Miss Lisa Chadwick
Profession: Paramedic
Registration Number: PA40637
Hearing Type: Final Hearing
Date and Time of hearing: 10:00 22/06/2020
End:
17:00 25/06/2020
Location:
Virtual Hearing
Panel: Conduct and Competence Committee
Outcome: Conditions of Practice
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Allegation
On 26 August 2016, whilst registered as a Paramedic and employed by the
North West Ambulance Service, you attended Service User A and you:
1. Made inappropriate comments to the effect that:
a) Service User A was not unwell or was feigning illness
b) Regarding not lifting Service User A, you asked who would
look after your children if you hurt your back
c) You told Service User A to ‘get up’ or words to that effect
when she collapsed
2. Did not communicate appropriately with Service User A and/or
her family, in that:
a) Following Service User A’s collapse, you did not update
Service User A’s family before transporting Service User A to
the hospital.
b) You did not inform Service User A [or her family] of her potential
diagnoses and the risks associated with those.
3. Did not complete and/or record an adequate clinical
assessment and/or examination.
4. Walked Service User A to the ambulance, despite her being
tachypnoeic and/or without offering appropriate assistance.
5. Did not provide a wheelchair to Service User A despite this
being requested by Person B.
6. Did not assist Service User A to stand when she collapsed on
multiple occasions.
7. Did not provide care to Service User A in a timely manner following
her collapse.
8. Did not transport Service User A to the hospital in a timely manner
despite Service User A hyperventilating
9. Did not provide an adequate treatment plan in response to Service
User A’s hyperventilation
10. Did not complete and/or record regular observations of Service
User A
11. Did not assist Service User A to travel down the stairs,
including by not using a track chair
12. Informed your employer that care was provided to Service User
A in a timely manner following her collapse, when this was not the
case.
13. Your actions as described at paragraph 12 above were
dishonest.
14. Your actions as described at paragraphs 1 – 11 above
amounted to misconduct and/or lack of competence.
15. Your actions as described at paragraphs 12 – 13 above
amounted to misconduct.
16. By reason of your misconduct and/or lack of competence, our
fitness to practise is impaired.
Finding
Preliminary Matters
Service of Notice
1. The notice of this Hearing was sent to the Registrant at her address as it appeared on the register on 9 December 2019. The notice contained the date, time and venue of today’s hearing.
2. The Panel accepted the advice of the Legal Assessor and was satisfied that notice of today’s Hearing has been served in accordance with Rule 6(1) of the Conduct and Competence Committee Rules 2003 (the “Rules”).
Proceeding in the absence of the Registrant
3. The Panel then went on to consider whether to proceed in the absence of the Registrant pursuant to Rule 11 of the Rules. In doing so, it considered the submissions of Ms Constantine on behalf of the HCPC.
4. Ms Constantine submitted that the HCPTS has taken all reasonable steps to serve the notice on the Registrant. She told the Panel that the Registrant had not substantially engaged with the process and that the Registrant’s last contact to the HCPC was on 31 January 2020, when she submitted a bundle of references for the consideration of the Panel. Ms Constantine reminded the Panel that there was a public interest in this matter being dealt with expeditiously.
5. The Panel accepted the advice of the Legal Assessor. He advised that, if the Panel is satisfied that all reasonable efforts have been made to notify the Registrant of the hearing, then the Panel had the discretion to proceed in the absence of the Registrant. He cautioned the Panel that the discretion was to be exercised with care and caution as set out in the case of R v Jones [2002] UKHL 5.
6. The Legal Assessor also referred the Panel to the case of GMC v Adeogba and Visvardis [2016] EWCA Civ 162 and advised the Panel that the Adeogba case reminded the Panel that its primary objective is the protection of the public and of the public interest. In that regard, the case of Adeogba was clear that “where there is good reason not to proceed, the case should be adjourned; where there is not, however, it is only right that it should proceed”.
7. It was clear, from the principles derived from case law that the Panel was required to ensure that the interests of fairness and justice were maintained when deciding whether or not to proceed in a Registrant’s absence.
8. The Panel was satisfied that all reasonable efforts had been made by the HCPTS to notify the Registrant of the hearing. It was also satisfied that the Registrant is aware of the hearing.
9. In deciding whether to exercise its discretion to proceed in the absence of the Registrant, the Panel took into consideration the HCPTS Practice Note entitled ‘Proceeding in the Absence of a Registrant’. The Panel weighed its responsibility for public protection and the expeditious disposal of the case with the Registrant’s right to a fair hearing.
10. In reaching its decision the Panel took into account the following:
• The Registrant sent an email on 13 January 2020 to the HCPC, stating that she is unable to attend this hearing because she is unable to take time off nor is she able to financially afford to travel to London and stay for the entirety of the hearing;
• The Registrant has not made an application to adjourn today’s hearing and implicit in her email sent on 13 January 2020 is an expectation that proceedings today proceed in her absence;
• The Registrant has engaged with the process and has submitted documentation for the attention of the Panel;
• There is a public interest that these matters are dealt with expeditiously;
• This is a joint hearing and witnesses and the other Registrant are in attendance.
11. The Panel was satisfied that the Registrant was absent voluntarily. There is a distinction between a case where the Registrant is clearly aware of the hearing date, and one where there has been no response from the Registrant. It determined that it was unlikely that an adjournment would result in the Registrant’s attendance at a later date. Having weighed the public interest for expedition in cases against the Registrant’s own interest, the Panel decided to proceed in the Registrant’s absence.
Amendment of Allegation
12. Ms Constantine, on behalf of the HCPC, applied to amend paragraph 2(b) of the Allegation, by inserting the words “or her family” after the words “Service User A”. She submitted that the amendment sought was consistent with the evidence and served to clarify the allegation by giving further and better particulars.
13. The Registrant did not object to the amendment. The notice of this application was sent to the Registrant dated 9 December 2019 to her registered address.
14. The Panel accepted the advice of the Legal Assessor, who advised that it was open to the Panel to amend the allegation, provided the Panel was satisfied that no injustice would be caused by the amendments. The Panel considered that the amendment sought did not change the substance of the allegation. The amendment did clarify the allegation and would not cause injustice, as it is always preferable that allegations are as clear as possible so that registrants are clear what is alleged against them in order for them to respond. The Panel therefore allowed the amendment to be made. The amended Allegation is as set out above and the original Allegation is appended to this decision.
Background
15. The Registrant was employed by North West Ambulance Service NHS Trust (“NWAST”) as a Paramedic.
16. On 26 August 2016, the other Registrant Paramedic, Mr Morris, attended to Service User A in response to an emergency 999 call made by Person C. He subsequently contacted the Ambulance control room and requested an ambulance crew as backup. The Registrant and Colleague A were dispatched to assist him and arrived in an ambulance. Colleague A was an Emergency Medical Technician (“EMT”) employed by NWAST. Service User A died shortly after her arrival at the hospital.
17. Person B, Service User A’s mother, submitted a written complaint to NWAST on 22 March 2017 in regard to the care that Service User A received from the Registrant and Mr Morris. PC, a Patient Experience Manager at NWAST, subsequently completed an investigation. JP, who was an Advanced Paramedic, conducted a clinical review of the incident.
18. A referral was made to the HCPC by NWAST on 25 July 2017 in regard to the Registrant’s fitness to practise.
Decision on Facts
19. The Panel considered all the evidence in this case together with the submissions made by Ms Constantine on behalf of the HCPC.
20. The Panel accepted the advice of the Legal Assessor who reminded the Panel that the burden of proof rests with the HCPC, and that the Registrant need not disprove anything. The Legal Assessor also reminded the Panel that the standard of proof is the civil standard, namely the balance of probabilities.
21. The Panel heard oral evidence from the following witnesses on behalf of the HCPC:
• PC, the Patient Experience Manager at NWAST who investigated this incident;
• JP, the Advanced Paramedic who carried out the clinical review of this incident;
• Person C, the niece of Service User A who was present at the time of the incident;
• Person B, the mother of Service User A who arrived at the incident shortly after the arrival of the ambulance crew and who was present throughout the incident thereafter;
22. The Panel also heard evidence from Mr Morris, the other paramedic who was first to arrive at the incident and who initially dealt with Service User A. Mr Morris is also subject to fitness to practise proceedings in relation to these matters and those matters were jointly heard with this case. Mr Morris gave oral testimony in his own defence and very little of his evidence related to the Registrant or what she is said to have done.
