Mrs Kielye L Mitchell

Profession: Paramedic

Registration Number: PA23115

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 13/06/2019 End: 17:00 14/06/2019

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

Panel: Conduct and Competence Committee
Outcome: Suspended

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Allegation

(As amended at the final hearing)

On 8 March 2016, during the course of your employment as a Paramedic for East of England Ambulance Service, you attended Patient A and:

1. During your assessment of Patient A you did not identify and / or document on the Patient Care Record (PCR) that Patient A had a rash.

2. You walked Patient A to the front door, despite her low blood pressure.

3. Despite Patient A’s symptoms, you did not:

a) transport Patient A to hospital under blue light conditions; and / or;

b) pre-alert the hospital prior to your arrival.

4. You did not inform and / or record informing the hospital of the deterioration in Patient A’s condition.

5. You did not consider and / or record on the PCR a differential diagnosis or diagnoses.

6. You did not undertake and / or record on the PCR any, or any adequate observations and / or vital signs monitoring after 18:10.

7. You did not record adequate information on the PCR in relation to Patient A’s deteriorating condition.

8. You inaccurately documented on the Patient Care Record that Patient A’s condition was unchanged at handover.

9. You did not adequately convey the severity of Patient A’s condition to hospital staff and / or did not record on the PCR your discussions with hospital staff.

10. Your actions as described at particulars 1 to 9 constitute misconduct and / or lack of competence.

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

 

Finding

Preliminary Matters

Application to Amend the Allegation

1. At the outset of the hearing Mr Foxsmith made an application to amend the Allegation. The Registrant had been put on notice of the proposed amendments in a letter dated 9 April 2018.

2. Mr Buxton did not oppose the HCPC application to amend the Allegation.

3. The proposed amendments were as follows:

i. Particular 1: Deletion of the words ‘the initial’ and ‘a)’ and insertion of the words ‘your’ and ‘on the Patient Care Record (PCR)’;

ii. Particular 1(b): HCPC offered no evidence;

iii. Particular 3: Insertion of the words ‘Despite Patient A’s symptoms,’ and then ‘(a)’ and ‘(b)’;

iv. Particular 4(a) – 4(c): HCPC offered no evidence;

v. Particular 5: renumbered to Particular 4. Deletion of the words ‘5. As a result of 4(a), (b) and (c), you did not effectively escalate the severity and’ and ‘to the hospital’. Insertion of the words ‘You did not inform and / or record informing the hospital of the’;

vi. Particular 6: renumbered to Particular 5. Deletion of the number ‘6’. Insertion of the words ‘and / or record on the PCR a’ and ‘diagnosis’ and ‘or’;

vii. Particular 6: Deletion of the words ‘carry out an ongoing clinical assessment whilst Patient A was in your care’. Insertion of the words ‘You did not undertake’ and ‘record on the PCR any, or any adequate, observations and / or vital signs monitoring after 18:10’;

viii. Particular 7: Deletion of the words ‘failed to accurately document’. Insertion of the words ‘did not record adequate information on the PCR in relation to’; and

ix. Particular 9: Deletion of the words: ‘provided a handover to the hospital that’. Insertion of the words ‘adequately’, ‘to hospital staff and / or did not record on the PCR your discussions with hospital staff’.

4. The Panel accepted the advice of the Legal Assessor and carefully considered the HCPC application to amend the Allegation. The Panel concluded, after reviewing each of the proposed amendments, that they would agree to the Allegation being amended for the following reasons:

• the Registrant had been provided with significant notice of the HCPC’s intention to amend the Allegation, having been put on notice in April 2018, nine months before the commencement of the substantive hearing;

• the Registrant had not raised any objection to the proposed amendments;

• on the whole, the proposed amendments were to provide clarification of the Allegation; and

• the proposed amendments did not seek to widen the scope of the Allegation, with the HCPC offering no evidence in respect of four sub-particulars.

5. The Panel therefore concluded that the proposed amendments did not heighten the seriousness of the Allegation and therefore there was no likelihood of injustice to the Registrant and agreed to the Allegation being amended.


Background

6. The Registrant is, and was at the relevant time, registered with the HCPC as a Paramedic.

7. The Registrant is employed by the East of England Ambulance Service NHS Trust (‘the Ambulance Service’), working as a Paramedic stationed at Colchester Ambulance Station.

8. On 8 March 2016, Person B (Patient A’s husband) contacted 111 to report that his wife was unwell. Following a conversation that ensued between the 111 call-handler and Person B, an ambulance was dispatched to Patient A at her home address.

9. The Registrant, along with a colleague (Witness SH), attended Patient A’s home address. The Registrant and Witness SH subsequently transferred Patient A to Colchester Hospital (‘the Hospital’). There was a significant delay in transferring Patient A to the care of the Hospital. Patient A died in the early hours of 9 March 2016.

10. Following the treatment provided to Patient A, Person B wrote letters of complaint to the Hospital and the Ambulance Service. Both the Hospital and the Ambulance Service conducted internal investigations into Patient A’s treatment whilst in their care.

11. In August 2016, Witness DP was asked to review the clinical care provided by the Registrant, following the internal investigation by the Hospital. In order to do this, he conducted a clinical case review.

12. Unsatisfied with the outcomes of the initial Hospital and Ambulance Service investigation, Person B referred his concerns, regarding the Registrant’s practice, to the HCPC in December 2016.


Decision on Facts

Patient A

13. Patient A was a 60-year old Learning Support Assistant who was otherwise well. She married Person B in 1979.

Assessment of Witnesses 

Person B

14. Person B works as an Electrical Project Engineer and has worked for the same company since 1977. He had been married to Patient A since 1979.

