Mr Nicholas Stock

Preliminary Matters

Service

1. The Panel had evidence before it that Notice of this hearing had been sent to the Registrant at his registered address on 5 May 2019. The Notice letter had also been sent by email to an address provided by the Registrant to the HCPC. The Notice letter contained the correct information relating to the time, date and venue of this hearing. There was also evidence that this letter had been posted in sufficient time in advance of today’s hearing, using the prescribed postal means. The Panel has therefore concluded that there has been good service in accordance with the rules.

Proceeding in the Absence of the Registrant

2. The Panel was informed that the Registrant has totally disengaged in the HCPC process. The Panel was provided with a schedule in which communications to and from the Registrant and Kingsley Napley were set out in chronological order with a note of the Registrant’s response or lack of. The HCPC drew attention to the fact that various letters and the hearing bundle had been returned by the post office. In a telephone conversation that the Registrant’s wife had with Kingsley Napley on 11 March 2019, it was made clear by the Registrant’s wife that the Registrant would be throwing away all papers sent to him. It would therefore appear that the non-collection of letters and the bundle was in accordance with that stated intent. The Panel saw documentary evidence of the return of this documentation and written communication.

3. There had been no request for an adjournment and given the stated intention of the Registrant not to attend the hearing, and not to participate in the HCPC process, it was unlikely that he would attend any future hearing. There were two HCPC witnesses in attendance and there was clearly public interest in this hearing progressing without delay.

4. The Panel received and accepted legal advice. The Panel took into account and noted the representations of the HCPC. In the Panel’s view the evidence of the Registrant’s stated and implemented intention not to participate in these proceedings was conclusive evidence that an adjournment would service no purpose. It appreciated that this Panel had to ensure that proceeding in the Registrant’s absence should be fair and not cause him any prejudice. The Panel concluded that it was capable of ensuring that the hearing was fair. It accepted that there was public interest in this hearing going forward and so accepted the HCPC’s application to proceed in the Registrant’s absence.

Application to Amend the Allegation

5. The HCPC made an application to amend the Allegation. The proposed amendments were set out in a letter sent to the Registrant on 7 May 2019. The Registrant has therefore had several months to consider these amendments. As the Panel heard in relation to the issue of proceeding in the Registrant’s absence, there has been a total lack of engagement and there has, therefore, been no response received from the Registrant to this letter. The HCPC noted however that this letter had not been returned by the post office.

6. It was submitted that the proposed alterations were limited in nature and required for clarity so that there was no ambiguity as to what is alleged. The HCPC argued that these alterations did not cause the Registrant any prejudice and there had been no significant change as to what is alleged. The main thrust had been to remove some of the bi-partite particulars therefore simplifying and making clear the intention.

7. The Legal Assessor gave her advice which included reference to the fact that a Panel of the Conduct and Competence Committee did not have a statutory power to amend an Allegation in any significant degree. This power rested with the Investigatory Panel. This was a matter aired obiter in the case of HCPC v Ireland and Ma [2015]. There was however a common law ability to amend where there is no substantial change in what is alleged, and it was fair to do so in that the amendments would not result in any prejudice to the Registrant. The Panel was advised to consider carefully whether the proposed amendments in any way widen or altered what had previously been alleged.

8. The proposed alterations are:

• Particular 1(a) – deletion of ‘and / or record’.
• New particular 1(b) to read as follows – ‘Did not record observations and / or the patient’s refusal to have observations taken.’
• Redesignate particular 1(b) to 1(c) and insert ‘undertake’ and delete ‘complete and / or record’.
• New particular 1(d) to read as follows – ‘Did not record assessments and / or the patient’s refusal to be assessed.’
• Redesignate 1(c) as 1(e) and 1(d) as 1(f).
• Redesignate 1(e) as 1(g) and add at the end of this particular the words ‘and / or conveyance.’
• Redesignate 1(f) as 1(h).

9. The Panel gave this matter very serious consideration. It was mindful of the Registrant’s absence from these proceedings and the over-riding need to ensure that these amendments do not cause him any prejudice. Except for the proposed addition to particular 1 (g), the Panel was content to accept the amendments as minor clarification of what is alleged. In relation to the addition of the words ‘and/or conveyance’ the Panel was of the view that this was an extension of what had previously been alleged and was therefore a widening of the Allegation and so was not approved.

Background

10. The Registrant was employed by South Western Ambulance Service NHS Trust (the Trust) from 2003 to 2018. He had originally worked as an Ambulance Technician before training as a Paramedic in 2011. At the time of the matters set out in the Allegation, he was a Band 6 Paramedic. This involved him working with members of the public in emergency medical situations and he was expected to attend to patients and treat them according to their direct needs.

11. On 9 May 2018 the Registrant was suspended from duty following an incident involving Patient A which had taken place on 8 May 2018. The Registrant, under instruction from his employer, self-referred this matter to the HCPC on 27 May 2018.

12. An internal Investigation was conducted by the appointed investigating officer ET, who had been the Registrant’s line manager since 2015 but had not worked directly with him. Her investigation resulted in a report dated 7 August 2018. There was a further investigation undertaken by RG and he produced a Concise Investigation Report (CIR) dated 23 August 2018. These reports led to an internal disciplinary hearing on 5 September 2018.