23. The Panel found PC, the Investigations Officer, to be a clear and cogent witness. Her recollection was reasonable. She was clear when she did not agree with matters put to her, and she did not speculate. Her evidence was internally consistent and was also consistent with other evidence in the case. Whilst she did not witness the incident, she was able to give clear and cogent evidence of her investigation and what witnesses had said to her during that investigation. The Panel found her to be a credible witness.
24. The Panel found JP to be a credible witness. His evidence was clear and cogent. His evidence related to a clinical review of the records of the events, and relevant policies. The Panel noted that JP made an error in respect of Mr Morris’ registration date and he conceded that he had made a mistake. However, in respect of his evidence relating to the clinical review, the Panel found JP’s evidence to be credible and consistent.
25. The Panel found Person C, Service User A’s niece, to be a credible witness. Person C was calm and collected in the way she gave evidence and she appeared to have a clear recollection of events. The Panel noted that her evidence on who had accompanied Service User A down the stairs differed from that of Person B, but the Panel concluded that this difference was not material to the allegation and did not detract from the Panel’s view of her evidence overall.
26. The Panel found Person B, Service User A’s mother, to be credible. Her account of what she witnessed was fairly detailed and generally corroborated by other evidence in this case. The Panel noted that there was a discrepancy between her oral evidence and her statement in respect of a comment made by Mr Morris, but determined that this did not detract from the Panel’s view of her evidence overall.
27. The Panel also received a bundle of evidence on behalf of the HCPC which included:
• The Patient Record Form (the “PRF”) completed by Mr Morris in relation to Service User A;
• The Bodycam footage taken by the Police Constable who attended the incident.
• The Investigation Report by PC;
• The Clinical Review carried out by JP;
• Various policy and guidance documents of NWAST;
• Guidance issued by the Joint Royal Colleges Ambulance Liaison Committee (“JRCALC”);
• Photographs of the building where the incident took place showing the stairwell, and the façade of the building; and
• Photographs of the building where the incident took place showing the stairwell, and the façade of the building; and
• Record of the inquest into Service User A’s death.
28. The Panel also had the statement made by the Registrant for NWAST’s investigation before it. The Panel was aware that it was not able to test the veracity of the Registrant’s statement, but it examined its consistency with the other evidence in the case.
29. The Panel noted several discrepancies between the Registrant’s recollection of events and those of Persons B and C. In that statement, the Registrant denies making any unprofessional comments. Her account of who assisted Service User A down the stairs contradicted the accounts of all the other witnesses including Mr Morris. She stated that Person B was hysterical at the time. In the Panel’s view the Bodycam footage demonstrated that Person B was not hysterical at the time but was subdued and co-operative.
30. The Registrant also stated in the statement that she thought she had taken less than a minute to go to the Ambulance and bring back the stretcher. However, the Bodycam footage, which is timed, demonstrated that she took at least five minutes to do so.
31. Furthermore, her account of her actions and her manner during the incident differs from that of Person B and Person C.
32. On the basis of the above, the Panel found it difficult to accept the contents of her statement made for the NWAST investigation as credible and reliable.
33. The Panel considered the Allegation and each of the particulars in turn and made the findings below in light of the evidence before it.
34. It was not in dispute that on 26 August 2016, the Registrant was registered as a Paramedic and employed by NWAST and that she had attended to Service User A. The Panel was satisfied that the stem of the allegation was made out.
Particular 1 – inappropriate comments
35. The Registrant states in her statement that was made for the purposes of NWAST’s investigation that she did not make any comments that may have been deemed as unprofessional nor did she express any concerns that the patient was pretending. She stated that she would not have remained at the scene for so long if she felt that this was the case. The Registrant stated that the paramedic team were all concerned for Service User A, and they had all wanted her to attend hospital as they did not want to leave her at home. She stated that all of them made attempts to persuade the patient to attend hospital, but the patient refused to do so.
Particular 1(a)
1. Made inappropriate comments to the effect that:
a) Service User A was not unwell or was feigning illness;
36. Person B told that Panel that she saw and heard the female paramedic say to her daughter, “there is nothing wrong with you, you can walk to the ambulance” or words to that effect.
37. On the Bodycam footage, the Registrant's demeanour and words at the bottom of the stairwell would suggest that she still did not believe that Service User A was truly ill.
38. The Registrant denied making this comment in her statement, but the Panel preferred the evidence of Person B.
39. The Panel determined that such a comment was inappropriate whether a service user was feigning illness or not. In the case of Service User A the evidence demonstrated that she was not feigning her illness and was in fact seriously unwell. In the Panel’s view, the Bodycam footage showed that the Registrant was more focussed on her view of Service User A being non- compliant than on attending the service user who had collapsed and was seriously unwell.
40. Taking the above into consideration Panel found Particular 1(a) proved on the balance of probabilities.
Particular 1(b)
1. Made inappropriate comments to the effect that:
b) Regarding not lifting Service User A, you asked who would look after your children if you hurt your back;
41. It was not in dispute that the Registrant was the only female paramedic on the scene, although she arrived later in the ambulance with her colleague. Person B told the Panel that as she was helping her daughter to walk out of the flat, her daughter collapsed on the floor and both Paramedics had queried whether she was pretending to collapse. Person B said that she heard the female paramedic say, “stand up, why are you acting like that? I can’t bend down and lift you up, what if I hurt my back? Who will look after my children?”, or words to that effect.
42. Person C also told the Panel that she had heard similar words being said to Service User A. The context that she said those had been spoken was the same as that give by Person B.
43. The Registrant denied making this comment in her statement, but the Panel preferred the evidence of Person B and Person C. Person B was very clear that she specifically recalled this being said and gave the context of the conversation.
44. The Panel determined that such a comment was inappropriate and unprofessional.
45. Taking the above into consideration Panel found Particular 1(b) proved on the balance of probabilities.
Particular 1(c)
1. Made inappropriate comments to the effect that:
c) You told Service User A to ‘get up’ or words to that effect when she collapsed.
46. Person B told the Panel that ‘the female Paramedic was the one who was talking too much and kept telling my daughter that she should “get up” and that she was not actually unwell’. Person B also told the Panel that the female paramedic had also said “why are you humiliating yourself lying in the dirt like that? Stand up, go to the ambulance.” or words to that effect.
47. The Panel accepted the evidence of Person B and concluded that such comments were inappropriate and unprofessional.
48. Based upon the evidence before it, the Panel finds Particular 1(c) proved.
Particular 2(a)
2. Did not communicate appropriately with Service User A and/or her family, in that:
a) Following Service User A’s collapse, you did not update Service User A’s family before transporting Service User A to the hospital.
49. At the start of the hearing, Miss Constantine for the HCPC made it clear that where a Particular alleged that the Registrant “did not” do something, then there was an implicit assertion that the Registrant was under a duty to carry out that action.
50. The Panel was satisfied that in the circumstances, the Registrant was under a duty to communicate the information set out in Particular 2(a) to Service User A’s family. Notwithstanding she was under preceptorship at the time and was not the first paramedic on scene, the Registrant was an autonomous practitioner and therefore had a shared responsibility.
51. Mr Morris, who was also present, had a similar duty. He told the Panel that he and the Registrant did not update the family because they were ‘working on’ Service User A in the ambulance and that they had told the Police Constable what they were doing and that they were going to take Service User A to hospital.
52. The Bodycam footage clearly showed the Police Constable going to the back of the ambulance and being told by the Registrant that they were ‘working on’ Service User A. Later in the footage, as the ambulance is leaving, the Police Constable approaches the ambulance and he is told by the EMT that they are taking Service User A to hospital. The Police Constable acknowledges the information on both occasions and tells the paramedic team that he will inform Service User A’s family.
53. It was Mr Morris’s evidence was that it was reasonable for him and the Registrant to conclude that the Police Constable would update the family.
54. PC confirmed that it was appropriate for a Police Constable to convey such information to a service user’s family in such circumstances. She said that it was not unreasonable for the paramedics to act in this way in the circumstances where they were dealing with a cardiac arrest. It would be unreasonable for paramedics to delay treatment to a service user in cardiac arrest when there was a Police Constable present who could convey the information to the service user’s family.
55. In the circumstances, the Panel was satisfied that the Registrant had discharged her duty once the Police Constable had been informed of the situation and undertaken to provide the information, set out in Particular 2(a), to Service User A’s family.