15. Person B gave evidence to the Panel that Patient A had been out to see friends on the evening of Monday, 7 March 2016. He informed the Panel that when Patient A returned home, there was nothing untoward regarding her health. However, at just past midnight, and in the early hours of the 8 March 2016, he was woken by Patient A shaking in bed. Person B informed the Panel that Patient A proceeded to vomit into a plastic container which he had obtained for her. Person B informed the Panel that Patient A vomited again ‘a couple more times that night’.

16. Person B gave evidence to the Panel that on the morning of Tuesday, 8 March 2016, Patient A informed him that she still felt unwell and would not be going into work. Person B proceeded to work, as usual. Upon returning home from work, on the same day, Person B informed the Panel that Patient A remained unwell and had asked for him to call a doctor. Owing to an unavailability of a doctor at Patient A’s surgery, Person B telephoned 111.

17. As a consequence of the questions answered by Person B, the 111 call handler requested an ambulance attend Patient A’s home address.

18. The Panel found Person B to be a credible and reliable witness. The Panel had no reason to doubt his recollection of events. His oral evidence was consistent with his witness statement and earlier letters of complaint. If he was unable to recollect a particular event he said so and he provided reasons for any views he expressed. Person B was measured in the giving of his evidence despite his personal loss.

19. The Panel noted that Person B’s recollection of the 111 telephone call was corroborated by the transcript of this call. The Panel also noted that Person B’s oral evidence was consistent with the written accounts, which he had made a short time after the 8 March 2016. The Panel found that Person B was clear and consistent regarding what had occurred at his home address. Person B acknowledged and accepted that he had not been with Patient A for the duration of the Registrant’s assessment at the home address, and had not travelled in the ambulance when the Registrant, and Witness SH, conveyed Patient A to Hospital.

Witness DP

20. Witness DP graduated in 2006, with a foundation degree in Paramedic Science and became a registered Paramedic after graduation. He has been registered with the HCPC ever since. He holds a Diploma in Immediate Medical care from the Royal College of Surgeons and is an examiner for the Royal College of Surgeons.

21. Since October 2015, Witness DP has been employed as an Area Clinical Lead (‘ACL’) for the Ambulance Trust. Part of his role requires him to supervise the practice of other paramedics.

22. In August 2016, Witness DP was asked to review the clinical care provided by the Registrant to Patient A, following a formal complaint to the Hospital and Ambulance Service by Person B.

23. Witness DP undertook a clinical review and clinical debrief covering the care provided to Patient A, by the Registrant. In order to carry this out, he looked at the 60-day Serious Incident Investigation Report and appendices carried out by Colchester Hospital, the Datix report carried out by Peter Bumphrey, Sepsis Guidance, and the witness statements of Witness SH, the Hospital Ambulance Liaison Officer (HALO) Neil Young, and the Registrant. He provided a copy of his reports to the HCPC and these amounted to eight pages.

24. The Panel found Witness DP to be credible, reliable and professional. He was clear and concise and gave compelling evidence regarding the Patient Care Record (‘PCR’) and the information that should be contained within that document. He was also very clear regarding the Mobile Data Terminal (‘MDT’) and the information that would have been practically available to the Registrant, prior to her attendance at Patient A’s home address. The Panel felt that Witness DP provided a balanced view of the Registrant and her practice.

Witness NM

25. Witness NM qualified as a Nurse in 2008 and is registered with the Nursing and Midwifery Council (‘NMC'). She is currently employed as an Emergency Department Matron at Ipswich Hospital. Part of NM’s role, as an Emergency Department Matron, requires her to provide line management to Accident and Emergency (‘A&E’) nursing staff and to provide clinical leadership.

26. Witness NM was the ‘Nurse in Charge’ of the Emergency Department at the Hospital on the 8 March 2016. Witness NM informed the Panel that on the 8 March 2016 nine ambulances were unable to offload their patients and some of the ambulances were parked on the forecourt. She informed the Panel that the Hospital was on ‘black status’ – meaning that the Hospital was struggling to cope with the number of admissions and the capacity concerns and acuity of the patients had been escalated to the Site Matron throughout that day.

27. The Panel found Witness NM to be reliable and professional. She accepted when she could not recollect things because of the passage of time. The Panel also found her to be honest and consistent.

Witness SH

28. Witness SH is employed as an Emergency Medical Technician (‘EMT’) for the Ambulance Service. He informed the Panel that he has been in his role for nearly 12 years. Part of his role requires him to assist paramedics and to provide support to a paramedic during the assessment, diagnosis and treatment of patients at the scene of an incident and during hospital transfers.

29. Witness SH informed the Panel that on the 8 March 2016, he was working alongside the Registrant when they were called to the home address of Patient A. Witness SH told the Panel that the Registrant was the clinical lead for the shift, indicating that his responsibilities on the 8 March 2016 extended to driving the ambulance, assisting with noting the Registrant’s observations of Patient A, and providing assistance when required.

30. The Panel found Witness SH to be inconsistent and evasive at times when giving his evidence. The Panel heard that Witness SH accepted that the PCR, in relation to Patient A, ‘could have been better’ and that the patient was very unwell. However, it found other aspects of his evidence to be inconsistent. The Panel noted, for example, that SH claimed in his oral evidence to have entered the Hospital to seek assistance from Hospital staff on four separate occasions. His statements differed in this regard. On questioning, he stated that it was his first statement that was likely to be correct in all factual aspects, other than when recalling how many times he had entered the Hospital. He concluded that the last statement was factually correct on the number of visits, in that he made four visits and not two.

Registrant

31. The Panel noted the Registrant’s previous good character and took this into account when assessing her evidence.

32. The Registrant informed the Panel that she has been working for the Ambulance Service for almost 16 years. She is currently employed as a Paramedic.

33. The Registrant explained to the Panel that her primary role was to attend and deal with emergency situations within the Ambulance Service and she confirmed that she was the Paramedic called out to Patient A’s home address on 8 March 2016, along with her colleague (Witness SH).

