Registrant at a care home, to assist Patient C, who was semi-conscious following a seizure.  They needed to move Patient C onto a stretcher to transfer him to hospital.

57. BT described the Registrant moving Patient C by taking hold of his collar and the waistband of his trousers and quickly lifting him onto the stretcher. She described how Patient C’s legs dangled so that she had to take hold of them to protect Patient C.

58. She described how she and three members of the care home witnessed the way the Registrant handled Patient C and were shocked. One of them commented, "that needs sorting out". She told the Panel how she apologised to the staff members.

1(a)(ii) Patient D – Found Proved

59. BT also told the Panel how she had attended a severely disabled patient’s (Patient D) home on either that or the following day in order to transport her to hospital. She recalled that Patient D was lying on her bed in considerable pain and her son and another man were present.

60. When giving evidence to the Panel, BT recalled that she had had a brief discussion with the Registrant about how to move Patient D, in which she suggested that they use the bedsheet to transfer Patient D because the equipment they usually used, known as a ”scoop", was not appropriate, because Patient D was lying on a soft hospital mattress.

61. She told the Panel that she had placed the stretcher next to the bed so that they could both move Patient D. However, before they could do this, the Registrant "grabbed hold of the bed sheet the patient was lying on and, in one abrupt movement, pulled the sheet so the patient was pulled onto the stretcher". She described him as using a "quick whip like motion". He had not even taken the time to check that the stretcher had been secured. Had it not been, Patient D could have fallen to the floor.

62. BT told the Panel that this incorrect technique and sudden, unexpected movement exacerbated the pain that Patient D was already suffering. She described how Patient D "squealed" in pain.

1a)(iii) Patient E – Found Proved

63. The Particular of the Allegation relating to Patient E arose out of the events of 11 April 2016, when the Registrant was working on a shift with LF1, who was an experienced EMT and had worked for NWAS since August 2007. She was also experienced at driving an ambulance in emergency conditions.

64. The Panel heard oral evidence from LF1 and read her written statement to the HCPC dated 4 March 2018. It also read the email she had sent on 18 April 2016, to CH1 and 2 other colleagues in the management team.  The Panel found her to be a reliable and balanced witness. She had a good grasp of the events and was willing to admit when there were details she could not remember.  Her account remained consistent and, unless stated otherwise, the Panel accepted her account entirely.

65. She told the Panel that she had been paired with the Registrant for two shifts, on 11 and 16 April 2016. She told the Panel she had attended with the Registrant, at either Patient E’s home or a residential care facility, to take Patient E to hospital, because she was suffering from a urinary tract infection. She described to the Panel how a urinary tract infection can be particularly serious for an elderly patient and can make them very confused.

66. She explained to the Panel how Paramedics in that situation should use a "manoeuvring belt" to assist the patient from her wheelchair onto the trolley bed in the ambulance. She explained this was a two-person manoeuvre and the belt should be secured around the patient's waist.

67. She described how, instead of doing this, the Registrant physically lifted or pushed the patient out of her wheelchair into the ambulance trolley bed.  She recalled that this had taken place in front of Patient E's son and he had remarked that he was unhappy about how his mother was being treated. The patient herself was visibly upset.

1b) took photographs at a road traffic collision on your personal mobile; – Not Found Proved

68. This Particular arises out of the Registrant’s attendance at a road traffic accident in Micklethwaite on 26 September 2016. The Panel heard the evidence of BT that she and the Registrant were in the last ambulance to arrive at the scene and were assigned to a male patient. She recalled that after a short while the Registrant disappeared and she couldn't confirm where he went.

69. Subsequently, BT was told by other NWAS staff that the Registrant had been taking photographs of the crash scene with his phone. She readily accepted that she had not herself seen him do this.

70. Ms Sharpe submitted that the Panel could find this Particular proved because the Registrant signed the document on 19 April 2016 in a way that indicated he accepted he had taken pictures "at scene of incident". The difficulty is that this document appears to pre-date the incident upon which the HCPC rely so that the Registrant’s signature cannot relate to this incident. Even if BT’s evidence should have referred to September 2015, rather than 2016, as seems likely, there is no evidence that the Registrant took photographs at this particular incident. He does, however, admit in his own representations to taking photographs at a road traffic collision, but asserts that this was “after all patients had been assessed and transferred to hospital”.

71. The Panel is mindful that there are circumstances where it is perfectly proper to rely upon hearsay evidence. However in this case the source of the report to BT about the Registrant taking photographs is completely unidentified and there are no details given. For the reasons set out above, there is no other evidence to support this Particular.  For these reasons, the Panel finds that this evidence is not sufficient to support this Particular of the Allegation.

1c) in incident number 14839537:

i) insisted that an 80 year old patient who had collapsed stand up by getting onto her hands and knees: - Not Found Proved

72. To prove this Particular of the Allegation the HCPC rely upon the evidence of LF2. She did not attend to give evidence. Nevertheless, Ms Sharpe invited the Panel to rely on LF2’s statement to the HCPC dated 19 March 2018 and the email she wrote to PH on 1 October 2015.  The statement shows that LF2 is a Paramedic who was employed by NWAS during 2015 and was experienced at driving under emergency conditions.