56. Therefore, the Panel finds that Particular 2(a) is not proved.
Particular 2(b)
2. Did not communicate appropriately with Service User A and/or her family, in that:
b) You did not inform Service User A or her family of her potential diagnoses and the risks associated with those.
57. The Panel applied the principle of autonomous practitioners having shared responsibility in these circumstances, as articulated in the Panel’s decision in Particular 2(a) above.
58. There is no evidence from Person B and Person C that potential diagnoses and associated risks were shared with them. Person B told the Panel that the Registrant kept saying that Service User A was pretending. Person B told the Panel that the first Paramedic and the subsequent ambulance crew that attended stated that there was nothing wrong with Service User A.
59. It appears to the Panel that the Registrant did not consider any potential diagnoses or associated risks and as a consequence, she was unable to inform Service User A or her family of any potential diagnoses or associated risks.
60. On this basis the Panel finds Particular 2(b) not proved on the balance of probabilities.
Particular 3
3. Did not complete and/or record an adequate clinical assessment and/or examination.
61. The Panel was satisfied that the Registrant was under a duty to complete and record an adequate clinical examination and assessment of Service User A. Whilst she arrived later, at 23:02, once she received the handover of Service User A from Mr Morris, she also became responsible for the care and welfare of Service User A. As an autonomous practitioner she should have carried out her own examination and assessment of Service User A and not relied upon what she was told by Mr Morris. The fact that Mr Morris remained at the scene did not absolve the Registrant of her duty. In the Panel’s view, the Registrant’s shared responsibility extended to the recording of any examination or assessment that she conducted and to ensuring the accuracy of any records relating to her involvement in the incident.
62. The Panel had before it the Patient Report Form (“PRF”). The evidence demonstrates that this was completed and signed by Mr Morris shortly after the debriefing that took place following the incident. PC and JP explained to the Panel how the information contained within the PRF did not constitute an adequate record of a clinical examination and assessment. In particular JP drew the Panel’s attention to the fact that the PRF did not record any differential diagnosis, or potential diagnoses, or give any information that would be expected from a detailed examination of Service User A. He also pointed out that it was clear from the evidence that in addition to shortness of breath, Service User A was complaining about abdominal pains but there was no record on the PRF of an abdominal examination having been carried out by either of the paramedics present.
63. JP drew the Panel’s attention to the JRCALC guidance that sets out a list of what would be expected when Paramedics examine and assess a service user.
64. JP pointed out that there was no evidence on the PRF of a clinical assessment having been carried out and no detail around any examination. He pointed out that there were observations that could have been recorded which did not require the cooperation of Service User A such as the nature of Service User A’s colour/pallor, breathing and her use of accessory muscles.
65. JP told the Panel that there were two points at which it was important that Service User A was assessed – the first was when she was seen initially by Mr Morris and the second was when Service User A collapsed. The Registrant was not present initially, but she was present when Service User A collapsed in the stairwell.
66. The Registrant in her statement does not assert that she did carry out an examination and assessment of Service User A. She stated that Service User A did not permit her or her colleagues to take a full set of clinical observations. She stated that because of Service User A’s presentation, the paramedics wanted her to go to hospital.
67. The Panel took into account that the evidence before it did indicate that Service User A was to some extent uncooperative with the paramedics. The fact that there were no recorded observations that did not require the cooperation of Service User A led the Panel to determine that it was more probable than not that the Registrant did not carry out any observations on Service User A herself.
68. Therefore, the Panel determined that Particular 3 is proved on the balance of probabilities.
Particular 4
4. Walked Service User A to the ambulance, despite her being tachypnoeic and/or without offering appropriate assistance.
69. The Panel has interpreted this Particular to mean that Service User A was permitted to walk despite her condition and without appropriate assistance from the paramedics. The Panel interpreted it as walking for any part of the journey to the ambulance. Tachypnoea is where a person experiences abnormal and rapid breathing.
70. Both paramedics present were responsible for the care and welfare of Service User A. The evidence before the Panel demonstrated that Service User A was tachypnoeic at that time. Mr Morris, the paramedic first on scene and who remained throughout the incident told the Panel that he accepted that Service User A was tachypnoeic.
71. The evidence from Person C and Person B was that when Service User A was walked down the stairs, neither paramedics offered any assistance to The Registrant’s statement does not mention that she offered Service User A assistance to walk to the ambulance via the stairs. She stated that she did not have any concerns about Service User A walking to the ambulance because as Service User A was walking “she was not short of breath, did not change colour or show any signs of distress.”
72. The Panel found the Registrant’s description of the presentation of Service User A to be at odds with that of Person C and Person B who both describe Service User A as needing assistance from Person B and a neighbour to go down the stairs and of Service User A collapsing at least twice whilst going down the stairs and before reaching the bottom. Mr Morris confirmed that a neighbour had attended to offer assistance.
73. In his oral evidence, Mr Morris also accepted Service User A was unwell with breathing problems, frequent collapses and that walking might have exacerbated her condition.
74. The Panel determined that Service User A’s condition was such that she should have been assisted by the Paramedics if she was to walk to the ambulance.
75. In the light of the evidence before it, the Panel determined that Particular 4 was proved on the balance of probabilities.
Particular 5
5. Did not provide a wheelchair to Service User A despite this being requested by Person B.
76. Person B told the Panel that she had specifically requested a wheelchair of the Registrant. This was corroborated by Person C and accepted by Mr Morris. Person B told the Panel that the Registrant replied, “no, we can’t waste our time giving you the wheelchair, she can walk.”
77. Person B also told the Panel that she remembered asking for a wheelchair because she told the paramedics that there was a ramp that could have been used when they queried how they were going to push the wheelchair downstairs.
78. JP told the Panel that a wheelchair was standard equipment in all the ambulances of NWAST and it was not disputed that the ambulance in which the Registrant arrived had a wheelchair.
79. Based upon the evidence before it, the Panel found Particular 5 proved on the balance of probabilities.
Particular 6
6. Did not assist Service User A to stand when she collapsed on multiple occasions.
80. The Panel considered the oral evidence it heard, particularly from Person B. It considered that there were three occasions when Service User A collapsed where she could have been assisted to stand up by the Paramedic team. One was when Service User A exited the property, and two occasions whilst she was going down the stairs. The Panel excluded the final collapse of Service User A at the bottom of the stairs because it was clearly inappropriate to get her to stand up at that stage.
80. The Panel considered the oral evidence it heard, particularly from Person B. It considered that there were three occasions when Service User A collapsed where she could have been assisted to stand up by the Paramedic team. One was when Service User A exited the property, and two occasions whilst she was going down the stairs. The Panel excluded the final collapse of Service User A at the bottom of the stairs because it was clearly inappropriate to get her to stand up at that stage.
81. Person B gave evidence of these collapses and Person C confirmed this.
82. Person B and Person C also told the Panel that at the time of these collapses, the paramedics were walking some six metres ahead of Service User A, and on each occasion, they did not offer any assistance. This was also confirmed by Mr Morris.
83. The Panel determined that in the circumstances, the Paramedics present should have assisted Service User A when she collapsed.
84. The Panel found Particular 6 proved on the balance of probabilities.
Particular 7
7. Did not provide care to Service User A in a timely manner following her collapse.
85. The Panel interpreted this factual particular is referring to the collapse by Service User A at the bottom of the stairwell. The Bodycam footage is evidence of what transpired after the Police Constable's arrival. The footage shows the Registrant shining a light into the eyes of Service User A and inserting a Nasopharyngeal Airway. She is then seen to go to the ambulance to get a second Nasopharyngeal Airway. She is subsequently seen to go to the Ambulance to fetch a stretcher for Service User A.
85. The Panel interpreted this factual particular is referring to the collapse by Service User A at the bottom of the stairwell. The Bodycam footage is evidence of what transpired after the Police Constable's arrival. The footage shows the Registrant shining a light into the eyes of Service User A and inserting a Nasopharyngeal Airway. She is then seen to go to the ambulance to get a second Nasopharyngeal Airway. She is subsequently seen to go to the Ambulance to fetch a stretcher for Service User A.
86. In the Panel’s view the footage shows a lack of urgency in the actions of the paramedics. The Registrant can be seen and heard talking to the Police Constable about how Service User A was “so non-compliant” on her way to the ambulance to get the stretcher. Furthermore, her pace of walking to the ambulance did not demonstrate a sense of urgency on her part. Whilst it is not expected that paramedics rush what they are doing in such circumstances, they are expected to act expeditiously and professionally.