34. The Panel found the Registrant was not always clear when giving her oral evidence. Having considered all of the evidence carefully, the Panel were troubled by numerous elements of it and the subsequent account of events she gave in oral examination, including a number of inconsistencies between the Registrant’s explanations. For example, in her witness statement, she describes Patient A as being continually monitored, when under oral questioning she conceded that the type of monitoring carried out was wholly inadequate to the situation.

35. The Registrant extended and amplified both her oral and written evidence during the course of the hearing. By example, the explanations she said she provided to the Nurse-in-Charge, when relaying Patient A’s symptoms and condition to her on 8 March 2016.

36. Taking all of the above into account, the Panel found the Registrant’s evidence to be inconsistent and unreliable in a number of respects and found that this undermined the totality of her evidence and her credibility as a witness. She sought to blame others in her explanations and was unwilling to concede on points of evidence put to her, even when such evidence was overwhelming. For example, Witnesses NM and SH, Person B together with the Emergency Department Assessment document all described Patient A’s appearance as being someone who was seriously unwell. However she did not accept this appearance was consistent to the one she had observed in the back of the ambulance. In addition she was unwilling to accept numerous points within the expert evidence of Witness DP.

Panel’s Approach

37. The Panel was aware that the burden of proving the facts was on the HCPC. The Registrant did not have to prove anything and the individual particulars of the Allegation could only be found proved if the Panel was satisfied on the balance of probabilities.

38. In reaching its decision the Panel took into account the oral evidence of the HCPC witnesses and the Registrant, the documentary evidence contained within the hearing bundles, as well as the oral submissions made by Mr Foxsmith on behalf of the HCPC, and those made by Mr Buxton on behalf of the Registrant.

39. The Panel also had regard to the fact that the Registrant admitted Particulars 2, 3(a), 3(b) and 8 contained within the Allegation and took her admissions into account when determining the facts of the case.

40.  The Panel accepted the advice of the Legal Assessor.

Particular 1 – Found Proved

On 8 March 2016, during the course of your employment as a Paramedic for East of England Ambulance Service, you attended Patient A and:

1. During your assessment of Patient A you did not identify and / or document on the Patient Care Record (PCR) that Patient A had a rash.

41. The Panel accepted that there was no dispute that the Registrant was employed as a Paramedic for the Ambulance Service. The Panel also noted that there was no dispute that the Registrant attended and treated Patient A on the 8 March 2016.

42. Person B informed the Panel that during the course of his telephone call with the 111 call handler, he was asked whether Patient A had any marks on her body. Person B informed the Panel that he pulled up Patient A’s t-shirt and noticed a ‘patterned area on her skin either side of her lower back going around under her elbows’.

43. The Panel also noted the contents of the 111 call transcript which documented the conversation between Person B and the 111 call handler. During the course of the telephone conversation Person B stated that Patient A had “a bruisey mark on her back on the side just like under her back”... “it just looks like a bruise-type thing”.

44. The Panel also had regard to the Discriminator Dictionary, contained with the Emergency Triage Manual, which described a Purpura as “A rash on any part of the body that is caused by small haemorrhages under the skin. A purpuric rash does not blanch (go white) when pressure is applied to it.”

45. Notwithstanding the slight difference in detail, in terms of the description provided by Person B in his oral evidence (as opposed to his witness statement), as to the specific appearance of the rash, the Panel found, as a matter of fact, that Patient A did have a rash on her body, visible to Person B during the 111 call on 8 March 2016, and that approximately 20 minutes later the rash was highly unlikely not to have been present when the Registrant initially examined Patient A.

46. The Registrant, during the course of her evidence, denied the presence of a rash on Patient A’s body, accepting that she did not notice and / or note the presence of a rash on the PCR.

47. The Panel were told by Witness DP that information included reference to a rash, sent to the crew via the MDT, stating “SPECIAL PATIENT NOTES shivering cold….vomiting. hot sweats. back pain and stomach. vomiting uo [sic] brown blood. and a rash END SPECIAL PATIENT NOTES”. The Registrant accepted that the MDT message had been received. However, she was unable to state whether she had in fact read it in full. The Registrant told the Panel in oral evidence that she had also received information from ‘Despatch’ prior to arrival, informing the crew that the patient had diarrhoea and vomiting.

48. The Panel was satisfied that the Registrant was under an obligation to conduct a thorough assessment of Patient A, she did not identify that a rash was present on Patient A’s body when she performed her assessment and consequently did not record the presence of a rash on the PCR.

49. Accordingly, Particular 1 is found proved.

Particular 2 – Found Proved

2. You walked Patient A to the front door despite her low blood pressure.

50. Person B, Witness SH and the Registrant provided evidence to the Panel that Patient A was walked to the front door of her home. Witness SH and the Registrant also admitted, and gave evidence, that they walked Patient A to the front door, despite her low blood pressure. Witness DP stated in his witness statement that “Patient A was hypotensive and this should have been a red flag in relation to allowing the patient to walk. In terms of standing, other than to perhaps transfer from her current position to a carry chair or stretcher, this should have been avoided.”

51. Consequently, the Panel were satisfied that the Registrant had walked Patient A to her front door, despite her low blood pressure.

52. Accordingly, Particular 2 is found proved.

Particular 3(a) – Found Proved

3.  Despite Patient A’s symptoms, you did not:

a) transport Patient A to hospital under blue light conditions; and / or

53. Witness DP informed the Panel that it was his view that Patient A should have been conveyed to the Hospital under blue light conditions. He explained that Patient A had hypotension which was suggestive of some form of circulatory compromise, coupled with the presence of a suspected infection (diarrhoea and vomiting) with associated cyanosis and abdominal pain. She therefore required urgent assessment in hospital.

54. Witness SH informed the Panel “we did not… drive under blue light conditions”. Witness SH also informed the Panel that when he had specifically asked the Registrant, who had primacy of care, whether she would like to travel to the Hospital under blue light conditions, she had said “no”.