73. The Panel was satisfied that it could accept LF2’s statement in evidence but approached the evidence with care because it had no opportunity to assess LF2 as a witness or even clarify matters by asking questions.

74. The Panel accepted the evidence in her statement that she worked a number of shifts with the Registrant including shifts in September 2015.  This Particular of the Allegation arises out of a shift which the Registrant worked with LF2 on 29 September 2015.

75. The Panel accepts that they attended an elderly lady, who had collapsed in a car park.  The Panel read the witness statement of LF2, which told how the Registrant dealt with the elderly patient, without helping her appropriately to get up from the floor and also not letting LF2 assist her.  However, the Panel noted that this Particular alleges not merely that the Registrant failed to assist appropriately an 80-year-old lady who had fallen over in a car park but that he "insisted that she stand up by getting onto her hands and knees".

76. The Panel found that this Allegation is not supported by what LF2 said in her signed statement. In that statement she described turning away from the scene to collect a wheelchair and turning back to see the patient “on her hands and knees trying to get up.” She made no mention of the Registrant “insisting” on this.

77. It noted that the Allegation that the Registrant “insisted” is contained in LF2’s email of 1 October 2015. However, without LF2 attending to give evidence, the Panel cannot ascertain which account is correct and, in those circumstances, does not find that the HCPC has discharged the burden of proving this Particular.

1c)ii) failed to conduct appropriate observations; - Not Found Proved

78. This Particular is also based upon the evidence of LF2, relating to the same patient’s transfer to hospital.

79. In her statement, LF2 said that, "before leaving the scene I assisted (the Registrant) to complete a full set of observations, including an ECG in the ambulance.” Nevertheless, she went on to say that while she was driving the ambulance she could not hear the sounds of monitoring equipment being used and, when she got to the hospital, she saw that the monitoring equipment had been packed away. She saw that one set of results had been recorded and these were "within normal range".  It is not clear from her statement whether these are the results of the observations with which she assisted the Registrant or another set.

80. Without LF2 attending to give evidence, the Panel cannot resolve these questions and, in those circumstances, does not find that the HCPC has discharged the burden of proving this Particular.

1d) in incident number 1480811, did not pre-alert the hospital for the arrival of a patient who was FAST positive indicating a potential stroke; - Found Proved

81. LF2 also gave evidence in her statement, which the Panel accepts, that she and the Registrant attended a 52-year-old male patient, who was suffering a suspected stroke. He was deemed to be FAST (face, arms, speech test) positive. The patient had a seizure prior to the ambulance arriving and again en route to the hospital.

82. LF2 said in her statement that, “Upon arrival at WCH (West Cumberland Hospital), it became apparent that (the Registrant) had not pre-alerted the hospital regarding the incident and our arrival. When I asked (him) why he had not done this, he said that he had not had time between completing paperwork and administering the Diazemuls as the patient had a seizure en-route.”

83. The Panel deals below with the issue of whether it was the Registrant’s responsibility to contact the hospital but, as a matter of fact, the Panel finds he did not do so.

2. Drove an ambulance vehicle at high speed and/or overtook vehicles when not on an emergency response and/or without good cause on or around:

a) 3 December 2015; - Found Proved

84. The Panel accepted the evidence of BT that on 3rd December 2015, the Registrant was driving an ambulance, in which she was a passenger. They were not responding to an incident or driving in emergency conditions. There had been heavy rain and significant flooding in the area where they were driving.

85. BT gave compelling evidence that the Registrant drove too fast, and for no reason, into floodwater at the bottom of a hill.  She recalled that it was dark, there was other traffic on the road, the weather was “foul” and there had been road closures because of the weather conditions.  She asked him to slow down but he did not.

86. She said that she knew that there had previously been concerns about the Registrant’s driving but thought they had been resolved through further training. For this reason she had been prepared to do an ambulance shift with him.  In addition, the opportunity had come up to be on a “seconded line” with the Registrant from January 2017.  This would have been a considerable advantage to BT who would, in this way, have acquired a fixed shift pattern, for which she had waited a number of years.

87. The Panel was struck by BT’s reaction to the Registrant’s driving, in particular that she refused to work with him again and so gave up the chance to have a fixed shift pattern.  In the email she wrote to PH at the time, she said, “I feel that I cannot work with him anymore. As you know I have been waiting for a seconded line for so long but I feel I am not going to put my job or life on the line".  She repeated to the Panel “the way he drives, I thought someone will get killed and I didn't want it to be me".

2b) 16 April 2016; Found Proved

88. This Particular of the Allegation is based upon the evidence of LF1 and LF2.

89. LF1 gave evidence that she was on a shift with the Registrant on 16 April 2016, transporting a patient from West Cumberland Hospital to Cumberland Infirmary Carlisle, together with a nurse, an anaesthetist and a specialised trolley. The patient was transferred in emergency driving conditions.

90. By way of background, LF1 described to the Panel her concerns about the Registrant’s driving in emergency conditions, when transporting the patient. In her view, his driving had been unnecessarily aggressive and prevented the nurse and anaesthetist doing their jobs properly because they were “thrown around” inside the ambulance.

91. Nevertheless, her main concern arose after the patient had been taken to the Cumberland Infirmary. The Registrant told her that he would return to West Cumberland Hospital in "emergency conditions". LF1 told him he should not do so, because there was no emergency. Nevertheless, he drove along the A595 at approximately at 70 miles an hour when the speed limit was 50 miles an hour, and also undertook “risky manoeuvres”.