87. JP referred the Panel to the guidance set out in the JRCALC. He explained that the guidance is clear that when a patient collapses, a Paramedic dealing with that patient is expected to carry out an immediate re-assessment to ensure that they are breathing. This was corroborated by PC. As an autonomous practitioner, the Registrant had a responsibility to act independently of her colleagues.
88. The Bodycam footage demonstrated that the Registrant failed to carry out an immediate re-assessment of Service User A and to provide care in a timely manner following her collapse.
89. The Panel finds Particular 7 proved on the balance of probabilities.
Particular 8
8. Did not transport Service User A to the hospital in a timely manner despite Service User A hyperventilating.
90. The Registrant's responsibility for Service User A began at 23:02 when she arrived. In her statement she stated that she observed Service User A hyperventilating when she arrived.
91. Both PC and JP referred the Panel's attention to the guidance issued by NWAST in relation to hyperventilation syndrome (HVS). They pointed out that when a paramedic encounters such a situation, they are obliged to also consider the possible underlying causes for hyperventilation when carrying out their assessment of the service user.
92. PC and JP both stated that a hyperventilating service user should be transported to hospital if, after 10 to 15 minutes of coaching their breathing, there had not been insufficient improvement in their condition and no underlying cause had been identified.
93. The Panel accepted that this was a challenging situation in which the Registrant found herself. Service User A had declined to be examined and assessed, and also had declined to be transferred to hospital several times.
94. The Bodycam footage shows Service User A collapsed at the bottom of the stairwell, and she was clearly in no fit state to give instructions as to her care. It was the Panel’s view that from that point onwards there was a significant delay before Service User A was taken by stretcher to the ambulance.
95. The Bodycam footage shows that the paramedic team did not act with any sense of urgency. The Bodycam footage started almost an hour after the arrival of the Registrant at the scene. The Bodycam footage runs for about 20 minutes, recording what was said and done from the viewpoint of the Police Constable and culminating in the ambulance leaving the scene with Service User A.
96. The Panel determined on the balance of probabilities, that the Registrant did not transport Service User A to the hospital in a timely manner despite Service User A hyperventilating.
97. Therefore, the Panel finds Particular 8 proved.
Particular 9
9. Did not provide an adequate treatment plan in response to Service User A’s hyperventilation.
98. The Panel is satisfied that on the evidence before it, there was an adequate treatment plan in response to Service User A's ventilation. That plan was to transfer her to hospital as soon as possible, and it was in place before the Registrant's arrival on scene and continued to be the treatment plan after she had arrived. The problem that arose is not in the adequacy of the treatment plan but rather in its execution.
99. Therefore, the Panel determined that Particular 9 is not proved.
Particular 10
10. Did not complete and/or record regular observations of Service User A
100. The Panel was satisfied that the Registrant was under a duty to complete and record regular observations of Service User A whilst she remained under her care.
100. The Panel was satisfied that the Registrant was under a duty to complete and record regular observations of Service User A whilst she remained under her care.
101. On the evidence before the Panel, there was a set of observations taken at 22:05 hours. However, it was not a full set of observations as Service User A was not cooperating. There was another set of observations taken at 23:10 hours by the EMT.
102. JP told the Panel that if a patient was stable then observations should be taken every 30 minutes up to an hour apart. He also said that a service user‘s condition was not stable then the observations should be taken in closer proximity in time.
103. It was clear from the evidence that Service User A’s condition was not stable. The Panel determined that in the circumstances there should have been at least one other set of observations taken between the 22:05 and 23:10 hours.
104. Furthermore, the evidence shows that the next set of observations was taken at 00:25, which is an interval of 75 minutes, during which Service User A's condition was unstable. The Panel determined that there should have been at least 2 more sets of observations taken within that 75 minute interval. None was taken.
105. The Panel determined that Particular 10 is proved on the balance of probabilities.
Particular 11
11. Did not assist Service User A to travel down the stairs, including by not using a track chair.
106. It was not in dispute that the paramedics who attended Service User A on the night in question had a duty to assist her to travel down the stairs because of her presenting condition. This duty included consideration of any and all alternatives in order to expedite Service User A's transfer from the flat to the ambulance downstairs.
107. JP agreed that the ambulance that was used by the Registrant was not her regular ambulance, but one drawn from the general pool of vehicles. He told the Panel that every ambulance from the pool would have a track chair as part of the standard equipment.
108. JP also told the Panel that the track chair was the appropriate manner in which to bring a patient down a flight of stairs. He said that there were circumstances where a track chair would not be appropriate, for example due to the narrowness of the staircase. In his oral evidence, Mr Morris told the Panel that with hindsight, Service User A should have been taken down the stairs on a track chair.
109. The evidence before the Panel demonstrated that the paramedics did not consider the use of a track chair in this case.
110. It was the evidence of Person B and Person C, that it was Person B who assisted Service User A down the stairs and that the paramedics did not assist Service User A travel down the stairs. This is corroborated by the oral evidence of Mr Morris.
111. The Registrant's recollection, as set out in her statement, is at odds with the other evidence in this case. She stated that Service User A crawled over the threshold of the flat, but once outside the flat Service User A suddenly stood up and walked along the landing and down the stairs. She also stated that Colleague A and Mr Morris were on either side of Service User A with Person B following behind.
112. The Panel determined that Particular 11 is proved on the balance of probabilities.
Particular 12
12. Informed your employer that care was provided to Service User A in a timely manner following her collapse, when this was not the case.
113. The Panel has already determined that the care provided to User A by the Registrant was not provided in a timely manner (see the Panel’s determination in relation to Particular 7above).
114. The evidence of what the Registrant told her employer is contained in her statement made as a result of this incident. Paragraphs 40 and 41 of her statement is her account of the collapse:
“Tony was nearest to the patient and took hold of her head to prevent any injury as a result of the collapse. The patients [sic] mum witnessed the collapse an understandably became quite hysterical. At the point of collapse the patient was breathing and Tony palpated a carotid pulse. The patient responded when I touched her eyelash, but she was not making any verbal response.
I grabbed the bag at the RRV, Tony and Colleague A remained with the patient. I was aware from the information being relayed to me by Tony that the patient still had a pulse and was breathing. When I returned, I place a size 6 Nasopharyngeal Airway (NPA) in the left nostril this was tolerated by the patient. I attempted to place an NPA in the right nostril but met some resistance.
I am unable to recall the patients [sic] pulse rate or respiratory rate at the time of the collapse, Tony was monitoring this. Colleague A and I went to the ambulance for the stretcher, this was about 6 metres away, and this took less than a minute. The patient was immediately lifted onto the stretcher and transferred to the ambulance; the patient still had a palpable carotid pulse which Tony checked ….”
115. In the above paragraphs, in the Panel’s view, the Registrant gave the impression of care that was provided in an urgent and timely manner. She uses phrases like “grabbed the bag” and “took less than a minute.” In particular, her assertion that it took less than a minute to go to the ambulance, which was 6 metres away, and return with a stretcher was not correct. The Bodycam footage shows that this took at least 6 minutes, and she appeared to walk in an unhurried manner to the ambulance.
116. What the Registrant wrote in her statement did not convey the actual length of time between the point of collapse and when the patient was put on a stretcher to be transferred to the ambulance.
117. The Panel was satisfied that Particular 12 was proved on the balance of probabilities.
Particular 13
13. Your actions as described at paragraph 12 above were dishonest.
118. The Panel’s attention was drawn to the case of Ivey v Genting Casinos (UK) Ltd t/a Crockfords [2017] UKSC 67 which overruled the use of the Ghosh test when determining dishonesty. The Panel noted the change in the test to be applied for dishonesty. The Legal Assessor advised the Panel that the change in the test for dishonesty did not change the fact that dishonesty is an offence of specific intent. He advised that dishonest acts must be committed intentionally and cannot be committed recklessly, negligently or in ignorance.
119. The Legal Assessor also advised the Panel that any allegation of dishonesty is one of the most serious allegations any professional can face and that the Panel should approach that issue on the basis that the more serious the allegation, the less likely it is that the event occurred. Hence, the need for stronger evidence before a panel should conclude that the allegation is established on the balance of probabilities. He advised the Panel that it did not mean that something is proved on the balance of probabilities merely because there is some evidence that alleges it happened and there is no evidence to say otherwise.
