Mr Terence King

Profession: Paramedic

Registration Number: PA34386

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 27/01/2020 End: 17:00 29/01/2020

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

Whilst registered with the Health and Care Professions Council as a Paramedic and employed by East of England Ambulance Service between approximately 2016 and May 2018, you:

1. Deliberately recorded incorrect details relating to Morphine usage in:

a. Your controlled drugs records book; and/or
b. Patient Care Records.

2. Hid ampoules of Morphine during Morphine checks.

3. Used Morphine from the same ampoule on two separate patients on two or more separate occasions.
 
4. Used a single use only syringe on more than one patient on approximately three occasions.

5. Your actions set out in particulars 1(a) and/or 1(b) and/or 2 were dishonest.

6. The matters set out in paragraphs 1-5 constitute misconduct.

7. By reason of your misconduct your fitness to practise is impaired.

 

Finding

Preliminary matters:

The HCPC’s Application to amend the allegation 

1. Ms Sheridan, on behalf of the HCPC, applied to amend the particulars of the allegation in the following terms:

Whilst registered with the Health and Care Professionsal Council as a Paramedic and employed by East of England Ambulance Service between approximately January 2017 2016 and May 2018, you:

1. Deliberately falsified recorded incorrect details relating to Mmorphine usage in records:

a. Your controlled drugs records book; and/or
b. Patient Care Records.

2. Hid ampoules of Morphine during Morphine checks.

3. 2 Used Morphine from the same ampoule on two separate patients on two or more separate occasions.
4. 3 Used a single use only syringe on more than one patient on approximately three occasions.

5. 4 Your actions set out in particulars 1(a) and/or 1(b) and/or 2 were dishonest.

6. 5 The matters set out in paragraphs 1-5 4 constitute misconduct

7. 6 By reason of your misconduct your fitness to practise is impaired.


2. Ms Sheridan submitted that the proposed amendments would ensure that the allegation more accurately reflected the HCPC’s case and the evidence.   The amendments further particularise the allegation and clarify the HCPC’s case. There are also minor typographical amendments.

3. Ms Sheridan submitted that the Registrant had been given substantial notice of the proposed amendments. She submitted that the amendments do not change the gravity of the case against the Registrant, that none of the proposed amendments are prejudicial to him and that they will enable him to understand clearly the HCPC’s case against him.  

4. The Registrant confirmed he had no objection to the amendments.

5. The Panel received advice from the Legal Assessor.  The Panel was satisfied that no unfairness or prejudice was caused to the Registrant by allowing the amendments.  The Registrant had been given ample notice and had not submitted any objection, either in advance of or at the hearing. The Panel was satisfied that the amendments sought clarified the allegation and did not affect the gravity of the case against the Registrant, but provided clarification and greater specificity.  The Panel agreed to all the amendments sought. 

Registrant’s response to the allegation

6. The Registrant admitted the facts alleged in particulars 1 to 5 (as amended).

Documents

7. The Panel received a paginated bundle of documents running to page D227 and a copy of the Health and Social Care Act 2008 and associated guidance, running to page D325.

8. During the hearing the Registrant submitted documents, namely a letter to him from the Trust dated 20 June 2018 (R1) and four “QA5 Quality Assurance Summative Assessments”, dated 2 October 2018, 29 January 2019, 29 May 2019 and 3 December 2019 (R2).

Background:

9. The Registrant is a Paramedic registered with the HCPC.  At the relevant time, he was employed at East of England Ambulance Service (“the Trust”) as a Senior Paramedic at Thetford Station.

10. Concerns came to light when, on 3 May 2018, CH, the Thetford Station Supervisor, found a pouch containing 3x 10 mg ampoules of Morphine Sulphate and 7.5 mg of Morphine Sulphate, drawn up in a syringe with saline, inside the bag on the filing cabinet in the supervisor’s office at Thetford Ambulance Station.  The bag was labelled as belonging to the Registrant.  The Morphine was not recorded in the Registrant’s controlled drugs book. CH submitted a DATIX, a clinical incident reporting tool, recording his concerns. This led to a further investigation which was conducted by LS, an interim Senior Locality Manager for the Trust. 

