Mr Laurence P Milton

Profession: Paramedic

Registration Number: PA16865

Hearing Type: Review Hearing

Date and Time of hearing: 10:00 03/01/2019 End: 12:30 03/01/2019

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

The following allegation was considered by a Panel of the Conduct and Competence Committee at a Substantive Hearing on 10 to 13 July 2017.

During the course of your employment as a Paramedic for East of England Ambulance Service NHS Trust, whilst attending to Patient A on 15 November 2015:

1. You did not adequately assess Patient A’s cardiac rhythm on arrival at the scene;

2. You did not carry out Cardio Pulmonary Resuscitation (CPR) on Patient A in a timely manner;

3. You did not attach defibrillation pads to Patient A; and

4. You did not adequately carry out full Advanced Life Support (ALS) on Patient A in that;

a) [Found Not Proved]

b) [Found Not Proved]

c) Patient A did not receive an adequate dose of drugs;

5. As lead clinician, you:

a) asked Colleague A and Colleague B if they would like to insert the cannula;

b) said “It’s okay, you can do it on my ticket” or words to that effect.

6. [Found Not Proved]

7. The matters set out in paragraphs 1 – 6 constitute misconduct.

8. By reason of your misconduct your fitness to practise is Impaired.

Finding

Preliminary Matters

Service

1. The Panel was provided with a copy of the Notice of Hearing sent by first class post to the Registrant’s registered address on 4 December 2018, setting out the time, date and venue for this review and the possibility of the Panel proceeding without the Registrant in the event that he did not attend. The Panel was provided with proof of postage by way of a signed declaration by an HCPTS employee. The Panel was thus satisfied with service in this case.

Proceeding in the Absence of the Registrant

2. The Registrant did not attend the review hearing.

3. Ms Simpson, on behalf of the HCPC, made an application to proceed in the Registrant’s absence.

4. When deciding whether to proceed in the absence of the Registrant, the Panel took into account the submissions made by Ms Simpson and accepted the advice of the Legal Assessor. It bore in mind that, although it had a discretion to proceed in the absence of the Registrant, this discretion should be exercised with the utmost care and caution. The Panel was cognisant of the fact that this was a statutory review and its purpose was to review a Conditions of Practice Order before the date it was due to expire. The Registrant, in emails dated 4 and 28 December 2018, indicated that he had retired and was no longer working as a Paramedic. In the latter email he said he would not be attending this hearing, or be represented, and he did not request an adjournment. He also said, “I have made my intentions known, that I wish to be removed from the register.” There was, therefore, nothing to suggest the Registrant would attend on another occasion. In light of the correspondence, the Panel decided that the Registrant had voluntarily absented himself and thereby waived his right to be present. The Panel considered there was a public interest in the matter proceeding and it was also in the Registrant’s own interests that the Order be reviewed.

5. In all the circumstances, the Panel decided to proceed in the absence of the Registrant.


Background

6. The Registrant was employed as a Paramedic for the East of England Ambulance Service NHS Trust (EEAST) between April 2003 and August 2016. On 15 November 2015, a Datix report (written concerns about the care of a patient) was completed by two student paramedics, Colleague A and Colleague B. The concerns related to the care provided to Patient A who had suffered a cardiac arrest. The Registrant was alleged to have failed to act in accordance with Advanced Life Support (ALS) guidelines.

7. In its findings of fact the original panel stated as follows: “… it recognised that the Registrant had been required to carry out a number of actions on arrival at the scene, including assessment of the patient, dealing with the patient’s wife and conducting a safety assessment. In the circumstances the Registrant should have assessed the patient’s cardiac rhythm as a matter of priority. Having decided to use a basic three lead ECG, the Registrant should have carried through this action until a cardiac rhythm assessment was made. However, having attached the leads, he abandoned this course of action prior to switching on the ECG monitor and on arrival of the ambulance crew, changing his mind and allowing the ambulance crew to attach the defibrillator which they had brought with them.”