120. The Legal Assessor also drew the Panel’s attention to the case of In Re H (Minors)(Sexual Abuse: Standard of Proof) [1996] AC 563, wherein it was stated:
"When assessing the probabilities the court will have in mind as a factor, to whatever extent is appropriate in the particular case, that the more serious the allegation the less likely it is that the event occurred and, hence, the stronger should be the evidence before the court concludes that the allegation is established on the balance of probability. Fraud is usually less likely than negligence. Deliberate physical injury is usually less likely than accidental physical injury. ... Built into the preponderance of probability standard is a generous degree of flexibility in respect of the seriousness of the allegation. … The more improbable the event, the stronger must be the evidence that it did occur before, on the balance of probability, its occurrence will be established.”
"When assessing the probabilities the court will have in mind as a factor, to whatever extent is appropriate in the particular case, that the more serious the allegation the less likely it is that the event occurred and, hence, the stronger should be the evidence before the court concludes that the allegation is established on the balance of probability. Fraud is usually less likely than negligence. Deliberate physical injury is usually less likely than accidental physical injury. ... Built into the preponderance of probability standard is a generous degree of flexibility in respect of the seriousness of the allegation. … The more improbable the event, the stronger must be the evidence that it did occur before, on the balance of probability, its occurrence will be established.”
121. The evidence before the Panel shows that the Registrant wrote some notes after the debriefing on the night of the incident. The Panel has not seen these notes and therefore the level of detail contained within them is unknown. The PRF was written by Mr Morris and he signed it. There is no evidence that the Registrant saw the completed PRF or had the opportunity to check the accuracy of the PRF at the time it was completed. There is no evidence that when the Registrant wrote her notes on the night in question she had had sight of the PRF.
122. The Registrant was requested to write her statement some 8 months after the event. It is reasonable to infer that she relied upon her notes and in paragraph 45 of her statement she refers to the PRF. However, the PRF is inaccurate regarding the time that the 00:25 hours observations were taken, as it is clear from the Bodycam footage that that Service User A was in the ambulance at that time.
123. In the circumstances, the Panel could not be satisfied that the Registrant was aware that, at the time she made her statement, that the timings were wrong. There was no evidence to indicate that it would be safe and reasonable to infer that she knew the timings were wrong, or that the impression given in the statement about the care provided was inaccurate. The Registrant wrote her statement before the Bodycam footage was available.
124. The Panel concluded that in the light of the evidence, the reasonable and honest person would not consider the Registrant’s actions and reasons to be dishonest in circumstances where they could not be certain that the Registrant was aware of the inaccuracies in her statement. The reasonable and honest person would take into account that matters of dishonesty cannot be committed recklessly, negligently or ignorantly.
125. Therefore, the Panel determined that Particular 13 is not proved.
Resuming hearing on 22 June 2020
Service of Notice
126. The notice of this hearing was sent to Registrant’s registered email address as it appeared on the register on 22 May 2020. The notice contained the date, time and venue of today’s hearing. A read receipt was received confirming successful delivery.
127. The Panel accepted the advice of the Legal Assessor and is satisfied that notice of today’s hearing has been served in accordance with Rule 6(1) of the Conduct and Competence Rules 2003 (the “Rules”).
Proceeding in the absence of the Registrant
128. The Panel then went on to consider whether to proceed in the absence of the Registrant pursuant to Rule 11 of the Rules. In doing so, it considered the submissions of Ms Hastie on behalf of the HCPC.
129. Ms Hastie submitted that the HCPTS has taken all reasonable steps to serve the notice on the Registrant. She further submitted that the Registrant has not engaged with the HCPC, nor with the HCPTS, since the start of the substantive hearing on 3 February 2020 and that an adjournment would serve no useful purpose. Ms Hastie reminded the Panel that there was a public interest in this matter being dealt with expeditiously.
130. The Panel accepted the advice of the Legal Assessor. He advised that, if the Panel is satisfied that all reasonable efforts have been made to notify the Registrant of the hearing, then the Panel has the discretion to proceed in the absence of the Registrant. He cautioned the Panel that the discretion should be exercised with care and caution as set out in the case of R v Jones [2002] UKHL 5.
131. The Legal Assessor also referred the Panel to the case of GMC v Adeogba and Visvardis [2016] EWCA Civ 162 and advised that the Adeogba case reminded the Panel that its primary objective is the protection of the public and of the public interest. In that regard, the case of Adeogba was clear that “where there is good reason not to proceed, the case should be adjourned; where there is not, however, it is only right that it should proceed”.
132. It was clear, from the principles derived from case law, that the Panel is required to ensure that fairness and justice are maintained when deciding whether or not to proceed in a Registrant’s absence.
133. The Panel was satisfied that all reasonable efforts had been made by the HCPTS to notify the Registrant of the Hearing.
134. In deciding whether to exercise its discretion to proceed in the absence of the Registrant, the Panel took into consideration the HCPTS practice note entitled ‘Proceeding in the Absence of a Registrant’. The Panel weighed its responsibility for public protection and the expeditious disposal of the case with the Registrant’s right to a fair hearing.
135. In reaching its decision the Panel took into account the following:
• The Registrant has not made an application to adjourn today’s Hearing and implicit from her correspondence received before the start of this substantive hearing was an expectation on her part that she would not be participating in these proceedings, and that the proceedings will continue in her absence;
• There is a public interest that these matters are dealt with expeditiously.
136. The Panel was satisfied that the Registrant was absent voluntarily. It determined that it was unlikely that an adjournment would result in the Registrant’s re-engagement with these proceedings, in the light of her non-engagement thus far. Having weighed the public interest for expeditious hearing of the case against the Registrant’s own interest, the Panel decided to proceed in the Registrant’s absence.
Consideration of Statutory Ground
137. The Panel then went on to consider whether the factual particulars found proved amounted to misconduct and/or lack of competence. The Panel heard the submissions of Ms Hastie on behalf of the HCPC.
138. Ms Hastie submitted that the Panel might consider that this was a case where the appropriate statutory ground is that of misconduct rather than lack of competence. This is because the allegation arises out of a single episode, of which the Panel might consider not to be a representative sample of the Registrant's work sufficient to show lack of competence.
139. Ms Hastie submitted that the Registrant's conduct fell substantially below that which would be expected of a registered Paramedic. She reminded the Panel of their factual findings in relation to the Registrant's comments and conduct and submitted that those comments and conduct were unprofessional, dismissive and demeaning. Ms Hastie submitted that they demonstrated a serious failing by the Registrant to provide appropriate care for Service User A.
140. Ms Hastie submitted that completing an adequate clinical assessment and/or regular observations is a fundamental part of the paramedic’s duty and that the Registrant failed in this duty. She further submitted that the Registrant failed to provide Service User A with the required level of care including allowing her to walk despite her condition and without appropriate assistance, not providing her with a wheelchair or using a track-chair, not assisting her when she collapsed and not transporting her to hospital in a timely manner.
141. Ms Hastie also reminded the Panel of what was seen on the video evidence presented during the hearing. She submitted that the video evidence demonstrated a lack of urgency on the part of the Registrant after Service User A had collapsed at the bottom of the stairwell. She submitted that the Registrant's behaviour resulted from assumptions made by her that Service User A was feigning illness.
142. Ms Hastie submitted that the Registrant’s actions breached the following paragraphs of the HCPC’s standards of conduct, performance and ethics (2016 edition): 1.1, 2.1, 2.2, 6.1, 6.2 and 9.1.
143. The Panel accepted the advice of the Legal Assessor. He referred the Panel to the decisions in the following cases:
a) Calhaem v GMC [2007] EWHC 2606 (Admin)
b) Roylance v GMC (2000) 1 AC 311
c) Andrew Francis Holton v General Medical Council [2006] EWHC 2960
d) Hindmarsh v NMC [2016] EWHC 2233 (Admin)
144. The Legal Assessor advised that misconduct is “a word of general effect, involving some act or omission, which falls short of what would be proper in the circumstances.” He stressed that Misconduct is qualified by the word “serious” and that it is not just any professional misconduct, which will qualify.
145. The Legal Assessor also advised that not every instance of falling short of what would be proper in the circumstances, and not every breach of the HCPC standards would be sufficiently serious such as to amount to misconduct in this context.
146. The Legal Assessor also reminded the Panel that the fact that although there could have been, and possibly were, serious consequences as a result of the Registrant's conduct, this is only one factor to be taken in consideration when considering whether her actions amounted to serious misconduct; it was not to be the main factor.