11. Subsequently, the HCPC received a self-referral from the Registrant.

Summary of evidence of the HCPC’s witnesses

Witness – CH

12. CH confirmed the truth of his witness statement. At the time when the concerns came to light, CH was the Registrant’s Line Manager and was Thetford Station Superviser. He had described the Registrant as a Senior Paramedic, which meant that he had responsibility for mentoring and supervising students. 

13. CH explained that the pouch in which the Morphine was found was like a “pencil case”.  He said that as a controlled drug, Morphine should be kept securely and locked away.  At the time, the Trust was moving from personal issue to station-based Morphine.  The Paramedics’ personal issue Morphine was signed in and out of the hospital pharmacy by the Paramedic and was their own responsibility. Each Paramedic was required to record their Morphine administration in their personal issue controlled drugs record book. Entries were to be made in these books and witnessed on each occasion when a controlled drug was used. 

14. Personal issue Morphine would be kept securely in the Paramedic’s home, car or in a locked box when not on duty.   CH confirmed that it was also not usual for Paramedics to have pre-drawn up Morphine in their bags.  Any Morphine that had been drawn up and partially used should be disposed of, and the disposal should be witnessed and recorded. 
  
15. When the concern came to his attention on 3 May 2018, CH consulted with his colleague, SB.  They spoke to the Registrant on the telephone and he said words to the effect of “I’ve been found out” and “I’ve made a big mistake”. 

16. Subsequently, the Registrant, who was on a rest day, was asked to come into Bury St Edmunds ambulance station.  He told CH and SB regarding the drawn-up Morphine that he had been trying to save the Trust money by saving Morphine leftover from one patient in his bag for administration when another patient required Morphine.  CH explained that this was not safe or hygienic and put other patients at potential risk of harm from cross contamination and infection. 

17. The Registrant told CH he had been following this practice for years.  CH had been carrying out the monthly Morphine checks when the Morphine physically held by the Paramedic was checked to ensure that it tallied with the record of Morphine issued.  As CH had not noticed any discrepancies, CH concluded that the Registrant must have been making false entries in the usage records. This also concerned CH, as patient safety could be affected if Morphine use was not recorded properly.  When CH told the Registrant that he believed that he (the Registrant) must have been lying, the Registrant apologised. 

Witness LS

18. LS confirmed the truth of his witness statement. He is an HCPC registered Paramedic and, at the relevant time, was employed in an interim role as a Senior Locality Manager for the Trust. LS was appointed to investigate the concerns reported by CH. 

19. LS produced, and referred in his evidence, to the June 2018 report he prepared following his investigation (“the Report”). The Report produced the evidence and documentation gathered during the investigation. LS also made reference to the Trust’s Medicines Management Policy which set out the procedures for the administration and management of controlled drugs and to relevant provisions of the Health and Social Care Act 2008 concerning single use medical devices. 
  
20. LS told the Panel that the Registrant had provided a written statement dated 3 May 2018 in which he admitted that he had recorded Morphine use in his controlled drug book incorrectly on several occasions.  He explained that if he used the same ampoule for two different patients, he would make a record in his book as if he had used two different ampoules.  

21. As part of his investigation, LS had interviewed the Registrant on 22 May 2018.  LS produced the written record of the interview which was signed by the Registrant as true and accurate. At the interview, the Registrant made a number of admissions.

22. In respect of using the same ampoule for two patients, the Registrant stated that this had happened on three occasions and that the entries relating to the batch numbers, expiry date and remaining balance would have been incorrect.   The Registrant admitted to fraud and offered no mitigation.  LS explained that this contravened the Trust Infection Prevention and Control Policy.  LS told the Panel that it would be acceptable to use the remainder of a partly-used ampoule of Morphine on the same patient later, but not for a different patient. The left-over Morphine should have been destroyed in the presence of a colleague and the destruction recorded in the Controlled Drugs book or patient care record.

23. The Registrant also admitted to LS that he had been dishonest at the monthly Morphine checks and said that he had kept his spare ampoules in another pouch during the checks and only showed the morphine he was supposed to be holding.  Again, he admitted to fraud and offered no mitigation.   LS stated that it had not been possible to identify which entries in the controlled drugs book were false, as the Registrant himself did not know. The Registrant also admitted that he recorded incorrect Morphine batch numbers on patient care records.  LS told the Panel it was a requirement of the Medicines Management Policy to record batch numbers on patient care records. These were legal documents.  LS stated that it had not been possible to identify which entries in the patient records were incorrect, as the Registrant himself did not know.  The Registrant admitted to fraud and offered no mitigation.