8. In doing so, the Registrant delayed the assessment of cardiac rhythm by the time taken to attach the defibrillator pads and to switch on the defibrillator. The original panel found that this delay amounted to a failure on the part of the Registrant to adequately assess Patient A’s cardiac rhythm on arrival at the scene. That panel went on to conclude that if an adequate assessment of the patient’s cardiac rhythm had been conducted by the Registrant on arrival at the scene, this would have indicated immediate commencement of CPR. Therefore, whilst that panel accepted that CPR commenced after the arrival of the ambulance crew, this was not timely.

9. In its findings, the original panel went on to state that it was satisfied that the ALS procedure continued long enough to require (under relevant guidelines) more than two doses of adrenaline to be administered and that there should have been at least one, and likely more than one, additional dose.

10. The original panel found that the statutory ground of lack of competence was not made out. This had been an isolated incident in an otherwise unblemished career of 13 years and did not represent a fair sample of the Registrant’s work. There was no evidence before the panel to suggest that the Registrant lacked competence as a Paramedic.

11. However, that panel found that the Registrant’s actions in failing to establish a cardiac rhythm at the earliest opportunity, failing to commence CPR at the appropriate time and in administering only two doses of adrenaline, when three or more were needed, fell well short of what was proper in the circumstances. These amounted to failures to comply with a number of the requirements of the HCPC’s “Standards of Conduct, Performance and Ethics” and the HCPC’s “Standards of Proficiency for Paramedics”. That Panel concluded that the Registrant’s failures were serious and amounted to misconduct.

12. In deciding the issue of impaired fitness to practise, the original panel concluded that the Registrant’s actions had placed Patient A at risk of harm as the shortfalls in the care he had received did not maximise the chances of resuscitation. Such misconduct, the panel found, could only act to harm the reputation of the profession in the eyes of the public. There was limited insight shown by the Registrant. While there were some indications of insight, such as the Registrant’s admission that a further dose of adrenaline might have been appropriate, the original panel decided that this was not enough. It concluded that the Registrant had not undertaken the necessary reflection so as to fully accept that what he had done had been wrong and there had been no evidence before it to suggest remorse.

13. Whilst the Registrant’s misconduct was, in theory, capable of remediation, there was no evidence, especially without the necessary insight, to suggest that this had been achieved. There was a risk of repetition of the misconduct. The original panel found that the Registrant’s current fitness to practise was impaired on the grounds of public protection and that a finding of impairment was also necessary in the wider public interest.

14. In considering the issue of sanction, the original panel referred to the following mitigating factors: this had been an isolated incident in an otherwise unblemished career spanning 13 years; the Registrant had made partial factual admissions; he had attended the hearing and fully engaged in the process and had produced positive testimonials and character evidence. There were two aggravating factors, namely the Registrant’s lack of insight and the seriousness of the misconduct.

15. That panel stated that the Registrant was capable of effective practice but that it did not consider that it was possible to formulate workable, verifiable and relevant conditions of practice in the circumstances of the case, because the Registrant was aware of the appropriate procedure and had chosen not to follow it.

16. That panel imposed a Suspension Order and in its decision to do so, stated that this would afford the Registrant an opportunity to reflect on his misconduct and to develop full insight. It would also provide a clear marker to the wider profession that such misconduct was unacceptable, whilst acting similarly to protect the reputation of the profession. The original panel concluded that a period of six months was the minimum necessary to achieve those aims and stated that the panel conducting that review might be assisted by the following:

a. The Registrant’s attendance at the review hearing.

b. A reflective piece demonstrating the necessary level of insight and acceptance, and exploring the boundaries of autonomous practice relative to adherence to evidence-based guidelines.

c. Evidence of CPD undertaken by the Registrant in order to maintain and develop his professional skills, especially in the delivery of ALS.

d. Any other evidence which the Registrant considered might assist that Panel

17. The Suspension Order was first reviewed at a hearing on 4 January 2018, at which the Registrant was present and represented. That reviewing panel concluded that the Registrant’s responses to its questions and his reflective piece, showed insight into his shortcomings in his practice in ALS. However, that panel was not satisfied that the Registrant’s shortcomings, had been fully remediated and concluded that the Registrant’s fitness to practice remained impaired.