147. The Panel has had careful regard to the context and circumstances of the matters found proved. The Panel determined there was not a representative sample of the Registrant’s work sufficient to conclude that there was a lack of competence.
148. The Panel then went on to consider whether or not these matters found proved amounted to misconduct. It reminded itself that these matters related to a single incident in which the Registrant was not the first upon the scene but had arrived after another paramedic had been on scene and had already attended to Service User A for a significant period of time.
149. The Panel also looked to the HCPC's Standards of Conduct Performance and Ethics (2016 edition, in force at the time) to consider whether there were any breaches of the standards set out therein.
150. As this was a single incident that took place over a single hour on a single night, the Panel looked at the factual particulars found proved as a whole, rather than as individual and unconnected behaviour. The factual particulars found proved represent a continuous course of conduct by the Registrant in relation to Service User A on the night in question.
151. The Panel excluded Particular 12 from its consideration at this stage because it had determined at the factual stage that the error as to timing in her statement appeared to be as a result of relying upon the PRF written by her colleague, Mr Morris, who had recorded the wrong times. The Panel could not be satisfied that the Registrant was aware that the timings recorded in the PRF were wrong when she wrote her statement.
152. The Panel considered each of the remaining factual particulars and determined that the Registrant’s behaviour towards Service User A, and the care that she provided to Service User A, fell far short of what would be expected of a registered Paramedic in the circumstances. This is demonstrated by the phrases used by the Registrant towards Service User A and her family, which included:
• "we cannot waste our time giving you a wheelchair"
• “why are you acting like that?”
• “stop pretending”
• "why are you humiliating yourself"
153. The manner in which she spoke to Service User A and her family was disrespectful to such a degree that fellow practitioners would find it inexcusable and deplorable. It demonstrates an attitudinal problem on the part of the Registrant.
154. The Registrant did not carry out her duties diligently but rather relied upon the assessment made by her colleague, Mr Morris. After Mr Morris had given her a 'handover' briefing, she did not carry out her own clinical assessment of Service User A. Even after Service User A had collapsed in the stairwell, the Registrant took limited action to ensure the safety and well-being of Service User A, relying instead on her mistaken belief that Service User A was pretending to be ill. The Registrant’s demeanour on the Body Cam footage shortly after Service User A had collapsed in the stairwell was not one of urgency but of nonchalance, with the focus being on the perceived non-compliance of Service User A rather than on rapidly treating a gravely ill person. In the Panel’s view fellow practitioners would find her actions inexcusable and deplorable.
155. The Panel considered that on the facts found proved the Registrant had breached the following paragraphs of the HCPC’s standards of conduct, performance and ethics (2016 edition):
Treat service users and carers with respect
1.1 You must treat service users and carers as individuals, respecting their privacy and dignity.
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.
Communicate with service users and carers
2.1 You must be polite and considerate.
2.2 You must listen to service users and carers and take account of their needs and wishes.
Work with colleagues
2.5 You must work in partnership with colleagues, showing your skills, knowledge and experience where appropriate, for the benefit of service users and carers.
Identify and minimise risk
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 would put the health or safety of a service user, carer or colleague at acceptable risk.
156. The Panel determined that these failings related to fundamental areas of practice of a registered Paramedic and the Panel considers the Registrant’s failings to be serious. The Panel did not find that there were any circumstances that mitigated the seriousness of the Registrant's conduct.
157. The Panel determined that the Registrant's failings in her care of Service User A amounted to misconduct.
Consideration of Impairment of Fitness to Practise
158. The Panel then went on to consider, whether the Registrant’s fitness to practise is currently impaired by reason of her misconduct. The Panel heard the submissions of Ms Hastie.
159. Ms Hastie submitted that the Registrant's fitness to practise was impaired. She reminded the Panel that the purpose of fitness to practise proceedings is not to punish a practitioner for past misconduct but rather to protect the public against the acts and omissions of those who are not fit to practise. She also reminded the Panel that not every finding of misconduct would result in a finding of impairment of fitness to practise.
160. Ms Hastie submitted that the lack of engagement by the Registrant meant that the Panel could not ascertain whether or not she had gained insight into her misconduct in order for her to make changes to her behaviour and attitudes. She submitted that the character references provided by the Registrant do not provide cogent evidence of the Registrant's insight and remediation.
161. The Panel also accepted the advice of the Legal Assessor. He drew the Panel’s attention to the approach set out in the case of CHRE v NMC and Grant (2011) EWHC 927 (Admin) and reminded the Panel that there was a personal and public component when considering whether the Registrant’s fitness to practise was currently impaired.
162. For this purpose, the Panel adopted the approach formulated by Dame Janet Smith in her fifth report of the Shipman inquiry by asking itself the following questions:
“Do our findings of fact in respect of the Registrant’s misconduct show that her fitness to practise is impaired in the sense that she:
a) has in the past acted and/or is liable in the future to act so as to put service users at unwarranted risk of harm; and/or
b) has in the past brought and/or is liable in the future to bring the Paramedic profession into disrepute; and/or
c) has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the Paramedic profession?”
163. The Panel took into account the following factors:
(a) promoting and protecting the interests of service users as a fundamental tenet of the profession;
(b) the Registrant has not engaged with the Hearing and has not attended to tell the Panel what, if any, insight she has gained into her actions. The Panel did note that one of the references sent by the Registrant mentions the insight and remorse demonstrated by the Registrant during her discussions with the author of that reference. However, the Panel could only place little weight upon the opinion of that person because it was not in a position to test the veracity of that person's opinion;
(c) the Registrant has not provided any evidence of her personal reflection, if any, into her actions on the night in question. As such, there is no cogent evidence of any insight on the part of the Registrant. This is a matter of misconduct, and there can only be very limited remediation without insight. There has been no evidence of any action taken by the Registrant to remediate her misconduct. Therefore, there is a real risk of repetition on the part of the Registrant;
(d) the Panel determined that the Registrant's misconduct was easily remediable, but that there was no evidence upon which it could be satisfied that the Registrant had begun to or has already remediated her misconduct.
164.Taking the above into consideration, the Panel determined that the Registrant's fitness to practise is currently impaired due to the lack of evidence of insight and remediation. The Panel determined that the answers to all the above questions of Dame Janet Smith’s test were in the affirmative in relation to past, and future possible conduct.
165.The Panel also determined that the Registrant’s misconduct was such that the need to uphold professional standards and public confidence in the professions would be undermined if a finding of impairment were not made in these circumstances. This is not just because there remains a real risk to the public due to the lack of evidence of insight and remediation. Even if there was full insight and remediation on the part of the Registrant, a member the public with full knowledge of the facts and information before the Panel today, would be shocked if no finding of impairment were made. This is because of the serious nature of the Registrant's misconduct.
166.Therefore, Panel determined that the Registrant’s fitness to practise is currently impaired on both personal and public interest considerations.
Impairment
167.Following submissions made by Ms Hastie and advice from the Legal Assessor, a decision had been made by the Panel that the Registrant’s fitness to practise was impaired on both the personal and public components. That decision on impairment is a matter of record.
168.However, at the beginning of the sanction stage it was revealed that the Interim Orders Committee had imposed an Interim Suspension Order on the Registrant’s registration on 29 September 2017 and that that order had subsequently been changed to one of Conditions of Practice on 21 June 2018. That Conditions of Practice Order remains in place, having been extended at the High Court in March 2020.
169.Given that this information potentially indicated that the Registrant had been engaging with HCPC proceedings previously, and complying with conditions, the Panel considered that the associated documentation may be relevant to the sanction stage. The Panel therefore requested copies of relevant interim order determinations from the HCPC.
170.On receipt of two interim order determinations it became apparent to the Panel that the Registrant had previously submitted material to the HCPC that related to reflection and remediation. Given that the Registrant had not submitted any such documents to the Panel for this Hearing, the Panel requested any documents that might assist in the assessment of insight and/or remediation at this stage.
171.The Panel received further documents, which included the Registrant’s reflection, evaluation and analysis of the events, an action plan, references to CPD undertaken and a further reference.
172.The Panel notes that information associated with interim orders is not ordinarily provided to panels prior to the sanction stage. However, given the absence of any information related to insight or remediation, and the relevance of the new material to the decision on impairment, the Panel decided to take the documents pertaining to reflection and remediation into account. The Panel also concluded that an unrepresented and absent registrant may have incorrectly assumed that all material previously submitted, for any purpose, would be viewed by the Panel in a Final Hearing.