24. The Registrant admitted to breaching the Trust’s Medicines Management Policy and accepted that he was fully familiar with it.  He admitted to fraud and offered no mitigation.   LS stated that it had not been possible to identify which entries in the controlled drugs book, were false as the Registrant himself did not know.

25. LS told the Panel that Morphine is administered by Paramedics through a cannula inserted into a patient’s vein.  A syringe is inserted in a port at the top of the cannula.  The Registrant admitted using the same syringe on more than one patient on three occasions. LS said that the Registrant would have known that the syringes were single use, as this was marked on the packaging.  LS referred to the provisions for this in the Trust’s Infection Control Policy and also in the Health and Social Care Act 2008.

26. LS said that, at the interview, the Registrant said that he had been trying to save the Trust money and that he did not like to see Morphine wasted.  LS confirmed that he was not aware of any specific harm having been caused to patients by the Registrant’s actions and there had been no complaints.  LS also confirmed that during his investigation, the Registrant had been “honest, co-operative and took full responsibility for his actions”.

The Registrant’s case

27. The Registrant represented himself at the hearing.  He made full and frank admissions to the facts alleged.  He admitted that he had acted dishonestly.

28. The Registrant gave evidence on oath and submitted to cross-examination and questions from the Panel. He maintained the full and frank admissions to the particulars of the allegation which he had made at the time of the Trust’s investigation, and as recorded in the written documentation. He expressed remorse and regret for his actions

29. The Registrant told the Panel he now recognised that he had acted stupidly in not admitting the initial incident and allowed the situation to continue, leading him to repeat his conduct on further occasions. He had accepted that in seeking to conceal his actions, he had acted dishonestly by deliberately hiding the Morphine he had accumulated from the Trust management at monthly controlled drug book checks.  He also accepted that, in order to conceal his actions, he had made false entries in the controlled drugs book and in patient records cards in respect of the batch numbers of Morphine.

30. As he had at the Trust investigation stage, the Registrant accepted in evidence at the hearing that he was aware of the Trust’s Medicines Management policy and the provisions of the Health and Social Care Act 2008 in relation to single use medical devices and that his actions had contravened these provisions. 

31. The Registrant said that at the time he had not realised, or acknowledged, the risk of harm caused to patients by his actions in using a single use syringe twice in respect of two different patients.  He thought that flushing the syringe with saline addressed the cross-contamination risk, but since the risk had been pointed out to him, he understood and accepted that his actions had posed a risk to patients.

32. The Registrant wished to assure the Panel that he had not acted for personal gain or with malice and that he had sought to provide good care to his patients. He accepted that he found it difficult to provide an explanation for why he had acted as he had.  He accepted that he could not be sure that his actions would not have continued, had they not come to light and been stopped by the Trust.

33. The Registrant told the Panel that at the time of the Trust’s investigation, he had believed that his career as a Paramedic would be ended as a result of these matters and had offered his resignation.  When the Trust issued a Final Written Warning and allowed the Registrant to remain in its employment, it set out a programme of six actions which he must complete. These were set out in a letter from the Trust dated 20 June 2018 confirming the decision of the disciplinary process and exhibited as R1.  Overall, the Trust’s programme continued from July 2018 until December 2019.  The Registrant told the Panel that the required actions were now complete and that he is working without restriction as a Paramedic at the Trust.  

Witness LB  

34. LB is an HCPC registered Paramedic and is currently employed by the Trust as Leading Operations Manager. LB was present at this hearing as support for the Registrant.  With the consent of the Panel, and the agreement of the HCPC, he was called by the Registrant to give evidence relevant to the Panel’s consideration of current impairment.  LB was not involved in the Trust’s disciplinary process in respect of the Registrant, but oversaw aspects of the programme subsequently put in place by the Trust for the Registrant.

The Panel’s approach

35. In the light of the full admissions to fact made by the Registrant, the Panel, with the agreement of both parties, considered its findings on facts, ground and current impairment of fitness to practise as one stage, following all the evidence and submissions.  However, as reminded by the Legal assessor, it was careful to consider each stage separately and sequentially, and to consider only the evidence relevant to each decision.

The parties’ submissions

36. Ms Sheridan for the HCPC submitted that the facts of all particulars could be found proved by the admissions made by the Registrant, and were also supported by the HCPC’s witness and documentary evidence.