55. The Panel noted the Registrant’s admissions in respect of this particular.

56. The Panel was satisfied that Patient A should have been transported to Hospital under blue light conditions and that the Registrant, despite Patient A’s signs and symptoms, chose not do so.

57. Accordingly, Particular 3(a) is found proved.

Particular 3(b) – Found Proved

b) pre-alert the hospital prior to your arrival.

58. Witness DP informed the Panel that a pre-alert to the Hospital is a call ahead of arrival to inform the Hospital that the ambulance is inbound with a patient who requires immediate attention. He explained that this would allow the Hospital to prepare for the arrival of the patient.

59. Witness DP provided evidence, that for the same reasons, Patient A should have been blue lighted to hospital, a pre-alert call should also have been made by the Registrant to the Hospital, to inform them that they were en-route.

60. The Panel noted the Registrant’s admissions in respect of this particular.

61. The Panel was satisfied that the Registrant should have made a pre-alert to the Hospital and that she chose not do so, despite Patient A’s condition at the time.

62. Accordingly, Particular 3(b) is found proved.

Particular 4 – Found Proved

4. You did not inform and / or record informing the hospital of the deterioration in Patient A’s condition.

63. Although the Panel accepted the evidence showed that there were visible signs of deterioration in Patient A’s condition, the Registrant continued to assert on questioning that Patient A did not look seriously unwell. Having regard to the information included on the PCR and the other evidence before it, namely the ZOLL monitor report, evidence of Person B, Witness SH and the Registrant’s own account of events, the Panel was satisfied that Patient A’s condition was deteriorating.

64. Witness NM informed the Panel that, at approximately 19:00 hours, she was approached by the Registrant who informed her that Patient A was on their ambulance and was suffering with diarrhoea and vomiting. Witness NM informed the Panel that the Registrant told her that Patient A was stable, had a low blood pressure at 90 systolic and confirmed that intravenous fluids had been administered. However, the Registrant informed her that she had no other concerns. Witness NM recounted telling the Registrant to come and find her if she became concerned, but in any case she would try to find a side room as soon as possible for Patient A which was required due to the possibility of infection.

65. The Panel was satisfied, having regard to the HCPC Standards of conduct, performance and ethics (2016), that the Registrant was under an obligation to share relevant information with colleagues involved in the care and treatment provided to Patient A. The Panel was also of the view that Patient A’s deterioration was critical information that the Registrant was under an obligation to convey to her colleagues.

66. Witness DP informed the Panel that he would expect a aramedic to recognise the “‘red flags’ that Patient A was not well… and make the deteriorating condition clear to the hospital”. In her oral evidence the Registrant repeatedly used the words “not improving” to describe Patient A’s blood pressure rather than describing it accurately as deteriorating.

67. The Panel noted that, when questioned, the Registrant was unable to provide the names of the individuals she spoke to at the Hospital; she was unable to provide any meaningful detail in respect of what was discussed, nor was she able to provide any specificity regarding the times of the alleged conversations.

68. Consequently, the Panel find as a matter of fact that the Registrant did not inform the Hospital of Patient A’s deterioration.

69. The Panel also noted the Registrant’s admissions regarding not recording the conversations that she had with staff inside the Hospital. The Panel therefore find, as a matter of fact, that the Registrant did not record informing the Hospital of Patient A’s deterioration.

70.  Accordingly, Particular 4 is found proved.

Particular 5 – Found Proved

5. You did not consider and / or record on the PCR a differential diagnosis or diagnoses.

71. The Panel was satisfied, having regard to the HCPC “Standards of proficiency” for Paramedics (2014), that the Registrant was under an obligation to be able to conduct a thorough and detailed physical examination of Patient A using appropriate skills to inform clinical reasoning and guide the formulation of a differential diagnosis.

72. Witness DP informed the Panel that there was no evidence that the Registrant considered that Patient A was exhibiting symptoms of shock due to sepsis. He informed the Panel that the Registrant had the impression that Patient A was suffering from diarrhoea and vomiting, which had led to dehydration, this contributing to her low blood pressure. He stated that this initial conclusion may have led the Registrant to not provide sufficient attention to differential diagnoses.

73. The Panel did not accept the Registrant’s account of events that she considered a differential diagnosis. She was unable to give a differential diagnosis to the Panel when questioned and none are recorded on the PCR. Consequently, the Panel find as a matter of fact that the Registrant did not consider a differential diagnosis or diagnoses.

74. The Panel also noted that during her oral evidence, the Registrant accepted that she did not record a differential diagnosis or diagnoses and stated, “I accept the paperwork was not acceptable”.

75. Accordingly, Particular 5 is found proved.

Particular 6 – Found Proved

6. You did not undertake and / or record on the PCR any, or any adequate observations and / or vital signs monitoring after 18.10 hrs.

76. Witness DP informed the Panel that there were only four “vital signs entries in the observation section of the PCR”. He told the Panel that he would have “expected further observations beyond 18.10 hours to be measured continually in terms of heart rate and oxygen saturations and blood pressures and respiratory rate regularly every five to ten minutes and at least every 15 minutes up until handover at 20.32”.

77. Noting the contents of the PCR and considering the evidence of Witness DP and Witness SH, the Panel was satisfied that the Registrant was under an obligation to undertake and record, on a PCR, her observations of Patient A and Patient A’s vital signs.

78. Whilst the Panel acknowledges that the vital signs can include a number of different things (including but not limited to:- heart rate and blood pressure, capillary refill, respiration rate, oxygen saturations, Glasgow Coma Score [‘GCS’], temperature, BM [Boehringer Mannheim, which is used to measure blood sugar], and pain score), given Patient A’s presentation in this case, the Registrant should have taken further temperature readings. She should also have completed further observations in the two hours and thirteen minutes that Patient A was on-board the ambulance with the Registrant.

79. Furthermore, the Panel also noted the Registrant’s own admissions, during her oral evidence, whereby she acknowledged that given Patient A’s presentation, she should have taken further temperature readings and recorded them.