92. LF1 told the Panel that the road was known to be a dangerous road and she had attended many crashes on that stretch of road. The road had, she said, particularly bad visibility. She told the Panel that she had told the Registrant to slow down but he would not. When she reminded the Registrant that he was breaking rules and should slow down he replied, “don’t worry, no-one will know”.

93. LF1 told the Panel that this reaction was one she had heard from the Registrant before when he had been reminded of the need to observe rules, such as not smoking in the ambulance garage.

94. The Panel found that a particularly striking feature of this incident was that, while the Registrant was driving, LF1 received a text message from an off duty colleague, LF2, who had witnessed this driving from her own private car and wanted to know who was driving the ambulance. She told the Panel she had never received a message like that before.

95. The Panel read LF2’s account of the driving she had witnessed and was satisfied it must have been the Registrant’s driving she saw, because it was the driving about which she sent a text to LF1.  She described the driving as follows: “the ambulance overtook numerous vehicles. We were on a two lane road with one lane of traffic going in the opposite direction. Several times the ambulance pulled into the other line of traffic’s lane in an attempt to overtake but remained in that lane for a significant amount of time.” She described the manoeuvre she had witnessed as "extremely dangerous and inappropriate."

2c) 7 June 2016 – Not Found Proved

96. This Particular of the Allegation is based upon an account given by PH, an Advanced Paramedic, who was sitting in his office close to the ambulance garage when the Registrant drove into the garage in a way that caused him concern.

97. The HCPC had not taken any statement from PH but Ms Sharpe invited the Panel to rely upon the contents of an email that he wrote to colleagues, CH2 and CD, that day. The Panel does not doubt that PH would be an honest witness and it is no criticism of him at all that his email is not written in the detail that a statement would have been written.

98. The Panel read his email with care but cannot form a clear enough picture of what he saw rather than heard and what his vantage point was and how long he observed the Registrant’s driving to be satisfied that the HCPC have discharged the burden of proving this Particular.

3. In or around October 2015, in relation to Patient A, you:

a) shouted at the patient; - Found Proved

99. The Panel heard the evidence of KSP, who was an EMT working for NWAS since December 2003. It also read her signed statement to the HCPC dated 22 February 2018 and an email she had written to colleagues on 16 September 2015.

100. The Panel was satisfied that her evidence was consistent and found her to be a straightforward and accurate witness.  Unless otherwise stated, the Panel accepted her account in full.

101. She told the Panel that in October 2015 she and the Registrant had gone to a care home to transport a resident of the home to the West Cumberland Hospital. The patient was suffering from dementia, which caused him to shout at members of staff who were trying to help him, including her and the Registrant.

102. She was clear that the patient was indeed very challenging and was "yelling a lot and used bad language frequently. Any movement or contact with him caused in yell in such a manner" nevertheless she recognised that the patient was elderly, suffering from dementia and had to be treated with respect.

103. She told the Panel how she and the Registrant took the patient to hospital and then had to move him from the stretcher onto a bed. During this manoeuvre the patient had to lie flat on the stretcher and this caused his shouting to increase. When this happened, she told the Panel, the Registrant “walked towards Patient A’s upper body and put his face very close in front of the patient's face. He yelled at the patient “don’t you shout at me like that". (He) then stood back upright, raised his hands in the air and started yelling in Hungarian. He was walking around the room as he was doing this.”

104. The Panel found that KSP gave a clear and compelling account of incident. The Panel was satisfied that the Registrant’s face was very close to the patient and she had a clear view of the patient's face, from which she could see how distressed he was. She also said that Patient A shouted at the Registrant even more after this interaction.

4. On or around 8 January 2016, in relation to Patient B, you:

a) cannulated the patient without wearing gloves;

b) put the cannula in your mouth;  - Both Found Proved

105. The Panel heard the evidence of RS.  The Panel has already referred to a part of her evidence above. She never worked on a shift with the Registrant but was already present at the scene of an incident at Patient B’s home on 7 January 2016 when the Registrant arrived. She had arrived first in a rapid response vehicle.  The Registrant arrived shortly after her in an ambulance with BT.

106. RS told the Panel that Patient B required pain relief and she watched the Registrant preparing to administer that by means of a cannula.  She saw that, as the Registrant was finding a vein on the patient’s arm, he was not wearing gloves.  She also saw him put the cannula he had opened into his mouth.

107. She told the Panel that she suggested to the Registrant that “he should put the cannula that was in his mouth into the sharps box and use a new one. The sharps box is where we dispose of failed cannulas or ones we do not end up using after being opened. He ignored my suggestion so I asked him a second time.”

108. RS told the Panel that the Registrant ignored her suggestion twice and replied, “"what can I do, I don’t have three arms”.  However, when she insisted, he did as she suggested and carried out the procedure properly, managing to handle all parts of the cannula appropriately, without putting anything in his mouth.

109. She told the Panel that, “Under no circumstances would it be appropriate to put the cannula in the mouth at any time. Cannulas are sterile pieces of equipment and it is important to ensure they are kept sterile for infection prevention purposes.”