37. Ms Sheridan submitted that, if proved, the facts, which included an allegation of dishonesty and clinical failings which breached the HCPC’s Standards of Conduct, Performance and Ethics, amounted to misconduct.  The HCPC’s position was that the Registrant’s fitness to practise is currently impaired in relation to both the personal and public components of impairment.

38. The Registrant told the Panel he had been as honest as he could be during this and the Trust’s process.  He had fully accepted his failings throughout.  He accepted that he had not met the standards expected by the profession, the public and himself. He accepted the facts and described misconduct as “self-evident”.

39. In respect of the personal component of current impairment, the Registrant submitted that he had fully complied with the Trust’s requirements and had now been in practice for 18 months since these events without further issues.  He had taken responsibility for his actions and was confident he would not act in such a foolish way again. In respect of the public component, he asked the Panel to accept that the risk of repetition was low.  He had fully accepted blame, had learned from his past actions and asked to be allowed to move forward in his practice.   

Decision on facts:

40. The Panel received and accepted advice from the Legal Assessor.  The Panel was reminded that the burden of proof is upon the HCPC which brings the allegations.
 
41. The standard of proof in HCPC proceedings is the civil standard, on the balance of probabilities, meaning that before finding a fact proved, the Panel must be satisfied it is more likely than not that it occurred.

42. The Registrant had made admissions to all the factual particulars of the allegation, which the Panel was entitled to take account and accept.

43. In relation to particular 5, it was alleged that the Registrant had acted dishonestly.  The Panel was reminded by the Legal Assessor of the test to be applied as set out in Ivey v Genting Casinos (UK) Ltd. t/a Crockfords [2017] UKSC 67, at paragraph 74.

44. The Panel was reminded that it should reach its own decisions in this matter, uninfluenced by the outcome of the Trust’s disciplinary process which the Registrant had put in evidence, per the case of Enemuwe v NMC [2015] EWHC 2018 Admin.  The Panel should take into account the evidence as to the Registrant’s remedial actions only in its consideration of current impairment (although it may be relevant again at the sanction stage, if reached). 
   
45. The Panel first considered the issue of witness credibility.

Witness CH

46. The Panel found witness CH to be an honest and credible witness.  If he was unsure of any details, he was willing to say so.  He showed no malice towards the Registrant.  The Panel accepted the evidence of CH. 
 
Witness LS

47. The Panel similarly found LS to be a credible witness. He gave evidence of his investigation in a straightforward manner and also showed no malice towards the Registrant.
  
The Registrant

48. The Panel recognised that as an unrepresented registrant, the hearing process was difficult for the Registrant. At times he was understandably nervous.    However, the Panel accepted that he was honest and frank and he openly accepted his failings.  He engaged and co-operated fully with the process.
 
Witness LB

49. LB gave evidence relevant to the impairment stage. He had worked with the Registrant regularly from 2008 to 2012 and less frequently after he was promoted.  The Panel found him to be open and honest.  His evidence was helpful and the Panel accepted it.  

50. The Panel accepted the Registrant’s full admissions to facts. The Panel considered the written statement of the Registrant dated 3 May 2018, the written record of the interview with the Registrant by LS on 22 May 2018, which the Registrant had signed to confirm as accurate, and the Registrant’s detailed, undated reflective piece.  In these various accounts, including in his oral evidence to the Panel at the hearing, the Registrant had frankly and consistently admitted his past actions. 
  
51.  The Panel also considered carefully the oral evidence of the witnesses and the documentary evidence presented in support of each factual particular and sub-particular in the allegations.

52. In respect of particulars 1(a) and 1(b), the Panel saw a copy of the controlled drugs book and received evidence from CH and LS. The Panel noted the admission in the Registrant’s initial statement were given at the time of discovery of the incidents, on 3 May 2018.

53. In respect of particular 2, the Panel had sight of the DATIX record and the evidence of CH and LS.  The Registrant clearly explained in his evidence the process by which he had hidden ampoules of Morphine at the monthly checks.
 
54. In respect of particular 3, the Panel accepted the admission of the Registrant and took into account the evidence of CH and LS.  Again, the Registrant in his evidence explained the detailed the process he had followed.
  