173.Taking all the above into account and in fairness to the Registrant, the Panel decided to review its decision on Impairment.
Reviewed Decision on Impairment
174.The Panel then went on to consider, whether the Registrant’s fitness to practise is currently impaired by reason of her misconduct.
175.The Panel heard the further submissions of Ms Hastie.
176.Ms Hastie submitted that the Registrant's fitness to practise was impaired. She reminded the Panel that the purpose of fitness to practise proceedings is not to punish a practitioner for past misconduct but rather to protect the public against the acts and omissions of those who are not fit to practise. She also reminded the Panel that not every finding of misconduct would result in a finding of impairment of fitness to practise.
177.Ms Hastie submitted that the lack of engagement by the Registrant meant that the Panel could not ascertain whether or not she had gained insight into her misconduct in order for her to make changes to her behaviour and attitudes. She submitted that the character references provided by the Registrant do not provide cogent evidence of the Registrant's insight and remediation.
178. The Panel considered the documents before it as follows:
• Interim Order decision 21 June 2018
• Interim Order decision 9 December 2019 (the most recent review)
• Consent Order (of the High Court) dated 20 March 2020
• The bundle provided by the Registrant to the Panel in January 2020 for the purposes of the Final Hearing. This included 9 references from registered paramedics, 7 of whom had worked with her, and 5 supervision reports provided by senior staff at the care home at which the Registrant currently works.
• A 12-page bundle of material previously submitted to the Interim Order Committee in June 2018 (as described above).
179. The Panel accepted the advice of the Legal Assessor. He drew the Panel’s attention to the approach set out in the case of CHRE v NMC and Grant (2011) EWHC 927 (Admin) and reminded the Panel that there is a personal and public component when considering whether the Registrant’s fitness to practise is currently impaired.
179. The Panel accepted the advice of the Legal Assessor. He drew the Panel’s attention to the approach set out in the case of CHRE v NMC and Grant (2011) EWHC 927 (Admin) and reminded the Panel that there is a personal and public component when considering whether the Registrant’s fitness to practise is currently impaired.
180. For this purpose, the Panel again adopted the approach formulated by Dame Janet Smith in her fifth report of the Shipman inquiry by asking itself the following questions:
a) “Do our findings of fact in respect of the Registrant’s misconduct show that her fitness to practise is impaired in the sense that she:
b) has in the past acted and/or is liable in the future to act so as to put service users at unwarranted risk of harm; and/or
c) has in the past brought and/or is liable in the future to bring the Paramedic profession into disrepute; and/or
d) has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the Paramedic profession?”
b) has in the past acted and/or is liable in the future to act so as to put service users at unwarranted risk of harm; and/or
c) has in the past brought and/or is liable in the future to bring the Paramedic profession into disrepute; and/or
d) has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the Paramedic profession?”
181. The Panel took into account the following factors:
(i) promoting and protecting the interests of service users, and treating service users with respect and dignity, are fundamental tenets of the profession;
(ii) the decisions of the Interim Order review Panels and the documents submitted by the Registrant demonstrate that the Registrant has been engaging with the HCPC and this process, however she has not participated in this substantive hearing;
(iii) the reports from the Registrant’s supervisor in respect of the Registrant’s role as senior carer in an elderly care home are very positive;
(iv) there is evidence of some reflection and insight, particularly with regard to the clinical failings demonstrated by the documentation before the Panel;
(v) the Panel determined that the Registrant's misconduct was easily remediable, but that there was limited and untested evidence upon which it could be satisfied that the Registrant has fully remediated her misconduct.
182. The Panel was unable to fully test the level of the Registrant’s insight into her failings because she has not attended this substantive hearing. Therefore, based upon the evidence before it, the Panel determined the following:
(i) The Registrant has demonstrated significant insight into her clinical failings as shown in her reflective piece submitted to the HCPC in 2018. She speaks of not acting with independent thought, not carrying out her own assessment of Service User A, and not working with a level of urgency even after Service User A collapsed. She reflects that she should have challenged the presumptions made by her colleague and further that she should have provided a wheelchair for Service User A.
(ii) The Registrant has demonstrated limited insight into her attitudinal failings. In her reflection piece, the Registrant focusses on the clinical failings, but does not comment to any significant degree about her thoughts concerning her attitude and actions towards Service User A and her family and how these impacted upon how the Registrant had failed to carry out her clinical duties diligently. The Panel recognises that the Registrant has started to develop insight but there is insufficient evidence before the Panel that this is fully developed.
(iii) The Registrant submitted that she had undertaken CPD in relation to her clinical failings. However, no independent evidence of courses attended or CPD undertaken was presented to the Panel. Therefore, the Panel concluded that there was insufficient evidence of remediation in relation to either the clinical or attitudinal failings of the Registrant.
(iv) Without evidence of sufficiently developed insight or remediation the Panel concluded there remains a likelihood of repetition.
183. The Panel notes that the Interim Conditions of Practice Order stipulates that the Registrant must confine her professional practice to working as a registered Paramedic only at Shannon Court Care Centre, where she is currently employed. However, there is no evidence that the Registrant has been employed as a Paramedic by the Care Centre, nor is there a job description of her role at the centre, which is titled Senior Carer. If there had been evidence that the Registrant was employed as a Paramedic, the Panel could have placed more weight upon the reports prepared by her managers.
184. Taking all of the above into consideration, the Panel determined that the Registrant's fitness to practise is currently impaired. The Panel determined that the answers to all the above questions of Dame Janet Smith’s test were in the affirmative in relation to past, and future possible conduct.
185. The Panel also determined that the Registrant’s misconduct was such that the need to uphold professional standards and public confidence in the professions would be undermined if a finding of impairment were not made in these circumstances. This is because there remains a real risk to the public due to the lack of evidence of insight and remediation. Even if there were full insight and remediation on the part of the Registrant, given the serious nature of the misconduct, a member of the public with full knowledge of the facts and information before the Panel today, would be concerned if no finding of impairment were made.
186. Therefore, Panel determined that the Registrant’s fitness to practise is currently impaired on both personal and public interest considerations.
Decision on Sanction
Submissions
187. Having determined that the Registrant’s fitness to practise is currently impaired, the Panel then considered what sanction should be imposed. It heard the submissions of Ms Hastie on behalf of the Council.
188. Ms Hastie reminded the Panel of the approach that it should take and that it should have regard to the Sanctions Policy issued by the HCPC.
Legal Advice
189. The Panel accepted the advice of the Legal Assessor. He advised the Panel that as it has found the matters proved amounted to Misconduct, the full range of sanctions is available to the Panel. He advised the Panel that it should bear in mind that its over-arching duty is:
(i) to protect, promote and maintain the health, safety and wellbeing of the public;
(ii) to promote and maintain public confidence in the professions regulated by the HCPC;
(iii) to promote and maintain proper professional standards and conduct for members of those professions.
190. The Legal Assessor advised the Panel that any sanction it imposes must be the least restrictive sanction that is sufficient to protect the public and the public interest. It should take into consideration the aggravating and mitigating factors in the case. He reminded the Panel that the purpose of a sanction is not punitive, although it may have that effect. The purpose of a sanction is to protect members of the public and the wider public interest. The Legal Assessor advised that the Panel should consider the least restrictive sanction first and moving up the scale of severity only if the sanction being considered is inappropriate. He also reminded the Panel it must apply the principle of proportionality, weighing the Registrant’s interest against the public interest.
191. The Legal Assessor drew the Panel’s attention to the following cases in relation to proportionality when considering any sanction to be imposed:
(i) Kamberova v NMC [2016] EWHC 2955 (Admin); and
(ii) McDermott v HCPC [2017] EWHC 2899 (Admin)
Panel’s consideration and decision
192. The Panel has had regard to all the evidence presented, and to the Council’s Sanctions Policy and accepted the advice of the Legal Assessor.
193. The Panel considered the aggravating factors in this case to be:
i) the psychological harm to the family of Service User A; and
ii) the impact of her conduct has had upon their confidence in the profession, and by inference the public’s confidence in the reputation of the profession.