5. In or around April 2016:

a) responded to three incidents and transported the patients to a hospital single manned and without requesting back up; - Found Proved

110. The Panel saw three Patient Report Forms (PRFs), which showed that the Registrant had transported three patients to hospital on 17 April 2016 whilst alone in the ambulance, that is to say with no crewmember to assist or to drive.

111. The Panel heard the evidence of CH1 who explained how he had discovered this and what the forms demonstrated. He also told the Panel how unacceptable, indeed dangerous, this was because the driver of an ambulance cannot see, much less attend to, a patient in the back in case their condition should deteriorate. He told the Panel that the driver is in a particularly disadvantageous position to see if a patient requires help because there is a bulkhead in the way and anyway a patient seated in the back of an ambulance will sit facing the rear. In addition, CH1 told the Panel that patients should not be left unsupervised in an ambulance, given the access to medical equipment and drugs.

112. The Panel also saw an email from the Registrant, dated 12 July 2017, in which he responded to this Particular of the Allegation in the following terms: "all the patients were safe, did not need medical supervision during the transport to the hospital, control was happy to transfer these patients. I was checking the patients through the mirror and also I was talking to them. I explained the patients the transfers, they were happy to travel in this way. My suggestion was to save time for my patients and save money to the Trust as there was no need to another Ambulance." The Panel could not accept this explanation given the credible evidence of CH and the risks involved in leaving a patient alone while transporting them to a hospital.

5b) in treating a patient who was suffering a cardiac arrest, you:

(i) did not put an O.P. airway in place; - Found Not Proved

113. The Panel heard the evidence of LF1, who told the Panel that she had attended an incident with the Registrant on 16 April 2016, where a relatively young man had suffered a cardiac arrest at a school where his wife worked.

114. When LF1 arrived with the Registrant there were two colleagues already on the scene, Paramedic PC and EMT VA, but they had arrived only a few seconds before. She told the Panel that each staff member present took responsibility for specific clinical roles. LF1 described this way of working as the “pit stop” approach. The Registrant became responsible for the patient's airway and breathing. LF1 said that she could not recall whether the Registrant used it or not, but it was not certain that an OP airway needed to be inserted, in the circumstances.

115. The Panel considered carefully the evidence relating to the use of an O.P airway and found that there is not enough evidence about the use of that device to prove that Particular.

5b)(ii) began to assist the patient's breathing with a Bag Valve Mask (BVM) but did not turn on the oxygen; - Found Proved

116. LF1 gave compelling evidence about the Registrant’s attempt to use a Bag Valve Mask to assist the patient's breathing. She recalled that her colleague, VA, noticed that the reservoir bag was not inflated, which indicated that the oxygen had not been turned on. She heard her ask the Registrant on several occasions to turn the oxygen on. However, he did not listen to her and she saw VA lean over and turn the oxygen on herself while still attempting to conduct CPR on the patient. The Panel noted that LF1’s evidence was supported by email accounts written separately to management by PC and VA on 17 April 2016 and 23 April 2016 respectively.

5b(iii) attempted to intubate the patient incorrectly; - Found Proved

117. The evidence of LF1 was that intubation was attempted after the insertion of an I-gel, which is a specially curved tube used to secure an airway for the patient. Nevertheless, the Panel will deal with this Particular in the order it is set out in the Allegation.

118. The Panel heard and accepted LF1’s evidence that the Registrant attempted to intubate the patient more than once and that he did it so clumsily that he appeared to injure the patient's throat so that blood came out of his mouth. Another member of staff stopped him from continuing.  LF1 could not recall who did that and the Panel was reassured that she did not try to guess.

119. The Panel accepted that, in any event, intubation was not required because the I-gel was effective and being tolerated by the patient. The patient reacted to intubation with a “gagging reflex”, which is itself good evidence that intubation is not required.

5b(iv) attempted to put an I-gel in place incorrectly. – Found Proved

120. LF1 gave clear evidence that the Registrant tried to Place an I-gel in the patient's airway, through his mouth, to assist his breathing. She saw that he was placing the I-gel the wrong way round so that it would not fit down the patient's throat. The Panel noted that it was a striking feature of her evidence then she recalled that both she and her colleague, VA, told the Registrant on a number of occasions that he was doing it the wrong way but he ignored them and continued until she took the I-gel from him and inserted it herself. The fact that LF1 and others tried to correct the Registrant is supported by the emails written by VA and PC.

121. The Panel also read the Registrant’s response in his email dated 12 July 2017, in which he said that “the patient was treated by bystanders and the response time was over 20 minutes”. He then said that, “assessing the patient I realised that the CPR was not effective (no vital signs, dilated pupils, no reaction to light, asystole on ECG, no breading (sic) cold pale skin) but decided to perform CPR. In this case, it was not relevant to connect the BWM (sic) to the O2 because the patient was dead.”

122. The Panel accepted the evidence of LF1 that the patient was resuscitated, albeit that he may have died later. She gave clear evidence that resuscitation was not hopeless in this case because the patient appeared to be young and had received bystander CPR, and was also connected to an AED (Automated External Defibrillator).