Evidence

13. The Panel had before it the HCPC bundle of documentation. The following documents were within this bundle:

• Three sworn witness statements;
• The Trust’s Standard Operating Procedure for Deployment, Supervision and Clinical Practice;
• The Trust’s Appropriate Care Pathways Policy (ACPP);
• Safeguarding Policy (SP);
• Copies of the two reports arising from the incident on 8 May 2018 dated 7 and 23 August 2018;
• Statement prepared by the Registrant on 9 May 2018;
• Statement prepared by MC on 9 May 2018;
• Notes of an interview with MC on 24 May 2018.
• Sequence of events log dated 8 and 9 May 2018;
• Notes of an interview conducted by ET with the Registrant on 25 May 2018;
• Notes of the disciplinary hearing dated 5 September 2018.

14. The Panel received live evidence from two HCPC witnesses.

• ET, Operations Officer at the Trust since 2015. She had interviewed the Registrant on 25 May 2018 as part of her investigation. She had a clear and good recollection of that interview. Her evidence was consistent. She gave straight forward answers and was prepared to admit when she was unable to fully recollect something. In the Panel’s view she was a credible and reliable witness.

• MC, who was the Emergency Care Assistant (ECA) attending the incident on 8 May 2018 with the Registrant. He was naturally nervous in giving his evidence and at times measured in his responses. However, his evidence gave a consistent account of what had happened. There were details he could not recall at this distance from the event but he readily acknowledged this. The Panel considered him to be a credible and reliable witness.

Decision on Facts

15. The Panel acknowledged that the burden of proof at this fact-finding stage lay with the HCPC. The burden of proof is the balance of probabilities. The Panel received the HCPC’s written submissions and it took and accepted the Legal Assessor’s advice.

16. The incident involved a patient, Patient A, who was known to the emergency services. She was an alcoholic who had, just before these events on 8 May 2018, lived with her mother. She was, on the 8 May 2018, living in a car in a poorly lit church car park. That evening she had contacted the emergency services stating that she had taken an overdose. Ambulance control reported Patient A as being difficult to understand due to heavily slurred speech, that she sounded confused and was disorientated to time and place.

17. The Registrant and MC had been dispatched to Patient A as an emergency call. The evidence is that Patient A was attempting to sleep in the car with the rear seats down. She was surrounded by bags of possessions which made use of the rear doors difficult meaning patient access was via the boot.

Particular 1(a) – Found Proved
Whilst registered as a Paramedic and working for South Western Ambulance Service NHS Foundation Trust

 On 8 May 2018, you attended Patient A and you:
a. Did not undertake adequate observations.

18. The Panel considered carefully what ‘an adequate observation’ would consist of. In this regard, the Panel relied upon the evidence of ET and the relevant sections of the ACPP. ET states that the list of the observations that should be undertaken ‘as a minimum’ were:

• Pulse rate
• Respiratory rate
• Capillary refill
• Glasgow Coma Score
• Blood pressure
• Temperature

19. Relying on this evidence and the Guidelines within the ACPP the Panel has accepted that this is the standard that should have been met by a registered Paramedic.

20. In her oral evidence, ET stated that there was no documentary evidence that any observations had been undertaken. MC in his oral evidence stated that there were no ‘specific observations’ taken, and further that no observation equipment had been taken to the car. He confirmed that the Registrant had not undertaken any ‘specific observations’ and the Registrant had merely watched Patient A through the car window. This is consistent with his sworn statement.

21. In the notes of interview on 25 May 2018, the Registrant replied to the question of what observations were taken - that ‘purely visual ones, I was under the impression that the patient was refusing treatment as they told me to go away’

Particular 1(b) – Found Proved
1.  On 8 May 2018, you attended Patient A and you:
b. Did not record observations and / or the patient’s refusal to have observations taken.

22. Particular 1(b) and/or both parts proved – there was no record found of observations or the patient’s refusal for treatment.

23. Having found that no adequate observations had been undertaken and there being no documentation to support specific observations, the Panel gave careful consideration to the issue of what constituted recording. The ACPP states that ‘that relevant paperwork should be completed to a high standard’ and ‘these details should be documented on the Patient Clinical Record’ (PCR) which in electronic format utilised by the Trust would be an ePCR.

24. The Registrant in his interview on 25 May 2018 with ET said ‘I recorded everything on the radio or by text’. The Panel noted that the Registrant had relayed information via text message to Ambulance control and this was supported by the entries on the sequence of events chronology before the Panel. This however did not, in the Panel’s view, satisfy the requirements of the Policy which identified the need to record information in a PCR either in paper format or electronically.

25. In oral evidence MC stated that an ePCR had not been completed. ET confirmed that there was no evidence of any documentation either in paper format or electronically during or after the incident.

26. There was also no record of the Registrant recording Patient A’s refusal to receive treatment other than a text message noted on the sequence of events chronology before the Panel. In the Panel’s view this fails to fulfil or comply with the ACPP or the standard practice which ET said should be adopted by all crews when they attend an incident.

Particular 1(c) – Found Proved
1.  On 8 May 2018, you attended Patient A and you:
c. Did not undertake an adequate clinical assessment.
27. In relation to the issue of what constitutes ‘adequate’ the Panel paid particular attention to the provisions of the ACPP which states:
An appropriate clinical assessment must be conducted. The range of clinical assessment conducted may include abdominal, chest, neurological or other appropriate examination.

28. The ACPP also states that:
It is the lead clinicians responsibility to ensure that sufficient clinical investigations are both undertaken and documented.