80. Notwithstanding the Registrant’s evidence that the ZOLL machine was recording Patient A’s blood pressure and heart rate, the Panel find as a matter of fact that relying on the ZOLL readings alone was wholly inadequate in the circumstances of this case.

81. The Panel was satisfied therefore that the Registrant did not undertake and / or record, on the PCR, adequate observations or vital signs after 18.10 hours.

82. Accordingly, the Panel find Particular 6 proved.

Particular 7 – Found Proved

7. You did not record adequate information on the PCR in relation to Patient A’s deteriorating condition.

83. The Panel was satisfied, having regard to the HCPC “Standards of conduct, performance and ethics” (2016), that the Registrant was under an obligation to share relevant and accurate information with colleagues involved in the care and treatment provided to a Patient A. This included information regarding Patient A’s deteriorating condition.

84. Witness DP informed the Panel that Patient A’s blood pressure was persistently low and it was his view that Patient A would have been unwell throughout the entire incident. Witness SH himself recounted the “significant deterioration” he observed in Patient A on arrival at the Hospital.

85. Person B informed the Panel that he raised concerns in the ambulance outside the Hospital, regarding the perception of deterioration of Patient A. Person B’s main concern was the appearance of what he now knows to be Cyanosis (a developing ‘bluey’ colour on Patient A’s lips and fingertips).

86. Witness DP informed the Panel that, given Patient A’s oxygen saturations had become unreadable, and her peripheral cyanosis presented as documented by the Registrant on the PCR, Person B’s concerns were warranted and should have been acted on. Witness DP indicated that he would therefore have marked Patient A’s condition as deteriorating on the PCR.

87. The Panel also noted that, in the ‘outcomes’ section of the PCR document, the Registrant had indicated that Patient A’s blood pressure did not change, despite the administration of Sodium Chloride. The Registrant marked the ‘outcomes’ box with an arrow pointing left to right, indicating that there had been no change in Patient A’s condition. This factor alone indicated a deterioration in Patient A and thus the Registrant should have marked on the PCR a downward pointing arrow.

88. Consequently, the Panel was satisfied that the Registrant did not record adequate information on the PCR in relation to Patient A’s deteriorating condition.

89. Accordingly, Particular 7 is found proved.

Particular 8 – Found Proved

8. You inaccurately documented on the Patient Care Record that Patient A’s condition was unchanged at handover.

90. The Panel noted on the PCR document, that the box marked ‘Patient’s condition & status on handover / completion’ was marked as unchanged and that the Registrant accepted completing this box.

91. The Panel noted the Registrant’s admission in respect of this particular. She gave evidence to the Panel that she had marked the box as ‘Unchanged’ when they had arrived at the Hospital at 18:19. She conceded it had been a mistake on her part not to correct it. She accepted that Patient A had deteriorated during the two hours thirteen minutes she had spent with the Registrant outside the Hospital on the ambulance, prior to the handover of Patient A to the care of the Hospital at 20:32 and this was not indicated by her on the PCR.

92. Consequently, the Panel find that the Registrant did inaccurately document on the PCR that Patient A’s condition was unchanged at handover.

93. Accordingly, Particular 8 is found proved.

Particular 9 – Found Proved

9. You did not adequately convey the severity of Patient A’s condition to hospital staff and / or record on the PCR your discussions with hospital staff.

94. Having regard to the HCPC “Standards of conduct, performance and ethics” (2016) the Panel was satisfied that the Registrant was under an obligation to convey to Hospital staff the severity of Patient A’s worsening condition.

95. Witness DP informed the Panel that:

“The root cause of this case is that [the Registrant] did not recognise the significance and severity of Patient A’s condition. If [the Registrant] had been going in to the Hospital to directly raise concerns of a clinical nature, stating that Patient A was in need of urgent assessment and she was not responded to and was being prevented from offloading, she should have escalated this within the management structure of the Hospital and the Ambulance Service to expedite the transfer of care.  There is no evidence that this was done. There appears there were multiple conversations with different hospital staff and an Ambulance Service HALO, but these were more in relation to when a bed would be available and the low blood pressure rather than the overall clinical picture and the significance of Patient A’s worsening condition”.

96. The Panel noted that in her own reflective piece, provided some time after 8 March 2016, the Registrant stated:

“I recall entering the department on numerous occasions to emphasize  the fact that the patient’s blood pressure had remained unchanged  regardless of fluid administration. I had also informed a consultant in the department of the situation who also stated that the patient must remain in the vehicle”.

97. Witness NM also gave unequivocal evidence to the Panel that the Registrant had not informed her of Patient A’s true condition, stating that the Registrant had indicated that Patient A’s blood pressure was 90 mm/Hg systolic, that she had diarrhoea and vomiting, but that she was stable. Evidence from the ZOLL monitor printout shows that the period Patient A was on the ambulance outside the Hospital, the blood pressure dropped to as low as 68/42 on arrival at the Hospital, and ranged between 70/48 and 83/57 between 19:31 and 20:11.

98. The Panel also noted the Registrant’s admissions that she did not record her conversations with Hospital staff on the PCR document.

99. Consequently, the Panel was satisfied that the Registrant did not adequately convey the severity of Patient A’s condition to Hospital staff and / or record on the PCR her discussions with Hospital staff.

100. Accordingly, Particular 9 is found proved.


Decision on Grounds

101. Having found all of the particulars proved, the Panel went on to consider whether the Registrant’s conduct amounted to misconduct and / or a lack of competence.

102. The Panel took into account the oral evidence of the HCPC witnesses and the Registrant, written submissions, the documentary evidence contained within the hearing bundles and the oral submissions made by Mr Foxsmith and Mr Buxton.