194. The Panel next considered the mitigating factors in this case. It considered them to be:
The Registrant has:
i) engaged with the process, albeit not with the Final Hearing;
ii) demonstrated partial insight;
iii) expressed remorse and an apology;
iv) a previously unblemished record as a Paramedic.
v) The Registrant was a newly qualified Paramedic at the time and was still on probation having qualified 4 months prior to the incident;
vi) This was a single episode of care;
vii) In the Panel’s view the circumstances were such that even experienced paramedics would have found challenging;
viii) There were no persistent or general failures in the Registrant’s practice;
ix) The Registrant has been working within an Interim Conditions of Practice order imposed upon her registration albeit in her role as a senior carer in a care home;
x) The positive reports from her supervisor about the Registrant’s work ethic and that she is valued and well-liked by the staff and service users where she works;
xi) The positive testimonials about the Registrant’s clinical ability from other paramedics who had worked with the Registrant prior to and after this incident, before she was dismissed from the Trust;
xii) The Registrant has started the process of remediation in respect of her clinical shortcomings.
195. The Panel first considered taking no action but concluded that, given the seriousness of the Registrant’s misconduct and the on-going risk to the public, this would be wholly inappropriate.
196. The Panel then considered whether to make a caution order. The Panel was mindful of its finding that a risk of repetition remains due to the Registrant’s lack of insight into her shortcomings. It bore in mind that a caution order would not restrict her practice. In these circumstances, the Panel concluded that a caution order would not be sufficient to protect the public from the risk posed by the Registrant or, in any event, to satisfy the wider public interest.
197. The Panel next considered the imposition of a Conditions of Practice Order. The Registrant has demonstrated a desire to remain in practice as a Paramedic by her continued engagement with the Fitness to Practise process despite her limited engagement with the final hearing process.
198. This was a case involving serious misconduct that included:
(i) Making inappropriate comments to a service user and her family;
(ii) Failing to complete an adequate clinical assessment, examination and observations of the service user;
(iii) Walking Service User A to the ambulance when it was not appropriate to do so;
(iv) Not providing appropriate assistance to Service User A when she should have done so;
(v) Not providing care to Service User A in a timely manner; and
(vi) Not ensuring the expeditious transfer of Service User A to hospital.
199. The Panel determined that in the light of the significant mitigating factors outlined above, a Conditions of Practice order would satisfy the wider public interest, and that it was both fair and reasonable to provide the Registrant with the opportunity to return to unrestricted practice as a paramedic in the future.
200. Taking into account all of the above, the Panel concluded that conditions could be formulated which would adequately address the risk posed by the Registrant, and in doing so protect patients and the public during the period they are in force. In all of the circumstances, the Panel determined that a conditions of practice order is the appropriate and proportionate sanction.
201. The Panel decided to make a Conditions of Practice Order for a period of twelve months. In deciding on the period of the Order the Panel took into account the fact that this was a single episode of care, that the Registrant shows evidence of developing insight and of having started remediation. The Panel noted the positive content of the professional references provided by paramedic colleagues and that there are no persistent failings within her practice. With the right conditions, the Panel considers that the Registrant should be able to develop her insight further and to remedy the failings within the nine-month period whilst at the same time ensuring that the public is protected. A nine-month period of close supervision of the Registrant’s day-to-day practice by a registered paramedic is, in the Panel’s view, sufficient to satisfy public confidence in the profession and the regulatory process in the particular circumstances of this case.
202. The Panel went on to consider suspension and decided that this was not an appropriate sanction. It considered all the circumstances of the case and the relevant mitigation and concluded that it would be disproportionate and punitive to impose a suspension order.
Order
ORDER: The Registrar is directed to annotate the Register to show that, for a period of twelve months from the date that this Order comes into effect (“the Operative Date”), you Ms Lisa Chadwick must comply with the following conditions of practice:
1. You must work as a registered paramedic only where you are directly working with another registered paramedic.
2. You must place yourself and remain under the supervision of a workplace supervisor who is a registered paramedic.
3. You must supply details of your supervisor to the HCPC within 14 days of the commencement of your employment under these conditions.
4. You must attend upon that supervisor as required and follow their advice and recommendations.
5. Informing the HCPC and others:
i) You must promptly inform the HCPC if you cease to be employed by your current employer or take up any other or further employment.
ii) You must promptly inform the HCPC of any disciplinary proceedings taken against you by your employer.
iii) You must inform the following parties that your registration is subject to these conditions:
A. any organisation or person employing or contracting with you to undertake professional work;
B. any agency you are registered with or apply to be registered with (at the time of application); and
C. any prospective employer (at the time of your application).
6. You must work with your workplace supervisor to formulate a personal development plan designed to address the deficiencies in the following areas:
• Managing challenging and non-compliant service users
• Treating service users and their families/others with respect and dignity
• Clinical assessment and examination
• Baseline observations
• Record keeping
• Appropriate extrication and conveyance of service users
• Timeliness of interventions
• Managing challenging and non-compliant service users
• Treating service users and their families/others with respect and dignity
• Clinical assessment and examination
• Baseline observations
• Record keeping
• Appropriate extrication and conveyance of service users
• Timeliness of interventions
7. Within three months of commencing employment as a Registered Paramedic you must forward a copy of your Personal Development Plan to the HCPC.
8. You must meet with your workplace supervisor on a monthly basis to consider your progress towards achieving the aims set out in your Personal Development Plan.
9. You must allow your workplace supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan every three months and prior to any review of this order.
10. You will be responsible for meeting any and all costs associated with complying with these conditions. Any condition requiring you to provide information to the HCPC is to be met by you and sent to the offices of the HCPC, marked for the attention of the relevant Case Manager.
11. The Order will be reviewed before its expiry on 23 July 2021 and any reviewing panel may be assisted by the following:
• Your attendance at the review;
• A reflective statement.
Notes
Interim Conditions of Practice Order:
203. The Panel decided that it was appropriate to consider the Interim Order application in the absence of the Registrant. In reaching this conclusion the Panel took into account that the content of the Notice of Hearing sent to the Registrant included the following words, under the heading Interim Orders: “Please note that if the Panel finds the case against you is well founded and imposes a sanction which removes, suspends or restricts your right to practise, it may also impose an interim order on you (under Article 31 of the Health and Social Work Professions Order 2001). An interim order suspends or restricts a registrant’s right to practise with immediate effect.”
204. The Panel was satisfied that the Registrant is aware that an interim order application was a possible outcome at this Hearing. The Panel remained satisfied that the Registrant had waived her right to be present at the hearing by her failure to engage.
205. The Panel could see no reason to adjourn the hearing in order to allow the Registrant to attend on a later date because there was no indication that she would attend on any other occasion. The Panel took into account the fact that it had identified there to be a continuing risk to the public if the Registrant were allowed to practise without restriction and decided it was clearly in the public interest to consider the Interim Order application in the absence of the Registrant.
206. Having heard submissions from Ms Hastie on behalf of the HCPC and having taken advice from the Legal Assessor, the Panel makes an Interim Conditions of Practice Order in the same terms as set out above, for a period of 18 months under Article 31(2) of the Health and Social Work Professions Order 2001, the same being necessary to protect members of the public and being otherwise in the public interest.
This order will expire: (if no appeal is made against the Panel’s decision and Order) upon the expiry of the period during which such an appeal could be made; (if an appeal is made against the Panel’s decision and Order) the final determination of that appeal, subject to a maximum period of 18 months.
Hearing History
History of Hearings for Miss Lisa Chadwick
| Date | Panel | Hearing type | Outcomes / Status |
|---|---|---|---|
| 22/06/2020 | Conduct and Competence Committee | Final Hearing | Conditions of Practice |
| 03/02/2020 | Conduct and Competence Committee | Final Hearing | Adjourned part heard |
| 09/12/2019 | Conduct and Competence Committee | Interim Order Review | Interim Conditions of Practice |
| 10/09/2019 | Conduct and Competence Committee | Interim Order Review | Interim Conditions of Practice |
| 21/06/2019 | Conduct and Competence Committee | Interim Order Review | Interim Conditions of Practice |
| 22/01/2019 | Conduct and Competence Committee | Interim Order Review | Interim Conditions of Practice |
| 21/06/2018 | Investigating committee | Interim Order Review | Hearing has not yet been held |
| 21/06/2018 | Investigating committee | Interim Order Review | Interim Conditions of Practice |
| 26/03/2018 | Investigating committee | Interim Order Review | Interim Suspension |
| 29/09/2017 | Investigating committee | Interim Order Application | Interim Suspension |