29. ET in her sworn statement confirms there was no record of clinical assessments having been conducted.

30. MC in his sworn statement and in his oral evidence stated that neither he nor the Registrant had ever got close enough to Patient A to be able to conduct appropriate clinical assessments.

31. The Registrant stated in his interview that ‘he wasn’t going to get into the car.’ It follows from this that the required clinical assessments would not have been possible.

Particular 1(d) – Found Proved
1.  On 8 May 2018, you attended Patient A and you:
d.  Did not record assessments and / or the patient’s refusal to be assessed.

32. MC in his sworn statement states ‘there were not any records or notes taken by NS upon attending to Patient A or after we had left the scene’. This also was confirmed in his oral evidence.

33. Again, this is proven by the fact that there could not be a recording of a clinical assessment when a clinical assessment had not been undertaken.

Particular 1(e) – Found Proved
1.  On 8 May 2018, you attended Patient A and you:
e. Did not complete and / or record an adequate capacity assessment.

34. The Panel determined that the meaning of ‘adequate’ by taking reference from the SP and the five key principles identified in the Mental Capacity Act. In his Concise Investigation Report RG records that the CURE test is adopted by the Trust to make an assessment of capacity and that this stands for:

Communicate – can a person communicate their decision to you (even if not verbally)?
Understand – can the person understand the information that would enable them to make an informed decision?
Retain – can a person retain the information in order to make the decision?
Employ and Explain – can the person employ the information to make the decision effectively and explain?

35. The Panel noted that the ACPP states that intoxicated patients are required to have an assessment of mental capacity carried out.

36. In the disciplinary hearing on 5 September 2018 the Registrant stated that he had not conducted a ‘formal assessment’. He stated that he had not undertaken one because ‘nothing had gone wrong’.

37. The Panel also noted that based on his responses made in interview on 25 May 2018, the Registrant indicated that he knew what a formal capacity assessment should have included but admitted that he only did an informal assessment.

38. MC in his interview on 24 May 2018 stated that no CURE test to assess capacity had been conducted.

39. The interview undertaken on 25 May 2018 and the disciplinary hearing on 5 September 2018 record that the Registrant may have undertaken a minimal mental health capacity test but in all the circumstances the Panel found it was insufficient and did not qualify as being ‘adequate’ as set out in the Trust’s SP.

40. In the disciplinary hearing on 5 September 2018 the Registrant is recorded as saying in response to the question ‘why wasn’t the ePCR completed’ -  ‘ I can only put my hands up to this I didn’t do one there was no decision not to do one I forgot’.

41. In the notes of interview 25 May 2018 ET asked if the Registrant had used an ePCR to record his capacity assessment and he replies ‘No’.

Particular 1(f) – Found Proved
1.  On 8 May 2018, you attended Patient A and you:
f. Did not complete a Patient Clinical Record (ePCR).
42. Based on the same evidence relied on for particular 1(e). MC in his live evidence confirmed that no notes or ePCR had been completed.

43. In his interview of 25 May 2018 the Registrant is recorded as stating that ‘he would not do anything differently other than complete an ePCR’ which is an inference that he had not completed an ePCR.

Particular 1(g) – Found Proved
1.  On 8 May 2018, you attended Patient A and you:
g. Did not explain to Patient A the risks associated with refusing assessment.

44. In the interview notes of 24 May 2018 ET asked MC ‘did you leave worsening advice and did the patient understand this?’ MC replied ‘No’. In oral evidence MC stated that ‘I don’t recall any worsening advice being given to Patient A.

45. In the interview notes of 25 May 2018, the same question was posed to the Registrant and he replied ‘I didn’t speak to her again’. The Panel concluded that this was an inference indicating that no worsening advice was given to Patient A.

Particular 1(h) – Found Proved
1.  On 8 May 2018, you attended Patient A and you:
h. Did not take adequate steps to safeguard Patient A.

46. In evidence ET told the Panel that adequate actions for safeguarding of a patient could include:

• Completing a vulnerable adult form and referral;
• Contacting Police;
• Contacting and/or referring to Social Services;
• Contacting or referring to the GP;
• Contacting the family and/or friends.

47. Some or all of these actions would constitute adequate action. The Registrant only contacted the Police; there is no evidence that he undertook any of the other measures.

48. The Panel noted that the Registrant had left the scene prior to the Police arriving and this is supported by the sequence of events chronology. The Registrant in his interview on 25 May 2018 and MC in his interview on 24 May 2018 with ET confirmed they did nothing more than alert the Police.

49. This was despite NS’s statement ‘it was disgusting/filthy, the car was full of plastic bags like a homeless person. The car smelt of alcohol. The patient had been incontinent.’ These concerns which should have been obvious to the Registrant made it obvious that adequate steps to safeguard Patient A needed to be considered and implemented.

Fitness to Practise

Submissions by HCPC on the Statutory Ground and current impairment

50. The HCPC made detailed written and oral submissions on the statutory ground and the issue of impairment of the Registrant’s fitness to practise. In support of those submissions the Panel was presented with a further small bundle of documentation consisting of email copies from the Registrant to HCPC. 

51. It was submitted that the correct interpretation of the Registrant’s behaviour at the time of the incident on 8 May 2018 amounted to misconduct, and a correct interpretation of his correspondence with the HCPC since his self-referral, demonstrated a current and continuing state of denial of the seriousness of those events and his role and responsibility in them.