123. Given that the patient was, in fact, effectively resuscitated, it is extremely concerning that the Registrant himself has made submissions indicating that he failed to recognize a viable resuscitation attempt. This suggests an inability to apply in a practical situation the clinical knowledge and practical skills that he was understood to have. This is consistent with the oral evidence of CH1 that, despite his strong academic credentials and ability to perform appropriately under direct supervision, the Registrant consistently appeared unable to apply his clinical assessment skills particularly in more complex and/or pressured circumstances. CH1 also told the Panel that, even as late as January 2016 when crewed with the Registrant, he found that the Registrant had failed to recognise that a patient required urgent airway management and had taken no steps to commence this, despite being able to explain the theory in a training environment.

6. On or around 31 January 2017, you did not achieve a pass in the following clinical assessments:

a) Advanced Life Support Assessment;

b) Trauma Assessment;

c) Consultation Assessment;

d) Advanced Life Support (Asthma) Assessment; - All Found Proved

124. Having considered all the documentation before it the Panel was satisfied that the Registrant attended a formal assessment of his core skills on 31 January 2017. He acknowledges this in the email to the Panel to which the Panel has referred above. The assessments fell into four areas:

i. Skills related to Advanced Life Support;

ii. Skills dealing with trauma;

iii. Skills relating to consultation and history taking;

iv. Skills relating to management of asthma issues.

125. The Panel saw a report of the assessments which show that they were carried out by MH, a Consultant Paramedic, and DW, a Clinical Practice Trainer at Energis Distinction.  It also saw two assessment sheets in respect of each test, signed by each of the examiners. Their marks are not precisely the same in each case but they are very similar and all show that the Registrant failed in significant areas that he was required to pass.

126. The report, to which the Panel referred above, sets out that the Registrant was given three weeks’ notice of the assessment including its format. It explains that the assessment took the form of four scenarios utilising either a mannequin or an actor as appropriate. It reports that in respect of each test the Registrant "did not demonstrate the essential elements of this scenario” and, in respect of the third scenario "did not demonstrate safe practice".

127. The examiners’ conclusion was that the Registrant "did not pass this clinical assessment. He showed dangerous practice at several points. This must be taken in the context of a clinician who has undergone a long process of mentoring and was aware of the assessment for at least three weeks.”

128. The examiners assessed the risk he presented as follows: "the risk is that if (the Registrant) continues to practice as a Paramedic on behalf of the NWAS… that the practice observed during these scenarios is translated into real scenarios, resulting in the death or serious harm to a patient."

Decision on Grounds

129. The Panel next considered whether the facts, found proved in Particulars 1-6, amounted to lack of competence and / or misconduct.

130. The Panel heard the submissions of Ms Sharpe regarding the test to be applied in each case.

131. The Panel also accepted the advice of the Legal Assessor. It bore in mind that there is no burden of proof at this stage and it is a matter for the Panel’s professional judgment in reaching its decision on this question.

132. The Panel considered each Particular in turn.

133. The Panel had regard to the following provisions of the Standards of Conduct, Performance and Ethics:

a. 2012 Standards: 1, 3, 5, 6, 7 and 11

b. 2016 Standards: 1, 2, 3, 6, 8 and 9

c. and also the Paramedic Standards of Proficiency: 14

134. The Panel reminded itself that not every failure by a Registrant will amount to either misconduct or lack of competence.

135. With regard to misconduct it applied the test set down by Lord Clyde in Roylance v GMC (No 2) :

“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.”

136. With regard to lack of competence the Panel asked itself whether the Registrant’s competence was what should be expected of a competent band 5 Paramedic, and whether it constituted a fair sample of his work.

137. Particular 1a relates to the handling of 3 particularly vulnerable patients, in a way that put them at risk and did not respect their dignity. The Registrant had passed his manual handling training and had received further training and yet wilfully and recklessly disregarded proper procedure. The Registrant also failed to recognise the nature of patients’ conditions, and compounded this lack of awareness with an insensitive and uncaring approach. The Panel found that his conduct not only caused pain to patients, but also caused distress to family members and other staff. His behaviour was likely to undermine public confidence in the ambulance service in general and in Paramedics in particular. The Panel has concluded that his behaviour amounts to serious misconduct.

138. Particular 1d – the Registrant not notifying the hospital of the arrival of the Patient.  Having reviewed the evidence with care, the Panel is not persuaded that it was the Registrant in particular who was under a duty to notify the hospital, rather than the Paramedic with whom he was crewed. The evidence appears to the Panel to demonstrate a responsibility shared between the two Paramedics. What occurred may have been no more than an excusable breakdown of communication in difficult circumstances.

139. Particular 2 a and b involve two examples of driving that the Panel found put colleagues, patients and the public at unjustifiable and unnecessary risk. They also had the potential to lower the reputation of the ambulance service in general and Paramedics in particular in the eyes of members of the public.  These driving issues were not only serious, they were also prolonged in duration and cannot be regarded as isolated instances when they endured for some time and ranged from December 2015 to April 2016. The concerns were raised by highly experienced emergency response drivers, both of whom refused to work with the Registrant subsequently, one of them at considerable cost to her own employment status. Accordingly the Panel finds that Particular 2 amounts to serious misconduct.

140. Particular 3 reflects the incident when the Registrant shouted at a vulnerable patient, causing him visible distress. The Registrant seemed not to recognise or understand the nature of the patient’s dementia, and responded in an entirely inappropriate and aggressive manner that can only have added to the distress and disorientation already experienced by the patient. The Registrant’s EMT colleague and a hospital nurse were appalled by his behaviour. The Panel found that this amounts to serious misconduct.