55. The Panel also accepted the Registrant’s admission to particular 5 that he has acted dishonestly in respect of the recording of incorrect details in the controlled drugs book and patient care records, and in hiding ampoules of Morphine during the monthly Morphine checks. The Registrant admitted that he deliberately concealed his actions and that he recognised at the time that, in doing so, he was acting dishonestly.  He accepted in cross-examination that ordinary, decent members of the public would consider his actions to be dishonest. 

56. The Panel was satisfied that the Registrant’s actions in respect of particulars 1(a), 1(b) and 2 were dishonest by the objective standards of ordinary, decent people, as per the Ivey test.
   
57. On the basis of the admissions of the Registrant, the evidence of CH and LS and the documentary evidence produced, the Panel found the facts of all the particulars, 1-5, proved.
 
Decision on the alleged ground – misconduct.

58. The Panel considered the submissions of Ms Sheridan and of the Registrant.  It received and accepted the advice of the Legal Assessor.  The Panel bore in mind that the issue of misconduct was a matter for its own judgment and took account of the guidance from the case law relating to the meaning of misconduct.

59. With regard to misconduct, the Panel bore in mind the guidance of Lord Clyde in Roylance v GMC [No 2] 2000 1 AC 311 and also reminded itself that not every falling short of the expected standard amounts to misconduct: the falling short must be serious and may be considered deplorable by other professionals. 

60. The Panel concluded that the findings of fact in this case were serious and fell far short of the required standards.  The clinical issues presented a risk of harm to patients. These involved the deliberate mishandling of a controlled drug.  Paramedics hold a privileged position in being able to administer Morphine which the Registrant did not respect.   The dishonest conduct was deliberate and serious and had continued over an extended period of time. It involved concealing his actions from his colleagues and employers by falsifying documents, including patient care records, which are legal documents.   There were numerous opportunities for the Registrant to remedy his dishonesty but he did not do so.  The Registrant himself told the Panel he thought the public would consider his conduct “appalling”.  The Panel concluded that fellow professionals would consider the conduct deplorable.  The Panel considered in this case that the following paragraphs from the HCPC standards were relevant and were not met:
 
HCPC Standards of Conduct, Performance and Ethics (January 2016 edition)

• 6.1 You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.
• 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 - Manage risk
• 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
 Making sure that service users or where appropriate, their carers, receive a full and prompt explanation of what has happened and any likely effects.

• 9.1 You must make sure that your conduct justifies the public’s trust and confidence in you and your profession.
• 10.1 You must keep full clear and accurate records for everyone you care for, treat or provide other services to.

61.  The Panel was of the view that the conduct proved fell far short of the expected standards and amounts to misconduct. 

Decision on Impairment of Fitness to Practise

62. The Panel next considered whether by reason of the Registrant’s misconduct his fitness to practise is currently impaired.

63. In considering current impairment, the Panel accepted the advice of the Legal Assessor and had regard to the HCPTS Practice Note “Fitness to Practise Impairment” of December 2019.

64. Impairment is a matter for the judgment of the Panel. The Panel kept in mind that not every finding of misconduct will necessarily result in a conclusion that fitness to practise is currently impaired. The Panel was also mindful that it must consider the currency of the alleged impairment.

65. The Panel was mindful that it should consider the personal and public components of current impairment. In relation to the personal component, the Panel considered whether there was any evidence that the failings were capable of being remedied, whether there was evidence that they have been remedied and whether there was a risk of repetition.

66. The Panel took into account the evidence presented by the Registrant and his witness, LB, as to the programme put in place by the Trust to support the Registrant following the conclusion of its disciplinary process in June 2018. This involved:

“1.1 to 1 meetings with the relevant Medicine Management Lead (LB) and ICP lead to discuss relevant policies associated with medicines management;
2. Reflective Written Practice and Learning outcomes;
3. 10 x Patient Records Forms (per month) to be reviewed randomly by the Designated Manager (DLO) or SLM for a period of 12 months;
4. Quarterly reviews to be held with the SLM OR Designated Manager;
5. Observation shifts with a DLO X4 over a 12 month period;
6. Work with a paramedic for the first month to support back into the workplace.” 

67. The Panel took into account the evidence of LB who had been personally responsible for overseeing points 1, 3, 4 and 5.  He confirmed that the Registrant had complied successfully with all the 6 elements of the Trust programme, that there had been no further concerns and that the Registrant was now practising as a Paramedic at the Trust without restriction. 