52. In relation to the issue of misconduct, the HCPC submitted that the Registrant’s actions were in breach of the HCPC’s Standards of Conduct, Performance and Ethics which came into force in January 2016 and the Standards of Proficiency for Paramedics 2014. The HCPC invited the Panel to consider the standards as a whole, but in particular:

In the Standards of Conduct, Performance and Ethic 1.2, 1.3, 1.4, 2.2, 2.3, 3.3, 3.4, 6.1, 6.2, 8.1, 9.1, 9.2, 10.1 and 10.2.

In the Standard of proficiency for Paramedics standards 1, 2, 3, 8, 9 and 10.

53. Whilst it was appreciated that breach of these provisions would not of themselves be sufficient to support a decision on misconduct they were strong evidence of the inappropriateness of the Registrant’s actions that resulted in a vulnerable patient being placed at risk and who did, in fact, suffer harm.

54. The HCPC submitted that this was not a case that fell within the ambit of lack of competence.

55. In relation to the issue of current impairment, the HCPC invited the Panel to consider the HCPC Practice Note on Finding that Fitness to practise is “Impaired” and in particular, the two elements set out within the Practice Note:

• The personal component which includes looking at the current competence, behaviour etc. of the individual registrant and;

• The public component which includes the need to protect service users, to declare and uphold proper standards of behaviour, and to maintain public confidence in the profession. 

56. It was submitted that in relation to the issue of assessing the personal component, a key consideration for the Panel will be the level of insight demonstrated by the Registrant. The further documentation presented to the Panel was relevant in this respect. The Panel’s attention was drawn to the Registrant’s responses to and demeanour throughout the referral and investigation process which included:

• The difficulties encountered by ET in investigating this matter and the evasive nature of some of the Registrant’s engagement. Further, the Panel has read that the Registrant maintained that the only thing he would do differently in the future in the same situation was to fill out the ePCR:

– Disciplinary hearing on 5 September 2018

NP – For clarity in terms of reflection the only thing you would have done differently is complete the ePCR?

NS – Yes

• The Registrant’s lack of insight in respect of the gravity of those facts: the Registrant has maintained a denial that he did anything wrong. Further, the Registrant has maintained throughout the regulatory proceedings that there was no case for him to answer: he did nothing wrong.

• The Panel has been given evidence of the Registrant’s interaction with the HCPC since the incident. The following are examples of the email responses made by the Registrant in response to communications sent to him by the HCPC as this matter progressed to a hearing:

• 05/09/2018 – “you as an organisation are clearly incapable and I no longer wish to be associated with such a disgusting bunch of morons. I have no case to answer, just for the record.”

• 01/10/2019 – “PATHETIC”

• 02/10/2018 – “You can shove your registration […] I have no case to answer […] It’s all beneath me, I’ve had enough and won’t be cooperating or involved with anything further”

• 29/10/2018 – “Do not contact me again. C U next Tuesday”.

• 29/10/2018 – “Couldn’t care less”.

• 29/10/2018 – “And who made these erroneous allegations?? I’m no longer practicing as a Paramedic, so I would sincerely suggest that you and SWAST go and FUCK yourselves.”

• 05/11/2018 – Subject: “TWUNTS” – text within the email “bearing in mind your ridiculous allegation that I made no attempt to assess this so called patient, then it can only be full of lies and hearsay. I look forward to meeting what I can only rightly assume are a seriously ugly, bottom feeding, sub normal, moronic, sorry excuse for human beings” [sic]

57. In the HCPC’s view, the Registrant has demonstrated a conspicuous and sustained lack of insight. In this regard the Panel will note the Registrant’s characterisation of these proceedings as “ridiculous allegations” and of Patient A, whom he terms “this so called patient”. There is clearly an absence of insight into the severity and consequences of the proven misconduct, along with a wanton lack of empathy. Given this information it is doubtful that the Registrant understands the deficiencies in his practice and is therefore is unable to address them.

58. When considering the public component, it is the HCPC’s view that if a finding of impairment were not made in this case, public trust in the profession and the upholding of proper professional standards would be undermined.

59. Within the Panel’s consideration of impairment it should make an assessment of culpability and harm. The HCPC referred the Panel to following extract from the Practice Note:

‘In assessing the likelihood of the registrant causing similar harm in the future, Panels should take account of:

• the degree of harm caused by the registrant; and
• the registrant’s culpability for that harm.

In considering the degree of harm, Panels must consider the harm caused by the registrant, but should also recognise that it may have been greater or less than the harm which was intended or reasonably foreseeable.

The degree of harm cannot be considered in isolation, as even death or serious injury may result from an unintentional act which is unlikely to be repeated. The registrant’s culpability for that harm should also be considered. In assessing culpability, Panels should recognise that deliberate and intentional harm is more serious than harm arising from the registrant’s reckless disregard of risk which, in turn, is more serious than that arising from a negligent act where the harm may not have been foreseen by the registrant.’

60. In the HCPC’s submission, the risk and degree of harm caused by the Registrant’s failure to safeguard Patient A in this case was significant. The Panel has read that Patient A died as the result of cardiac failure with cerebral ischaemia and acute on-chronic alcohol toxicity with liver cirrhosis. The Panel was reminded of the referral made and the specific representations and in particular the fact that Patient A had a cardiac arrest after the ambulance crew had left the scene and before the Police arrived.

The Panel’s decision on grounds

61. The Panel appreciates that at this stage in the proceedings there is no onus on the HCPC. In reaching its decision the Panel has noted the detailed submission of the HCPC. It has taken and accepted the advice of the Legal Assessor which included reference to the case of CHRE – v NMC and Grant which highlighted the importance of public interest in the Panel’s consideration of impairment.