141. Particular 4 arose from the Registrant’s cannulation of a patient, in a way that breached infection prevention control policy, a fundamental tenet of Paramedic practice, by not wearing gloves and by putting a cannula in his mouth. He ignored two requests to dispose of the soiled cannula, finally performing the task appropriately only when specifically instructed to do so. He then demonstrated that he was capable of performing the task without difficulty, without using his mouth. By its very nature, his disregard for safe procedure had the potential to put a patient at risk.  The Panel heard evidence that CH1 had already observed the Registrant make these basic errors and had warned the Registrant about this risk.  In any event, as RS testified, the Registrant demonstrated that he could carry out the procedure safely when he chose to do so. His behaviour therefore amounts to serious misconduct.

142. Particular 5(a) reflected the 3 occasions when the Registrant transported patients in an ambulance without a clinician in the back to supervise them.  The Panel found that this put patients at risk and was in breach of clear rules that were known to all, including the Registrant who acknowledged what he had done and yet had repeatedly sought to justify it, including in his most recent representations to the HCPC. The Panel found his actions amount to serious misconduct.

143. Particular 5(b) arises from the Registrant’s treatment of a man who had suffered a cardiac arrest.  The Panel found there were two aspects to his conduct which are significant. 

144. First, the Registrant persisted in his errors despite his colleagues pointing out to him he was making then. The Panel has inferred that this derived from a stubborn refusal to listen to colleagues, which put a critically ill patient at risk. The Panel came to this conclusion because it accepted the evidence that the Registrant must have heard what his colleagues were saying to him.

145. Secondly, the Panel found that his failure to insert the I-gel and his failure to either assess when intubation was required or carry out the procedure without causing injury, are evidence of significant lack of competence in an important area of work. By persisting in his failed intubation attempts, the Registrant probably caused the airway injury subsequently identified by an anesthetist. For those two reasons, the Registrant’s behaviour amounts to serious misconduct.

146. Particular 6 (a-d) arise from the Registrant’s failure in the assessment tests.  The Panel accepts that they were all carried out on a single day.  Nevertheless, the Registrant was notified in advance of the assessments, and the format.  The assessments covered a range of core skills.  His marks were very low across all 4 tests according to both assessors. As his assessors noted, the risk he presented if he continued to practise could result in “the death or serious harm to a patient”. The Registrant had already had what one witness described as an unprecedented amount of support and training.  Some of the failures in the assessment are in the area of life support and asthma issues, which are similar to the failings the Registrant demonstrated at 5(b) above.  Accordingly, the Panel finds that these assessments demonstrate a lack of competence on the part of the Registrant. Coming at the end of his 20 months of observed practice working for NWAS, and coupled with the supporting evidence of some of the other Particulars, these detailed assessments can be regarded as a fair sample of the Registrant’s work,

Decision on Impairment

147. The Panel then considered whether the Registrant’s fitness to practise is currently impaired by reason of his lack of competence and/or misconduct.

148. The Panel was aware that impairment is a question for its own judgement. It heard the submissions of Ms Sharpe and the advice of the legal assessor, which it accepted and incorporated into this determination. 

149. In reaching its decision, the Panel considered both the personal and public components of fitness to practise, which includes the need to protect service users, maintain confidence in the profession and the regulatory process, and uphold proper standards of conduct and behaviour for the profession.

150. In so doing it followed the Directions given to Panels by Silber J in Cohen v GMC [2008] EWHC 581 Admin;

Para 63. I must stress that the fact that the stage 2 is separate from stage 1 shows that it was not intended that every case of misconduct found at stage 1 must automatically mean that the practitioner's fitness to practise is impaired.

Para 64.  There must always be situations in which a Panel can properly conclude that the act of misconduct was an isolated error on the part of a medical practitioner and that the chance of it being repeated in the future is so remote that his or her fitness to practice has not been impaired. Indeed the Rules have been drafted on the basis that the once the Panel has found misconduct, it has to consider as a separate and discreet exercise whether the practitioner's fitness to practice has been impaired.

Para 62 Any approach to the issue of whether a doctor's fitness to practice should be regarded as "impaired" must take account of  "the need to protect the individual patient, and the collective need to maintain confidence profession as well as declaring and upholding proper standards of conduct and behaviour of the public in their doctors and that public interest includes amongst other things the protection of patients, maintenance of public confidence in the profession".

151. When considering the question of whether the Registrant’s fitness to practise is impaired, the Panel considered the questions posed by Dame Janet Smith in her Fifth Shipman Report and adopted by the High Court in a number of cases, including Cheatle v GMC [2009] EWHC 645 Admin and NMC v CHRE v NMC and P Grant [2011] EWHC 927 (Admin)

• Does the Registrant present a risk to patients/service users?

• Has the Registrant brought the profession into disrepute or is liable to do so in the future?

• Has the Registrant breached one of the fundamental tenets of the profession?

• Is it the case that the Registrant’s integrity cannot be relied upon?

152. The Panel found that the Registrant’s misconduct extended over many months, despite warnings, unprecedented support and an extraordinary amount of additional training.