103. The Panel accepted the advice of the Legal Assessor.

Lack of Competence

104. Competence describes knowledge and skills, i.e. what a Registrant ‘can-do’. The appropriate standard to be applied is that applicable to the post to which the practitioner had been appointed and the work he was carrying out; [Holton v GMC].

105. Competence of a Registrant is generally to be decided by reference to a fair sample of their work; R (on the application of Calhaem) v GMC [2007] EWHC2606 admin.

106. The Panel considered that the matters charged in the particulars of the Allegation did not represent a fair sample of the Registrant’s work as a Paramedic and therefore could not amount to a lack of competence.

Misconduct

107. In considering the issue of misconduct, the Panel bore in mind the explanation of that term given by the Privy Council in the case of Roylance v GMC (No.2) [2000] 1 AC 311 where it was stated that:

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

108. The Panel considered whether any of the facts found proved amounted to misconduct.

109. The Panel considered the HCPC’s “Standards of conduct, performance and ethics” (dated January 2016) and was satisfied that the Registrant’s conduct had breached the following Standards:

1 Promote and protect the interests of service users and carers;

1.2

2 Communicate appropriately and effectively;

2.2, 2.3, 2.5 and 2.6

3 Work within the limits of your knowledge and skills;

3.2

6 Manage risk;

6.1, 6.2

8 Be open when things go wrong;

8.1

10 Keep records of your work

10.1, 10.2

110. The Panel also found breaches of the following parts of the HCPC’s “Standards of proficiency” for Paramedics in England (2014):

Registrant paramedics must:

1 be able to practise safely and effectively within their scope of practice;

1.1, 1.3, 1.4

2 be able to practise within the legal and ethical boundaries of their profession;

2.1, 2.8

4 be able to practise as an autonomous professional, exercising their own professional judgment;

4.1, 4.2, 4.3, 4.4, 4.5, 4.6 and 4.8

8 be able to communicate effectively;

 8.1, 8.4, 8.6, and 8.7

9 be able to work appropriately with others;

 9.1, 9.6

10 be able to maintain records appropriately;

10.1

13 understand the key concepts of the knowledge base relevant to their profession;

13.7

14 be able to draw on appropriate knowledge and skills to inform practice;

14.2, 14.3, 14.6, 14.7, 14.9, 14.11, 14.12 and 14.16

111. The Panel was aware that breach of the standards alone does not necessarily constitute misconduct. However, the Panel was satisfied that the Registrant’s conduct and behaviour fell far below the standards expected of a registered paramedic.

112. The Panel did not find the Registrant’s numerous and varying explanations regarding why she had not adequately assessed or treated Patient A during her time on the ambulance, plausible. The Panel were particularly concerned with the Registrant’s suggestion that she did not continue to undertake full observations on Patient A, because she believed someone from the Rapid Assessment Team (‘RAT’) would be coming out to assess the patient. In her evidence the Registrant stated that she was expecting RAT to come out and so did not do the observations. She stated it was an oversight on her part. The Panel was of the view that the Registrant was under a continuing obligation to fully monitor and assess Patient A whilst she was still under her care. This included when it became apparent to the Registrant that the Hospital was on ‘black status’, and therefore struggling to cope with the demands being placed on it.

113. The Panel was also troubled by the serious lack of understanding and awareness regarding her own failure to see that Patient A was demonstrating obvious and worsening signs of cyanosis. This is a red flag indicative of circulatory compromise.

114. The Registrant’s conduct, in failing to treat Patient A, adequately, combined with not alerting the Hospital to her true condition, resulted in Patient A being denied timely care. Consequently this had an adverse effect on Patient A. When Patient A finally entered the Hospital, she was rapidly placed in the Intensive Treatment Unit.

115. The Panel considered that the above matters represented serious breaches of professional standards, falling far below the behaviour expected of a registered Paramedic and amounted to misconduct.

116. The Panel found that Particulars 3(a) 3(b), 4, 5, 6, 7, 8 and 9 each amounted to misconduct.


Decision on Impairment

117. Having found misconduct, the Panel went on to consider whether, as a result of that misconduct the Registrant's fitness to practise is currently impaired.

118. The Panel took into account all of the evidence, the submissions made by Mr Foxsmith and Mr Buxton, the oral and written submissions provided by the Registrant and the written testimonials provided by the Registrant.

119. The Panel took into account the HCPTS Practice Note “Finding that Fitness to Practise is Impaired”. The Panel also accepted the advice of the Legal Assessor. The Legal Assessor advised that in determining current impairment the Panel should have regard to the following aspects of the public interest:

i) The ‘personal’ component: the current behaviour of the individual Registrant; and

ii) The ‘public’ component: the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession.

120. The Panel considered that the Registrant’s conduct could be remediable. However, it was particularly concerned at the Registrant’s lack of insight into her behaviour, and the effect that such behaviour had on Patient A and her family. The Panel noted that the Registrant’s evidence, both oral and written, focussed primarily on how the incident had affected her and her practice, with little regard shown for how her actions had impacted Patient A, Patient A’s family, her colleagues, the reputation of the Hospital or the wider profession. The Panel were also concerned that she had provided no evidence of remorse. She simply indicated that she wished that everything had been different, that the Hospital had not been on ‘black status’ and that the whole thing should never have happened.

121. The Registrant gave evidence, on more than one occasion, that the reason for not noting down the observations on the PCR was because there was insufficient room on the document. The Panel was of the view that it is a required standard, for a registered paramedic, to demonstrate initiative in challenging situations. It was not beyond the Registrant’s capabilities to obtain a blank sheet of paper to note down her observations of Patient A upon. She could then have handed the further sheet over, along with the completed PCR, to the Hospital, just as she had done with the additional ZOLL monitor printout information. Exceptional circumstances, as was the case at the Hospital that day, require innovative courses of action and this was a reasonable method of negating the limited space on the PCR. The Panel was of the view that it is inconceivable that a paramedic would simply choose not to document a patient’s vital signs in a worsening condition, solely due to lack of space on a form. The Registrant failed to acknowledge this, stating that she had always been told “one patient, one form” and that she had not ever been trained on how to complete the PCR form. She did concede however that she had been using such a form during her entire employment with the Ambulance Service.