62. The Panel, having found all the facts proved, considered whether those facts, individually or collectively, amounted to the statutory grounds of misconduct and/or lack of competence. In this regard, the Panel took into consideration the Legal Assessor’s advice that a distinction can be drawn between the two. A lack of competence may more rightly derive from a lack of understanding, training or ability to do what is required in the particular circumstances. A falling short of the standards which are expected of a competent practitioner would be misconduct and may result from a reckless, wilful or intentional acts or omissions.

63. The Panel appreciated that for a finding of lack of competence it should have before it a fair sample of work which had fallen short of the standards, although in very exceptional circumstances it may derive from one single act. This was a sole incident which demonstrated a series of errors and omissions. In the Panel’s view, and based on the evidence before it, the Registrant’s actions derived from an intentional decision not to take appropriate action and did not arise from a lack of knowing what to do therefore the Panel concluded that this is not a lack of competence case. The Panel therefore went on to consider whether the Registrant’s acts and omissions could be considered as misconduct.

64. The Panel noted the provisions of the standards which the HCPC considered had been breached by the Registrant’s multiple failures to take appropriate action and the various omissions in his practice on this occasion. The Panel agreed that these matters were in breach of some of the numerous standards the HCPC case presenter cited, however not all. The Panel considered the following as relevant when making its decision.

Standards of Conduct & Competency

• Standard 1.1 - You must treat service users and carers as individuals, respecting their privacy and dignity.

• Standard 1.2 – You must work in partnership with service users and carers, involving them, where appropriate, in decisions about the care, treatment or other services to be provided.

• Standard 1.4 –You must make sure that you have consent from service users or other appropriate authority before you provide care, treatment or other services.

• Standard 1.5 - You must not discriminate against service users, carers or colleagues by allowing your personal views to affect your professional relationships or the care, treatment or other services that you provide.

• Standard 2.2 – You must listen to service users and carers and take account of their needs and wishes.

• Standard 2.3 – You must give service users and carers the information they want or need, in a way they can understand.

• Standard 3.4 – You must keep up to date with and follow the law, our guidance and other requirements relevant to your practice.

• Standard 6.1 – You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.

• Standard 6.2 – You must not do anything, or allow someone else to do anything, which could put the health or safety of a service user, carer or colleague at unacceptable risk.

• Standard 7.1 - You must report any concerns about the safety or well-being of service users promptly and appropriately.

• Standard 7.3 - You must take appropriate action if you have concerns about the safety or well-being of children or vulnerable adults.

• Standard 8.1 – You must be open and honest when something has gone wrong with the care, treatment or other services that you provide by:

• informing service users or, where appropriate, their carers, that something has gone wrong;
• apologising;
• taking action to put matters right if possible; and
• making sure that service users or, where appropriate, their carers, receive a full and prompt explanation of what has happened and any likely effects.

• Standard 9.1 – You must make sure that your conduct justifies the public’s trust and confidence in you and your profession.

• Standard 10.1 – You must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to.

• Standard 10.2 – You must complete all records promptly and as soon as possible after providing care, treatment or other services.

  Standards of Proficiency for Paramedics

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

• 1.3 – be able to use a range of integrated skills and self awareness to manage clinical challenges independently and effectively in unfamiliar and unpredictable circumstances or situations;

• 1.4 – be able to work safely in challenging and unpredictable environments, including being able to take appropriate action to assess and manage risk.

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

• 2.1 understand the need to act in the best interests of service users at all times;

• 2.2 understand what is required of them by the Health and Care Professions Council;

• 2.3 understand the need to respect and uphold the rights, dignity, values, and autonomy of service users including their role in the diagnostic and therapeutic process and in maintaining health and wellbeing;

• 2.4 recognise that relationships with service users should be based on mutual respect and trust, and be able to maintain high standards of care even in situations of personal incompatibility;

• 2.5 know about current legislation applicable to the work of their profession;

• 2.6 be able to practise in accordance with current legislation governing the use of medicines by paramedics;

• 2.7 understand the importance of and be able to obtain informed consent;

• 2.8 be able to exercise a professional duty of care.

• Standard 3 - be able to maintain fitness to practise

• 3.1 understand the need to maintain high standards of personal and professional conduct;

• 3.5 recognise the need to engage in critical incident debriefing, reflection and review to ensure that lessons are addressed for future patient safety and management.

• Standard 4 - be able to practise as an autonomous professional, exercising their own professional judgement

• 4.1 be able to assess a professional situation, determine the nature and severity of the problem and call upon the required knowledge and experience to deal with the problem;

• 4.2 be able to make reasoned decisions to initiate, continue, modify or cease treatment or the use of techniques or procedures, and record the decisions and reasoning appropriately;

• 4.3 be able to initiate resolution of problems and be able to exercise personal initiative;

• 4.4 recognise that they are personally responsible for and must be able to justify their decisions;

• 4.5 be able to use a range of integrated skills and self-awareness to manage clinical challenges effectively in unfamiliar and unpredictable circumstances or situations;

• 4.6 be able to make and receive appropriate referrals;

• 4.8 be able to make a decision about the most appropriate care pathway for a patient and refer patients appropriately.