68. The particulars found proved related to clinical failings and the issue of dishonest conduct. In respect of the clinical failings, the Panel was satisfied that these were capable of being remedied. The Registrant provided the Panel with reassurance that these issues had been remedied by means of the programme put in place by the Trust.  The Registrant had fully accepted the clinical failings and expressed remorse and shame at his actions.  Whilst he accepted that he was aware at the time of the Trust’s medicines management policy, he also accepted that he had not fully appreciated the infection and cross-contamination risks to the public arising from his conduct in using the same ampoule of Morphine on two patients and re-using a single use syringe. He now accepted that the risk, albeit there was no evidence of actual harm being caused to patients, was potentially serious.   

69. In respect of the clinical issues, the Panel was satisfied the Registrant had complied fully with the Trust’s programme, had developed insight and understanding of the clinical concerns.  He had practised for the past 18 months without further issues, as confirmed by LB.  The Panel noted that the Trust had been supportive of the Registrant and continues to employ him as a Paramedic. 

70. The Panel was mindful that dishonest conduct is usually difficult to remedy.  The Panel acknowledged the Registrant’s full and frank acceptance that his conduct had been dishonest.  He accepted that he had knowingly and deliberately sought to conceal his initial actions from his managers and colleagues by making false entries in the controlled drugs book and the patient care records.  He accepted that he was aware of the seriousness of these actions, given that patient care records are legal documents, and of the concern that, if batches of Morphine were wrongly recorded, they would not be able to be traced in the event of an incident or recall. 

71. The Panel observed that the Registrant’s dishonest concealment of the true position had continued over an extended period of time.  For example, he had repeatedly concealed the discrepancies in respect of the Morphine at monthly checks over the period of 18 months.  

72. The Panel took into account the Registrant’s reflections in respect of dishonesty, in his oral evidence to the Panel and in his detailed reflective piece.  However, the Registrant’s explanations were in the Panel’s view undermined by his inability to provide any logical rationale for his conduct in retaining a partly-used ampoule of Morphine. He was confused and unable to give a logical explanation. The Panel noted that initially he had referred to saving the Trust’s resources. The Panel heard evidence that the cost of Morphine is not significant; there was no evidence, as the Trust had accepted in its investigation, of re-sale of the drug or of any personal use by the Registrant. In his oral evidence, he retreated from this explanation, stating “the money was just me trying to justify it, it was really no thought of money.”  The Registrant was unable to offer any alternative explanations for his actions. It was the retention of a partly used ampoule of Morphine which had led to the Registrant’s further attempts to conceal his actions. 

73. The Panel concluded that the Registrant had made efforts to demonstrate remediation and insight into his past conduct.  However, in the absence of any real explanation for the dishonest conduct, the Panel could not be reassured that insight could be demonstrated or that that there did not remain a risk of repetition.   

74. In relation to the personal component of impairment, the Panel was satisfied that the clinical issues had been sufficiently addressed.  The Panel could not be so satisfied in respect of the dishonest conduct. 

75. The Panel considered the public component.  The Panel concluded that the public had been placed at risk of harm by the Registrant’s conduct. The Panel was mindful that it must consider the wider public interest.   The Panel was of the view that public confidence in the Paramedic profession would be undermined if a finding of impairment were not made in these circumstances.

76. The Panel accordingly found that the Registrant’s fitness to practise is currently impaired in respect of both the personal and public components of impairment. 
 
Panel decision on sanction

77. Ms Sheridan made submissions on the issue of sanction. She did not propose a particular sanction in this matter, but referred the Panel to relevant sections of the HCPC Sanctions Policy of March 2019. Ms Sheridan referred to the authority in the case of Igboaka V GMC [2016] EWHC 2728 (Admin) at paragraph 52, stating that clinical excellence cannot mitigate findings of dishonesty and that “Medical professionalism requires honesty and integrity as well as clinical competence.  The profession itself depends on the relationship of trust. Patients and the public more generally are entitled to expect medical professionals to be both fully competent and honest.  In cases of proven dishonesty, a severe sanction is to be expected because the balance will generally fall down in favour of maintaining confidence in the profession, notwithstanding that the doctor had had an exemplary professional career”.  

78. In his submission, the Registrant repeated his apology for his past conduct and said that he would leave the issue of sanction for the decision of the Panel.