18. The reviewing panel on 4 January 2018 imposed a six month Conditions of Practice Order which required the Registrant, within six months from the expiry of the Suspension Order, to satisfactorily complete and pass an accredited course on ALS provided by the UK Resuscitation Council or similar body and to provide proof of his attendance at that course to the HCPC

19. The reviewing panel, on 4 July 2018, imposed a further six month Conditions of Practice Order because the Registrant had not been able to comply with the condition that he pass an accredited course on ALS. That reviewing panel considered that such a condition was appropriate and notwithstanding the Registrant’s comments that it was difficult to find such a course, considered such courses to be widely available. On that occasion, the Registrant did provide documents that consisted of: ALS Training Reflection; CPD Diary 2016 - 2018; Certificate of successful completion of an Immediate Life Support Course on 14 February 2018; an unsigned and undated letter regarding further training undertaken by the Registrant; and reflective pieces by the Registrant regarding his practice and the incident giving rise to these proceedings. However, in the absence of completing an ALS course, which in particular would evidence the Registrant’s competence in administering intravenous medication in a resuscitation situation, the Panel could not be satisfied that his fitness to practise was no longer impaired.

20. The reviewing panel also stated:

“Furthermore, the Panel has been provided with no information from the Registrant as to what he has been doing since being employed as a paramedic in 2016. Whilst the Registrant provided a CPD log, the Panel considered that it lacked any specific information as to level of training undertaken or what had been learned from his CPD. In the Panel’s view, the CPD log read like an index of activities rather than informing the Panel as to how the Registrant had learned from undertaking the CPD.

The Panel considered that the Registrant could benefit from seeking the advice and assistance of the College of Paramedics and the HCPC in tailoring and presenting his CPD courses  positively.

Accordingly, the Panel determined that the Registrant’s shortcomings have still not been fully remediated. Notwithstanding the view of the previous review Panel, this Panel was not satisfied that the Registrant has demonstrated full insight into the effects of his misconduct on patients, colleagues and the general public.

For the above reasons the Panel concluded that the Registrant’s fitness to practice remains impaired.”

21. The reviewing panel on that second occasion accordingly added to the Conditions as follows:

1. You must satisfactorily complete and pass an accredited course on Advanced Life Support provided by the UK Resuscitation Council or similar body and;

A. forward a copy of proof of your attendance and your successful completion at that course to the HCPC.

B. provide a reflective piece detailing your developed understanding, following conclusion of the ALS course. This should also be forwarded to the HCPC prior to the hearing date.

C. provide evidence of any CPD undertaken which should include details of any courses, whether online or otherwise and a description of its contents.

2. You must provide to the HCPC prior to the next review hearing evidence of any employment, whether paid or unpaid which you have undertaken since your suspension in July 2017.

3. You must not practise as a lead Paramedic unless you have complied with paragraph 1 of these conditions.

4. You must inform the following parties that your registration is subject to these conditions:

A. any organisation or person employing or contracting with you to undertake professional work;

B. any agency you are registered with or apply to be registered with (at the time of application); and

C. any prospective employer (at the time of your application).


Decision 

22. The Panel considered with care the submissions made by Ms Simpson and took into account all the documentation and the content of the emails from the Registrant dated 4 and 28 December 2018. The Panel accepted the advice of the Legal Assessor and in reaching its decisions referred to the HCPTS’s Practice Note on “Finding Fitness to Practise is Impaired”. The Panel carried out a comprehensive review of the current Order in light of the circumstances as they existed today.