• Standard 8 - be able to communicate effectively

• 8.1 - be able to demonstrate effective and appropriate verbal and non-verbal skills in communicating information, advice, instruction and professional opinion to service users, colleagues and others;

• 8.3 - understand how communication skills affect assessment of, and engagement with, service users and how the means of communication should be modified to address and take account of factors such as age, capacity, learning ability and physical ability;

• Standard 10 - be able to maintain records appropriately

• 10.1 - be able to keep accurate, comprehensive and comprehensible records in accordance with applicable legislation, protocols and guidelines;

• 10.2 - recognise the need to manage records and all other information in accordance with applicable legislation, protocols and guidelines.

65. The Panel appreciated that breaches of the Standards do not of themselves amount to a finding of misconduct. The Panel however considered the Registrant’s numerous failings and omissions to be grave and concerning and supported a finding of misconduct.

66. The Panel was mindful of the evidence of ET which supported the view that the Registrant’s lack of treatment and care had, in her view, fallen far short of the professional standards expected of a Paramedic. She had stated in her evidence that the Registrant’s actions had shown a bias: he had chosen not to treat this known service user who was  reported to be alcoholic. The Panel agrees with this assessment of the Registrant’s conduct.

67. As stated by the HCPC, the Registrant has shown no humility, no compassion and given no care for this vulnerable service user and had failed to complete a thorough assessment.

68. The Registrant failed to put in place effective safeguarding measures and left Patient A alone in the car delegating responsibility to the Police, and leaving the scene before they arrived.

69.  In the Panel’s view this is manifestly serious misconduct.

Panel’s decision on impairment

70. The Panel again noted the HCPC’s detailed submissions. It noted and accepted the Legal Assessor’s advice that the Panel is assessing the Registrant’s current practice and current state of mind when considering this matter. The Panel was able to take into consideration information placed before it today of the Registrant’s recorded attitude towards the incident, the patient involved, these proceedings and this hearing Panel as displayed in his emails to the HCPC.

71. As pointed out by the presenting officer, this Panel had before it evidence from MC, who was an Emergency Care Assistant, of how one can learn from these events and improve one’s practice. MC displayed contrition, insight and remorse and has taken learning points from the events of 8 May 2018. Based on the further information before the Panel, this was clearly not the case with the Registrant.

72. The Panel noted that the Registrant has taken no steps to address his misconduct. There is no evidence to suggest that the Registrant would have acted differently in the same situation other than, by his admission, to fill out an ePCR. The Panel has nothing before it that would persuade it that on the personal component the Registrant had remediated his practice. This being the case, there is also no evidence that the Registrant would not repeat his misconduct in the future and so there is a very real risk of repetition and the potential for harm to patients in the future.

73. When considering the issue of the public interest in a finding of impairment, the Panel was of the view that the public would be concerned about the Registrant’s behaviour at this incident, the outcome of the incident, subsequent lack of insight, lack of humility, remorse shown or apology made. The Panel was also of the view that the public would be concerned at the lack of respect shown to his professional body and the regulatory process.

74. The Panel therefore finds current impairment on both the personal and public components.

Decision on Sanction

Further evidence

75. At this stage the Panel received a further set of papers. These included details of an earlier referral to the HCPC in 2015, and a Police Caution for assault in 2009 disclosed by the Registrant to the HCPC’s Registrations Department on first registering as a Paramedic in 2011. 

Previous referral to the HCPC

76. The Panel had placed before it the Trust’s Management Statement of Case dated 25 February 2016 which included reference to the incident on 6 November 2015 being the second serious incident (SI) that the Registrant had been involved in. The Trust’s Management Statement of Case had been considered by a Panel of the Investigating Committee. In that document it is recorded that:
‘On reviewing the patient clinical record for the attendance on 6 November 2015 it raised the following concerns:

• The patient had advised two episodes of fainting the previous day and she was feeling faint and fitty. Given this history and the fact she had a history of epilepsy which was non-medicated due to vomiting, discharge at home may not have been safe as living alone.

• Two sets of observations should be completed for patients being discharged on scene in line with Appropriate Care Pathway Policy.

• A 12 lead ECG should have been taken due to the history of faints, slight tachycardia and abdominal pain.

• Rather than instructions left for patient to contact her Doctor a safer option would have been for the crew to relay attendance information to the doctor utilising the Out of Hours service.

• The safety netting to discharge patient into care of a friend was a good idea however, the friend needed to be on scene in order to supervise the patient and summon help if required. Due to the patient being on her own discharge at scene was unsafe.

• The PCR was incomplete with inaccurate/misleading information which is contrary to HCPC standards of Conduct and Appropriate Care Pathway Policy.’

77. The details of the proposed Allegation to be faced by the Registrant are set out in the Investigating Committee’s Notice of Decision dated 5 August 2016:

During the course of your employment as a Paramedic for South Western Ambulance Service NHS Foundation Trust (The Trust):