122. Further, whilst the Registrant has provided the Panel with a reflective piece from 2016, initiated by Witness DP, she has not provided any updated reflection since that time. She has completed some training, but the Panel was not provided with any documentary evidence of the training courses undertaken. Further, given the Panel’s concerns regarding the Registrant’s attitudinal issues, the Panel does not have any evidence that the courses undertaken by the Registrant specifically cover the failings identified.

123. The Panel therefore believes that there is a risk of repetition of her failings and that her conduct is likely to be repeated.

124. The Panel went on to consider whether this was a case that required a finding of impairment on public interest grounds in order to maintain public confidence in the profession and the Regulator.

125. The Panel 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 failings, lack of insight and lack of remorse from the Registrant. The Panel was also satisfied that there was a need to uphold proper standards of conduct and behaviour in the paramedic profession and that an informed member of the public would expect there to be a finding of impairment in respect of the misconduct found in this case.

126. Accordingly, the Panel also found the Registrant’s current fitness to practise impaired on public interest grounds as well as for public protection.

127. The Panel therefore concluded that the Registrant’s fitness to practise is currently impaired on both the personal and public components.


Reconvened Hearing – 13 to 14 June 2019

Decision on Sanction

128. Having determined on 6 February 2019, that the Registrant’s fitness to practise was impaired by reason of misconduct, but there being insufficient time then to consider the issue of sanction, the hearing was adjourned. It reconvened on 13 June 2019 when the Registrant was in attendance.

129. In his submissions on behalf of the HCPC, Mr Foxsmith reminded the Panel of the proper purpose of a sanction, identified the available sanctions and suggested that the HCPC “Indicative Sanctions Policy” should guide the Panel’s decision. In the course of his submissions he stated that the tragic outcome of the Registrant’s involvement with Patient A would necessarily be regarded as the aggravating factor of the case. Nevertheless, he made clear that Patient A’s family held no feelings of vindictiveness or malice towards the Registrant and were aware of the apology she extended to them in her reflective piece today. Mr Foxsmith did not urge the Panel to apply any particular sanction.

130. The Registrant provided to the Panel the reflective piece she had prepared since the case was adjourned on 6 February 2019, as well as certificates evidencing completion of training programmes and confirmation that she had attended professional updating sessions since the event in March 2016. Included in the courses were those relating to sepsis, electronic patient care records, the diagnosis of shock, and clinical decision making. A further document presented to the Panel was a letter dated 12 June 2019 written by the Acting Chief Operating Officer of the East of England Ambulance Service (“the Trust”) that stated that the Trust took the view that, from the point when a senior clinical manager became involved in the investigation, the Registrant had acted professionally and engaged fully in the Trust’s process. The letter also confirmed that the Registrant was considered to be a kind and caring individual by her colleagues. Since the incident she had engaged in a process of reflection and learning. She had completed an action plan that had been set for her, and (subject to maternity leave) she had remained in the workplace delivering clinical care since the incident, and no issues had come to light over that 18-month period.

131. Mr SC gave evidence on behalf of the Registrant. Mr SC is an experienced and senior Paramedic who, since October 2018, has been employed by the Trust as an Assistant General Manager. In that role, Mr SC is responsible for the whole of the North Essex locality and has 10 Leading Operating Managers working under him. Mr SC had identified one of the Leading Operating Managers as a person to whom he would assign the Registrant on her planned return to work from 24 June 2019 in order to provide mentoring. He envisaged that the Registrant would be given the type of support aimed at easing the transition of a newly qualified paramedic from the academic stage of training to autonomous practice. It was planned that the mentoring would be for a minimum of 150 hours. Mr SC also answered additional questions from the Panel.

132. On behalf of the Registrant, Mr Buxton accepted that the incident was a serious one. Nevertheless, in circumstances where the Registrant had, as he submitted, a long unblemished career before the incident, had practised without issue since, had demonstrated a real commitment to her profession, had proffered an apology, and taken steps to remediate her shortcomings, he submitted that the Panel could properly impose a Caution Order of some length. If the Panel considered a Caution Order to be insufficient it was submitted that a Conditions of Practice Order requiring compliance with crafted measures designed to facilitate a return to work would be appropriate. He submitted that in the circumstances a Suspension Order, and even more so a Striking Off Order, would be disproportionate.

133. After Mr Buxton concluded his submissions, the Panel addressed questions to the Registrant, who in turn answered them.

134. The Panel accepted the advice of the Legal Assessor as to the proper approach to the imposition of a sanction, and it also paid close regard to the HCPC’s “Indicative Sanctions Policy”. The Panel approached its decision as follows:

• Accepting that a sanction is not to be imposed to punish a registrant against whom findings have been made. Rather, any sanction imposed should be the least restrictive outcome consistent with the proper sanction considerations of protection of the public, maintenance of a proper degree of confidence in the registered profession and the declaration and upholding of proper professional standards.

• A finding that an allegation is well founded does not of itself require a sanction to be imposed. Accordingly, the first question any panel must consider is whether the finding made in the particular case requires the imposition of a sanction.

• If a sanction is required, then the available sanctions must be considered in an ascending order of gravity until one that addresses the proper sanction considerations already identified is reached. The appropriateness and proportionality of the sanction identified by this approach can be tested by consideration of the sanction that would have been considered next.

135. The Panel first considered the factors that could properly be regarded as relevant to the sanction decision. In avoiding the use of the words “mitigating” and “aggravating”, and instead using “positive” and “negative” the Panel acknowledges that some of them relate specifically to the Allegation, while others do not.

The positive factors identified by the Panel were as follows:

• The Registrant has a long career working in patient care, since 2007 as a Paramedic. There is no suggestion that there has been an issue with the Registrant’s practice either before or during the 18 months she worked following the incident concerning Patient A in March 2016.