79. The Panel received and accepted the advice of the Legal Assessor.  The Panel was aware that the purpose of a sanction is not to be punitive, though a sanction may have a punitive effect. The Panel bore in mind that its primary function at this stage was to protect the public, while reaching a proportionate sanction, taking into account the wider public interest and the interests of the Registrant. The Panel referred to the HCPC’s Sanctions Policy and applied it to the Registrant’s case on its own facts and circumstances.


80. The starting point for the Panel was that the Registrant’s misconduct was serious. There were findings of a pattern of dishonest conduct. The Registrant had accepted and shown remorse for this, but the Panel had residual concerns about his level of insight into his dishonesty and the continuing risk of repetition.  The Panel had found that the Registrant’s clinical failings had put patients at risk of harm, but was satisfied that the remedial steps taken with the support of his employer had addressed these aspects. 

81. The Panel considered the mitigating and aggravating factors present in this case. 

82. The Panel identified the following aggravating factors:

• The Registrant was a Senior Paramedic with responsibilities for mentoring and overseeing students;
• He was a Paramedic with a significant level of experience and responsibility at the time in question;
• The dishonesty was not isolated, but took place over a period of approximately 18 months – for example at the monthly controlled drug checks;
• During this period the Registrant had repeated opportunities to come forward and put matters right, but did not do so; he only stopped when his actions were discovered by the Trust;
• There was a real risk of patient harm as a result of his clinical actions;
• His actions in relation to the handling of controlled drugs were serious.

83. The Panel identified the following mitigating factors:

• The Registrant has not previously been the subject of any regulatory findings;

• Prior to these events, he had a long unblemished career as a Ambulance Technician and as a Paramedic;

• He has practised for 18 months since these events with no further concerns;

• He has been open and frank about his actions since these events came to light in May 2018; 

• He expressed shame and remorse and throughout has fully admitted both his dishonest conduct and his clinical failings;

• He has made no personal or financial gain from his actions;

• There is no evidence of actual harm being caused to patients;

• He has engaged and co-operated with the Trust investigation and the HCPC process;

• He has demonstrated insight into his clinical failings in relation to patient safety and the handling of controlled drugs.

84. In light of all of the circumstances, the Panel referred to the Sanctions Policy in deciding what sanction, if any, should be applied. The Panel made particular reference to the guidance where dishonesty has been found, at paragraphs 56 to 58. These paragraphs highlighted the seriousness of dishonesty and reflected the comments to which the Panel’s attention had been drawn by Ms Sheridan in the case of Igboaka.

85. The Panel took a proportionate approach in considering any sanction and considered its powers in ascending order of seriousness.

Mediation

86. This was not appropriate as the issues found proved were too serious to be addressed by means of mediation.

No Further Action

87. Given the risk of harm to the public interest and the finding of dishonesty, no further action was inappropriate in a case of this seriousness.

Caution

88. The factors indicating that a Caution Order may be appropriate were not present: the dishonesty issue was not isolated or minor in nature, the Panel was not reassured at this stage that the risk of repetition was low; there were concerns about the adequacy of the Registrant’s insight and he had not undertaken adequate remediation. The Panel also considered that a Caution would be insufficient to mark the seriousness of the Panel’s findings and to maintain public confidence in the Paramedic profession.

Conditions of Practice Order

89. The Panel did not consider this was a case in which conditions of practice were appropriate. Whilst it accepted that the Registrant would be willing to comply with conditions, it was not possible to formulate conditions which could address this finding of dishonesty.

90. The Panel decided that a Conditions of Practice Order would not be effective in marking the seriousness of the findings, nor would such an order protect the public interest.
     
Suspension

91. The Panel considered whether a period of suspension would be appropriate.

92. The Panel has found that the Registrant has developed insight regarding the clinical findings.  He has completed the programme put in place by his employer which addressed these concerns. He has worked without further issue since the matters came to the attention of the Trust, some 18 months ago.
 