1. 
   On 6 November 2015:
   (a) you did not undertake and/or record a second set of observations for Patient A;
   (b) you did not record a pain score for Patient A;
   (c) you did not undertake an ECG for Patient A;
   (d) you did not ensure that a complete abdominal assessment of Patient A was undertaken;
   (e) you did not review and/or confirm the findings of the abdominal assessment undertaken by your colleague;
   (f) you did not adequately review and/or sign the Patient Clinical Record for Patient A;
   (g)you recorded inaccurate and/or misleading information on the Patient Clinical Record for Patient A, in that you recorded: ‘Advised friend to stay with pt. in meantime’;
   (h) You:
    (i) discharged Patient A at home; and/or
    (ii) discharged Patient A at home without a friend being present;
   2. Your actions described in particular 1 constitute misconduct and/or lack of competence.
   3. By reason of your misconduct and/or lack of competence your fitness to practise is impaired.
       Within the Investigating Committee’s Notice of Decision there is, under    the heading of ‘Learning Point’, the following statement:
   ‘Although the Panel has determined that there is no case to answer, it wants to draw to the Registrant’s attention the need to take full responsibility for the clinical care of patients and to recognise and manage risk appropriately.
2. 78. The HCPC drew the Panel’s attention to the statement that had been made soon after the events in November 2015 by the Registrant’s fellow crew member, that there had been no friend at the patient’s home and the patient had been left on her own by the ambulance crew when they left her. This statement appeared to be contrary to the record entered on the ePCR by the Registrant that patient had been left in the care of a friend.

79. When this matter was before the HCPC’s Investigating Committee in August 2016 there was, according to the decision, the following evidence:
‘The Panel had regard to the Registrant’s response in which he denies that his fitness to practise is currently impaired. The Registrant states that he has reflected on this incident and that, with hindsight, he would have acted differently.

The Registrant advised that he has completed 250 hours of supervised practice and provided a copy of the outcome letter which states ‘You appear to be able to be able to demonstrate clinical ability to undertake the required skills and have the underpinning knowledge base to evidence the action you take […] you are able to return to your full duties with immediate effect’

80. Based on this evidence the Investigating Committee had formed the view that it would be unlikely that there would be a finding of current impairment and so the matter was not taken forward to a final hearing.
 
81. It should be noted that the Registrant had been suspended by his employer at this time and demoted for a period, of about a year, to ECA/technician level.

82. The HCPC drew this Panel’s attention to the similarities of the incident in November 2015, with this case. The case in 2015, involved failure to carry out appropriate proper assessment processes; a lack of accurate recording of observations and information; a service user being left on her own; and the service user being discovered dead in her home four days later.

83. In regard to this issue of similarity of events the HCPC drew to the Panel’s attention the paragraph within the Management Statement of Case that stated:

On reviewing the Patient Clinical Record when the second ambulance attended and the consequent statement of [..] it appears that was dark diarrhoea in the toilet and a large amount of alcohol and cigarettes in the house, which suggested she may have been an alcoholic, which differs from the information gained by the previous crew Nick and [..] on 6 November.’

Police Caution

84. The HCPC has little by way of evidence of the Police Caution but given that the Registrant provided details to the HCPC there arguably should be no doubt of its existence.

Other matters

85.  As stated above, it was noted within the Management Statement of Case dated 25 February 2016 that this was the second SI (serious incident) involving the Registrant. There was reference to a ‘Previous ROP (restriction of practice) on 13 December 2013’. The HCPC has no information as to what these relate to and offers no further evidence on these matters.

HCPC’s submission on sanction

86. The Panel was reminded by the HCPC that there had been a conspicuous sustained lack of insight by the Registrant into the incident on 8 May 2018 and its consequences. The Panel was also reminded of the Registrant’s attitude in his emails to the HCPC, in particular his callous reference to ‘this so called patient’.

87. There was positive evidence of the Registrant’s attitude, frustration and impatience with the whole disciplinary and regulatory process. In particular, the content and tone of his responses in interview and in the disciplinary process where his replies lacked candour and indicated the Registrant’s view that the process was without purpose. He then reinforces his view of the process by handing in his notice and not seeing the matter through to its conclusion. There was therefore serious doubt that the Registrant would re-engage in this process or be willing to comply with any Conditions of Practice if this were the level of sanction the Panel considered appropriate and proportionate.

88. In the HCPC’s view, even without this further historic information of poor conduct, the matters before this Panel are very serious and warrant a sanction at the higher, if not the highest level. Given the further evidence before the Panel of a repetition of the same sort of clinical failings in 2015 as those identified in this case, there must be very serious doubt about the Registrant’s ability to practice safely again now, or in the future.

89. The Panel was reminded that sanctions are not only to provide service user protection but are to uphold and maintain the public confidence in the profession and the regulatory process. Further, sanctions are to act as a deterrent to other fellow professionals not to act in the same way.

Panel decision on sanction

90. The Panel noted the further fresh evidence and the HCPC’s submissions. It accepted the Legal Assessor’s advice and it took into consideration the terms of the HCPC’s Sanctions Policy.
 
91. The Panel appreciated that sanctions are not intended to be a punishment, but to provide service user protection, be in the wider public interest, and to uphold and maintain standards and the reputation of the profession. The Panel has no personal or professional information or evidence from the Registrant that would assist it in balancing his interests in the Panel’s determination of what is the proportionate and appropriate sanction in this instance.

92. As advised, the Panel first set out the mitigating and aggravating features of this case.

Mitigating

• The Panel was unable to identify any mitigating features.
However, the Panel identified a considerable number of aggravating features in this case.

Aggravating

• Sustained denial of wrongdoing.

• Not the first occasion the Registrant has been referred to his professional regulatory body.

• Police Caution for assault.

• No apology for his acts and omissions.

• A total lack of remediation of his identified failings.

• No demonstration any remorse or regret for his actions.

• Failure to participate in these disciplinary proceedings.

• Disrespectful, rude and crude in his language when communicating with his professional body.

• Serious attitudinal disposition.

• A complete lack of insight into his actions, and the impact they had on Patient A.