153. The Panel found that his misconduct put patients and (in the case of his driving) other members of the public and colleagues at risk, and caused actual harm to some patients.

154. The Panel also found that the findings of lack of competence relate to basic core areas of practice without which he cannot practise safely, so that patients would be put at risk if he were to be allowed to practise without restriction.

155. The Panel found that by repeatedly showing a disregard for the safety of patients, colleagues and the wider public over a considerable period of time, the Registrant had brought the profession into disrepute and broken fundamental tenets of the profession.

156. Looking first at the personal aspect of impairment, the Panel considered whether the Registrant has demonstrated any insight into this conduct or provided evidence of remediation.

157. The Panel found that the Registrant’s failures and misconduct were themselves capable, in principle, of remediation but was concerned that, in practice, the Registrant himself had not been able to demonstrate any insight nor to remediate despite a great deal of support, described by both CH1 and RS.

158. Across all areas of his practice and conduct covered by the Panel’s findings, there is ample evidence that the Registrant was repeatedly advised, warned and retrained and yet repeatedly dismissed legitimate concerns by saying “it’s ok, no one will know.” The representations sent to the HCPC by the Registrant seek to explain and justify his behaviour. He shows no insight into his behaviour, his impact on patients and colleagues, nor any awareness of the risks that his conduct poses to the public. He appears to be in complete denial.

159. There is nothing before the Panel to reassure it that the Registrant has developed any insight into his practice.  On the contrary, his email representations, to which the Panel referred above, describes the NWAS clinical assessments as “subjective” and, by seeking to justify at least some of his misconduct, demonstrates he either has little willingness or little understanding of the need to observe rules designed to protect service users and patients. The ‘rules’ that the Registrant disregards include manual handling, infection prevention and control, clinical competence and safe driving. These are all designed to protect patients, colleagues, the wider public and practitioners themselves

160. The Registrant did not attend the hearing but did place some material before the Panel.  In particular he placed 2 certificates before the Panel showing that on 15 January 2019, he had obtained qualifications in Hungary relating to Advanced Life Support and Advanced Airway Technique, Rapid Sequence Intubation.

161. Although attempts at remediation are welcome, the Panel has no knowledge of the content or assessment standards of these qualifications.  Nor does it have any assurance that they address the Registrant’s apparent inability to put learning into practise in emergency situations. It is hard to see how any training could affect his attitude to safety rules or his apparent lack of respect for vulnerable patients.

162. In those circumstances, the Panel found it could not have any confidence that there was not a risk of repetition. In the event of such repetition the Panel found there was an unacceptable level of risk to future service users, colleagues and the wider public.

163. The Panel then looked at the critically important objectives of the regulator to protect the public by pursuing the following objectives:

i. to protect, promote and maintain the health, safety and wellbeing of the public

ii. to maintain public confidence in the profession

iii. to promote and maintain proper professional standards and conduct for members of that profession

164. There can be no doubt that public confidence in the profession would be undermined if the Registrant’s behaviour did not result in a finding of impairment. That is particularly clear where there remains a risk of repetition. Nevertheless, the Panel is also satisfied that a finding of impairment would be required, in any event to maintain public confidence by demonstrating that misconduct such as this is not acceptable to the profession.

165. The Panel is also satisfied that a finding of impairment is necessary to uphold proper professional standards and conduct and send a clear message that this conduct is not acceptable.

166. For those reasons, the Panel considered that the Registrant’s fitness to practise is currently impaired on both the personal and public components.  That is to say because of the need to protect the public, maintain public confidence in the profession maintain proper professional standards and conduct for members of that profession.

Decision on Sanction 

167. Having found the Registrant’s fitness to practise impaired, for the reasons set out above, the Panel considered, what, if any sanction it should impose on the Registrant.

168. The Panel has heard submissions from Ms Sharpe on the issue of sanction. The Panel has also accepted the advice of the Legal Assessor and had regard to the HCPC’s Indicative Sanctions Policy (ISP).

169. The Panel is aware that the purpose of sanction is not to be punitive but to protect the public and the wider public interest, which includes the deterrent effect on other registrants, the reputation of the profession and public confidence in the profession and the regulatory process.

170. The Panel also bore in mind the principle of proportionality and balanced the Panel’s duty to protect the public against the rights of the Registrant.

171. The Panel had regard to the following mitigating factors:

a) There are no other regulatory matters recorded against the Registrant

172. The Panel also considered the following  aggravating factors:

a) The Registrant’s lack of competence was in areas which were vital to patient safety;

b) His lack of competence and misconduct continued despite unprecedented levels of support;

c) His misconduct persisted over a considerable period of time;

d) He ignored advice and warnings;

e) He caused harm to patients and put others at unnecessary risk;

f) He was uncaring and insensitive to vulnerable patients

g) He demonstrated a persistent resistance to observing proper standards when he thought he could escape notice;

h) The Registrant has demonstrated no insight.

173. The Panel considered the sanctions available to it in ascending order of severity. The Panel considered that to take no action or to impose mediation or a caution would not be appropriate given the serious nature of the misconduct found. Such a course would not protect future service users. Nor are they sufficiently restrictive to protect the wider public interest.