• The Registrant has taken steps towards remediating the serious shortcomings identified by the Panel’s findings, albeit that she has neither fully acknowledged where her shortcomings lay nor has she fully remediated them.

• The fact that, in the Trust, the Registrant has a supportive employer.

The negative factors were as follows:

• The most important negative factor, of course, is the tragic events resulting in the death of Patient A.

• Despite some positive improvement in the Registrant’s attitude since the case was adjourned in February 2019, from the Registrant’s recent reflective piece and from the replies to the Panel’s questions on 13 June 2019, the Panel has concluded that the Registrant’s acceptance of her failings and her remediation of them is still incomplete. In particular:

o The Registrant continues to attach blame to other parties. In the view of the Panel, this attitude fails to recognise that upon arrival at the Hospital, the Registrant was Patient A’s sole advocate, and as such it was her responsibility to ensure that Patient A obtained appropriate monitoring, recording and treatment, as far as was possible.

o The Registrant maintained that it was her lack of assertiveness that was a significant factor in what went wrong on the day in question. However, it was the Panel’s view that the Registrant’s failure to recognise and then professionally convey the gravity of Patient A’s condition to clinicians at the Hospital which was the most significant factor.

o By putting focusing on lack of assertiveness as a significant factor in what went wrong, the Registrant has minimised the importance of her responsibility to advance Patient A’s best interests on the day in question.

• It follows from the Panel’s view that the Registrant’s remediation is incomplete and therefore there remains a risk that the Registrant could fail to properly advance a patient’s interests sufficiently in the future.

136. With these factors in mind, the Panel first considered whether any sanction is required. The clear answer to this question is that this is not a case that could properly be concluded without the imposition of a sanction.

137. The Panel next considered a Caution Order. The Panel concluded that such an outcome would not be appropriate because it would not sufficiently recognise the seriousness of the failings represented by the Panel’s findings, nor would it provide a proper degree of protection from the risk of harm resulting from repetition. Furthermore, the Panel considers that a Caution Order would not sufficiently satisfy the public interest element of this case.

138. When the Panel considered a Conditions of Practice Order, it decided that the important issue to be decided was whether any conditions that would be consistent with continued autonomous practice, could provide the required degree of protection against the risk of harm that would result from any repetition of failings.

139. The Panel has been made aware of recent measures taken by the Hospital and the Trust in reducing the likelihood of similar events to the incident reoccurring when the Hospital is under severe pressure in the future. However, notwithstanding these measures, the Panel remains concerned that it was the Registrant’s lack of engagement with the support and screening tools available to her on the day in question, coupled with her lack of awareness of Patient A’s deteriorating condition, that was a major contributory factor in this incident. Having given the matter very careful consideration, the Panel concluded that a Conditions of Practice Order would not be appropriate or sufficient to protect the public. The Panel therefore rejected conditions of practice as an appropriate disposal.

140. Having concluded that a lesser sanction than suspension is not appropriate, the Panel then tested the appropriateness of suspension by considering striking off. The conclusion of the Panel was that a Striking Off Order would be a disproportionate outcome while there remains a realistic prospect that the Registrant will sufficiently remediate her shortcomings for the conclusion to be reached that there is no realistic prospect of repetition.

141. The Panel concluded that the Suspension Order should be imposed for a period of 12 months so that the Registrant has the best possible opportunity to provide the hoped-for evidence so as to minimise the prospect that a further period of suspension would be necessary upon the conclusion of today’s order.

142. It is important that the Registrant should be aware that, in common with all Suspension Orders, the Order made by the Panel today will be reviewed before it expires. When that review is undertaken, the panel undertaking it will have all the sanction powers that were available today, including the ultimate sanction of striking off. What, if any, order is made on the review will be entirely a matter for the panel conducting it, and, in offering guidance to the Registrant, the present Panel does not seek to usurp the powers that will be available when the review is undertaken. However, the reviewing panel might be assisted by the following:

• The Registrant’s reflections on the topic of patient advocacy when acting in a professional role.

• A report from a paramedic mentor, particularly concerning the failings identified in this case.

• A Personal Development Plan from the Registrant, covering the failings identified by this Panel.

Order

ORDER: The Registrar is directed to suspend the name of Mrs Kielye L Mitchell from the Register for a period of 12 months from the date this Order comes into effect.

Notes

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.

Reasons for making an Interim Suspension Order:

1. The Panel determined that it was proper to consider the HCPC’s application for an interim order because:

a. The notice of hearing letter dated 5 March 2019 put the Registrant on notice that, in the event of a substantive Suspension Order being made, an interim order might be applied for.

b. The Registrant was in attendance at the hearing and represented by Counsel.

2. In considering the application for an interim order, the Panel accepted that the default position established by the legislation is that following the imposition of a sanction there will be no restriction on a registrant’s ability to practise while his or her appeal rights remain outstanding. In deciding whether an order should be made, one of the three grounds contained in Article 31(2) of the Health and Social Work Professions Order 2001 must be made out.

3. The Panel decided that the risk of repetition identified in its determination had the consequence that an interim order is necessary for protection of members of the public and is otherwise in the public interest. Furthermore, having considered whether the factors giving rise to those grounds being met could be satisfactorily addressed by the imposition of conditions of practice on an interim basis. The Panel concluded that interim conditions of practice would not provide adequate protection for the same reasons that substantive conditions of practice were rejected in the Panel’s determination on sanction.

4. It followed from these findings that an Interim Suspension Order should be made. As any appeal could take some considerable time before being finally concluded, the Panel decided that the Interim Order should be made for the maximum period of 18 months.

Hearing History

History of Hearings for Mrs Kielye L Mitchell

Date Panel Hearing type Outcomes / Status
13/06/2019 Conduct and Competence Committee Final Hearing Suspended