93. In relation to the dishonesty aspect, the Panel had continuing concerns, as dishonesty is more difficult to remedy.  The Registrant has gone some way to developing insight into this aspect by demonstrating throughout this process full acceptance and contrition for his actions, and by his engagement with the HCPC process. He recognises that he acted foolishly and has assured the Panel there is no risk of his repeating such behaviour in the future. However, the Panel’s concern is that he has not yet been able to provide a satisfactory explanation for why he initially acted as he did, or why he continued to conceal his actions over a substantial period of time.  The Panel was not satisfied that he yet has sufficient insight into the seriousness of those actions.  However, the Panel took the view that by further reflection, in particular having undergone this hearing process, the Registrant could achieve greater insight.  

94. The Registrant has had an unblemished career prior to these matters and, with the support of his employer, has practised safely in the 18 months since these events.  He has shown commitment to remedying his past failings and has gone some way to developing insight into the past dishonesty. The Panel, after careful consideration, concluded that a suspension order would be sufficient to mark the seriousness of the matter and maintain public confidence in the Paramedic profession and the regulatory process.  It takes the view that members of the profession and the public who were aware of the circumstances of this case would consider a period of suspension to be an appropriate and proportionate sanction.  A period of suspension would also provide an opportunity for the Registrant to address the issue of insight regarding dishonesty and then at a future review hearing to satisfy a future hearing panel of his fitness to practise.

Striking off order

95. Having concluded that a suspension order would be appropriate, the Panel went on to consider whether the ultimate sanction, a striking off order, was required in this case.  The Panel was mindful that where dishonesty has been proved, striking off will often be appropriate.  The Panel considered the factors in the Sanctions Policy, this was not a case where the Registrant lacked any insight - he has developed some insight and the Panel considers that this is an ongoing process for the Registrant.  He is not unwilling to resolve matters.  There has been no repetition of any of his past misconduct since the events in question and he has worked safely with the support of his employer for a substantial period.   After thorough consideration, the Panel concluded a striking off order would be disproportionate and unduly punitive.

Decision

96. The Panel determined to impose a Suspension Order for a period of 12 months.  This period will demonstrate the seriousness of the matter to the profession and the public. There will be a review hearing before the conclusion of the suspension period, when the Registrant will be required to satisfy the reviewing panel that he is fit to return to unrestricted practice. 

97. Whilst this Panel cannot bind the future review panel, that panel is likely to be assisted by evidence of further reflection by the Registrant on the dishonesty issues and by character references from any employer for whom he works in any paid or unpaid capacity during the suspension period.    

Order

That the Registrar is directed to suspend the registration of Mr Terence King for a period of 12 months from the date this order comes into effect.

Notes

Interim Order

Application for an Interim Order:

1. Ms Sheridan made an application for an Interim Suspension Order to cover the appeal period, on the grounds that it was necessary for the protection of the public and was otherwise in the public interest.

2. The Registrant did not make submissions to the Panel. 

3. The Panel accepted the advice of the Legal Assessor. It bore in mind that an interim order in these circumstances is discretionary.  The Panel must consider whether an interim order is required, applying the test set out in Article 31(2) of the Health Professions Order 2001, and if it so decides, must act proportionately.  This means balancing the public interest with the interests of the Registrant, and imposing the lowest order which will adequately protect the public.

4. The Panel was referred to the guidance in respect of immediate interim orders in the Sanctions Policy and the HCPTS Practice Note, Interim Orders, of 12 September 2017. 

5. The Panel considered the issue of proportionality and balanced the interests of the Registrant with the public interest.  The Panel had determined to impose a substantive Suspension Order on the basis that there was a residual risk of harm to the public arising from the Registrant’s lack of sufficient insight into his past dishonesty and in the public interest, in order to maintain public confidence in the profession.  The Panel took into account that the Registrant has been practising until this hearing.  However, given the gravity of the issues and the sanction imposed, the Panel considered it would be inconsistent not to impose an immediate interim order of suspension to address the residual risk and public interest issues. 

6. The Panel considered whether interim conditions off practice would be appropriate, but concluded that conditions which would address the Panel’s concerns could not be formulated. 

7.  Accordingly, the Panel determined that an interim order of suspension was necessary in order to protect the public and in the wider public interest.    

8.  The Panel concluded that the appropriate and proportionate duration of the interim suspension order was 18 months, as the interim order would continue to be required pending the resolution of an appeal in the event of the Registrant giving notice of an appeal within the 28-day period.

Interim Order:

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

Hearing History

History of Hearings for Mr Terence King

Date Panel Hearing type Outcomes / Status
27/01/2020 Conduct and Competence Committee Final Hearing Suspended