174. The Panel also considered that a Conditions of Practice Order would not be appropriate given the nature of the Registrant’s conduct, the extent to which he had already had the benefit of extensive supervision, support and retraining while working at NWAS and his relative lack of engagement with the HCPC.

175. In coming to this conclusion the Panel had particular regard to paragraph 35 of the ISP which provides:

Conditions will rarely be effective unless the registrant is genuinely committed to resolving the issues they seek to address and can be trusted to make a determined effort to do so. Therefore, conditions of practice are unlikely to be suitable in cases:

• where the registrant has failed to engage with the fitness to practise process, lacks insight or denies any wrongdoing;

• where there are serious or persistent overall failings; or

• which involve dishonesty, breach of trust or the abuse of service users.”

176. The Panel next considered a Suspension Order. The Panel considered paragraph 39 of the ISP which provides that a “…suspension order is appropriate where the Panel considers that a caution order or conditions of practice order would provide insufficient public protection and where the allegation is of a serious nature but there is a realistic prospect that repetition will not occur and thus, striking off is not merited.”

177. The Panel found that the Registrant has neither developed insight nor engaged in significant remediation. The Panel acknowledges that the Registrant has obtained certificates in 2 important areas of practice.  However, the Panel has no information about the courses from which they derive. 

178. Further, and of at least equal importance, the Panel found that the Registrant has failed over a considerable period to put into practice the skills he has learned and the guidance he has been given.  The Panel found that his reaction to the warnings of colleagues demonstrated he has no insight or willingness to remediate his behaviour.

179. The Panel had careful regard to paragraph 41 of ISP, which provides that “If the evidence suggests that the registrant will be unable to resolve or remedy his or her failings then striking off may be the more appropriate option.” In the light of the findings the Panel has already made regarding the Registrant’s inability or unwillingness to respond to the help and support he has already had, the Panel concluded that this situation applied to the Registrant and, accordingly, the Panel next considered a Striking Off Order. 

180. The Panel had particular regard to paragraphs 47 – 49 of the ISP which provide:

“47. Striking off is a sanction of last resort for serious, deliberate or reckless acts involving abuse of trust such as sexual abuse, dishonesty or persistent failure.

48. Striking off should be used where there is no other way to protect the public, for example, where there is a lack of insight, continuing problems or denial. A registrant’s inability or unwillingness to resolve matters will suggest that a lower sanction may not be appropriate.

49. Striking off may also be appropriate where the nature and gravity of the allegation are such that any lesser sanction would lack deterrent effect or undermine confidence in the profession concerned or the regulatory process. Where striking off is used to address these wider public protection issues, Panels should provide clear reasons for doing so. Those reasons must explain why striking off is appropriate and not merely repeat that it is being done to deter others or maintain public confidence.”

181. The Panel has already found that the Registrant’s misconduct was deliberate, reckless, serious and persisted over a considerable period. This left the Panel with no sanction other than Striking Off that would sufficiently protect the public and the public interest.

182. The Panel was convinced that the Registrant would pose a risk to service users for the foreseeable future because there is no evidence he has developed insight into his conduct and has shown himself to be resistant to change,

183. The Panel was concerned that public confidence in the profession and the regulatory process would be seriously undermined if the Registrant remained on the Register despite his persistent disregard for patient and public safety.

Order

The Registrar is directed to strike the name of Mr Gabor Tekeres from the Register on the date this order comes into effect.

Notes

Application for an Interim Order

1. Following the announcement of the sanction and the Registrant’s right of appeal, Ms Sharpe applied for an Interim Suspension Order. She submitted that an Order was necessary for the protection of the public and otherwise in the public interest.

2. The Panel was satisfied that it was appropriate to consider the HCPC’s application for an interim order in the absence of the Registrant because he had been informed by the notice of hearing sent to him on 18 September 2018 that such an application might be made, and he has not responded with regard to that warning. The Panel found that all the conclusions that it reached at the outset of the hearing when considering the application to proceed in the absence of the Registrant still apply.

3. The Panel has considered whether it should impose an Interim Suspension Order pursuant to Article 31 of the Order which will apply during the time allowed for appealing against the final disposal order or, if such an appeal is made, whilst that appeal is in progress.

4. The Panel has had regard to paragraphs 51 to 54 of the ISP and reminded itself that it should only impose such an order if it is satisfied “that it is necessary for the protection of members of the public or is otherwise in the public interest, or is in the interests of the person concerned, for the registration of that person to be suspended”.

5. Having decided that the Registrant would put service users at risk and undermine public confidence in the profession if he were allowed to practise, the Panel is satisfied that an order is necessary both to protect members of the public and the public interest.

6. The Panel decided that the correct length of such an order is 18 months in order to cover the period in which any appeal by the Registrant is likely to be disposed of.

Interim Order:

The Panel makes an Interim Suspension Order under Article 31(2) of the Health and Social Work Professions Order 2001, the same being necessary to protect members of the public and being otherwise in the public interest.  This order will expire: (if no appeal is made against the Panel’s decision and Order) upon the expiry of the period during which such an appeal could be made; (if an appeal is made against the Panel’s decision and Order) the final determination of that appeal, subject to a maximum period of 18 months.

Hearing History

History of Hearings for Mr Gabor Tekeres

Date Panel Hearing type Outcomes / Status
21/01/2019 Conduct and Competence Committee Final Hearing Struck off