• Actions and comments that show bias, a lack of care, a lack of humility, lack of compassion and an alarming degree of callousness towards Patient A, her situation, and her subsequent death.

• Serious service user harm caused.

93. Given the length of the list of matters identified above as aggravating features, the Panel considered that it was totally inappropriate for it to consider taking no further action. Nor would the imposition of a Caution Order serve a purpose as it provides no level of service user protection.

94. When considering the issue of the imposition of a more serious sanction the Panel took into account the following information from the Sanctions Policy. These related to the evidence of repetition of concerns and patterns of unacceptable behaviour, and the issues of lack of insight, remorse or apology:

‘Repeated misconduct or unacceptable behaviour, particularly where previously addressed by employer or regulatory action, is likely to require more serious sanctions to address the risks outlined above.

Where a registrant lacks insight, fails to express remorse and / or refuses to apologise in a timely manner, they may pose a higher risk to service users.
Registrants who lack a genuine recognition of the concerns raised their fitness to practise, and fail to understand or take responsibility for the impact or potential impact of their actions, are unlikely to take the steps necessary to safeguard service user safety to address the concerns raised. For this reason, in these cases panels are likely to take more serious action in order to protect the public.’

95. Given this advice within the Sanctions Policy, and the seriousness of this matter, and the fact that the Panel has no evidence of any willingness on the part of the Registrant to comply with the terms of any Conditions of Practice Order even if the Panel was able to construct workable conditions. The Panel considers that a Conditions of Practice Order is neither proportionate nor appropriate.

96. In assessing whether, a period of suspension was the appropriate and proportionate sanction in this case, the Panel considered whether the Registrant’s actions were fundamentally incompatible with him remaining on the Register.

97. The Panel noted that it had nothing before it that would support the view that a period of suspension would be used to good effect by the Registrant to gain insight into his failings and to undertake reflection and further personal development. Further, given the evidence of serious attitudinal issues and the Registrant’s stated intention of having nothing more to do with his profession or his regulator, the Panel has no confidence that the Registrant is capable of accepting or addressing his failings.

98. The Panel considered that the matters found were so serious as to warrant permanent removal from the Register. The list of aggravating features above identify a total lack of the basic requirements of being a Paramedic namely compassion, care, clinical support and professionalism. The Panel considered that anything less than striking off order would undermine the public’s confidence in this disciplinary process and would not have the required deterrent effect on the profession.

99. The Panel has therefore concluded that the appropriate and proportionate sanction in this case is a Striking off Order.

 

ORDER: That the Registrar is directed to strike the name of Mr Nicholas Stock from the Register on the date this order comes into effect.

Interim Order

100. The Panel, having chosen to impose a striking off order, is required to consider the issue of imposing an interim order to cover the period of 28 days during which the Registrant may lodge an appeal, or a period up to 18 months to cover the period during which an appeal is considered by the court.

101. The HCPC made an application for the Panel to consider this matter of an interim order but before doing so, the Panel considered whether it was appropriate to consider this matter in the Registrant’s absence. In this regard the Panel noted that the Registrant had been informed in the letter of 5 June 2019 that this was an issue which the Panel may consider if it imposed a Conditions of Practice Order, Suspension Order or Striking Off Order. The Registrant had therefore been put on notice by the HCPC of consideration of this matter of an interim order.

102. The Panel reminded itself of the matters which had informed its previous decision to proceed in the Registrant’s absence. The body of evidence that supported the view that the Registrant had made an informed and intentional decision to disengage with this process had been considerable. There was no fresh evidence that the Registrant had changed that view that he did not wish to participate. There have been no communications received from the Registrant whilst this hearing had been progressing. The Panel therefore came to the conclusion that no purpose would be served by not considering this matter now. Further, there is public interest in ensuring that a registrant who has been considered a potential risk to service users should not be allowed to return to practice whilst an appeal is considered. The Panel therefore decided to proceed in the Registrant’s absence.

103. The HCPC emphasised the seriousness of the matters found in this case, and the evidence of previous conduct issues, that had supported the Panel’s decision that the ultimate sanction of striking off was the appropriate and proportionate measure in this case. It was submitted that it would place service users at risk if an interim order were not imposed. It was argued that it was proportionate given the Panel comments about this individual’s lack of core abilities that this interim order should be an interim suspension order. It was argued that the interim order should be for the maximum period allowed of eighteen months.

104. The Panel took legal advice and reminded itself of the guidance within the section relating to relating to interim orders within the HCPC Sanctions Policy and also the practice note relating to interim orders.

105. Panel considered that the matters raised were so serious, involving as they did service user harm, as to make the imposition of an interim order necessary for service user protection. It also considered that an interim order was required in this instance in the public interest.

106. Having made that decision, the Panel considered whether service user protection and the wider public interest would be served by the imposition of a conditions of practice order. Given the high potential risk of repetition, and the lack of any information from the Registrant as to his ability and willingness to comply with such a measure, the Panel came to the conclusion that an interim Conditions of Practice was neither proportionate nor appropriate.

107. The Panel has therefore concluded that an interim suspension order is necessary and appropriate and proportionate in this case for service user protection and the wider public interest. This interim order is to be for a period of 18 months which is a period that may be required to cover an appeal being considered if one is lodged.

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.

 

History of Hearings for Mr Nicholas Stock

Date	Panel	Hearing type	Outcomes / Status
16/09/2019	Conduct and Competence Committee	Final Hearing	Struck off