23. The Panel first considered the issue of current impairment. The Panel took account of the principle set out in Abrahaem v GMC [2008] EWHC 183 (Admin) that there is, in practical terms, a persuasive burden at a review hearing for the Registrant to demonstrate that he has “fully acknowledged why past performance was deficient and through insight, application, education, supervision or other achievement sufficiently addressed the past impairments.”

24. The panels at the Final Hearing, and subsequent reviews, found the Registrant’s fitness to practise impaired on both public protection and public interest grounds for the reasons stated above. At the most recent review on 4 July 2018, the reviewing panel concluded that the Registrant’s insight was still lacking and that it was imperative that he demonstrate insight by the provision of a reflective piece detailing his developed understanding, following conclusion of the ALS course. The Registrant had decided instead to retire from his career as a Paramedic. He had not provided a reflective piece, nor had he attended the ALS course in compliance with his Conditions of Practice Order. In the absence of such reflection and compliance, and in view of his non-attendance at this review hearing, the Panel today could not be satisfied that he had sufficient insight into his failings or that he had remediated his error. Accordingly, the Panel decided that the Registrant’s fitness to practice remained impaired on public protection grounds.

25. The Panel went on to consider whether a finding of impairment on public interest grounds was needed in order to maintain public confidence in the profession and the Regulator. It was satisfied that a fully informed member of the public, who was aware of all the background to this case, would have their confidence in the profession and the Regulator undermined if a finding of impairment were not made, given the nature and seriousness of the Registrant’s misconduct and his lack of insight and limited remediation.

26. Accordingly, the Panel found the Registrant’s fitness to practise remained impaired on public interest grounds also.

27. The Panel then considered what sanction was both appropriate and proportionate in all the circumstances and in doing so considered the HCPC’s “Indicative Sanctions Policy”. The Panel noted that the Registrant had now been retired for more than a year and had not complied with the two Conditions of Practice Orders that had been placed on his registration. He had not completed the ALS course and could not, therefore, demonstrate that he was able to practise safely. He had not provided the necessary reflective piece and, therefore, had not been able to demonstrate that he had properly developed his insight into what went wrong on the day in question. Accordingly, there was no indication that he was committed to resolving his failings. In such circumstances, to take no action or make a Caution Order would not be appropriate. It was also apparent that a further Conditions of Practice Order would not be appropriate or workable because the Registrant was not committed to complying with such an order.

28. In his email dated 28 December 2018, the Registrant indicated quite clearly that he had retired and he wished to be removed from the Register.

29. The Panel considered it had little choice but either to once again suspend the Registrant, or to remove him from the Register. The only purpose of further suspending the Registrant would be to allow him more time to reflect, show insight and demonstrate remediation. He had already had almost 18 months in which to do that. The Panel considered it was not sensible to continue the review process where it appeared that the Registrant was unwilling or unable to remediate his failings. In the absence of appropriate remediation or insight, or any evidence that the Registrant was prepared to engage with any further conditions placed on his registration, the Panel decided the only appropriate and proportionate sanction was to make a Striking Off Order.

30. The Panel took into account the impact this may have on the Registrant, however this was outweighed by the need to protect the public. In any event, the Registrant had made it clear that he was retired and wished to be removed from the Register. There was also a public interest in appropriately dealing with cases where a Registrant had chosen not to comply with conditions that were designed to ensure he was able to return to safe practice. Thus, whilst this may have been a disproportionate sanction at the time of the Final Hearing, the Panel did not consider it to be so now.

Order

The Registrar is directed to strike the Registrant from the Register with immediate effect, in accordance with Article 30(2) and (4).

Notes

No notes available

Hearing History

History of Hearings for Mr Laurence P Milton

Date Panel Hearing type Outcomes / Status
03/01/2019 Conduct and Competence Committee Review Hearing Struck off
04/07/2018 Conduct and Competence Committee Review Hearing Conditions of Practice
04/01/2018 Conduct and Competence Committee Review Hearing Conditions of Practice
10/07/2017 Conduct and Competence Committee Final Hearing Suspended