Mr Paul Anthony O'Neill

Profession: Paramedic

Registration Number: PA11097

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 19/04/2021 End: 17:00 23/04/2021

Location: Virtual via Video Conference

Panel: Conduct and Competence Committee
Outcome: Conditions of Practice

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Allegation

As a registered Paramedic (PA11097) your fitness to practise is impaired by reason of misconduct. In that:

 

1. On 4 November 2017, you used a Trust vehicle and/or Trust equipment to attend a Karate Competition and provide first aid support without the permission of the North West Ambulance Service NHS Trust

 

2. On 3 November 2018, you used a Trust vehicle and/or Trust equipment to attend a Karate Competition and provide first aid support without the permission of the North West Ambulance Service NHS Trust

 

3. Your conduct in relation to allegations 1 and 2 above was dishonest

 

4. The matters set out in allegations 1, 2 and 3 above constitute misconduct.

 

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

Finding

Preliminary Matters
1. The case for the Health and Care Professions Council (HCPC) was presented by Mr James Lloyd of Kingsley Napley, Solicitors. The Registrant was present and represented by Mr Jayesh Jotangia instructed by Thompsons, Solicitors. The Registrant admitted the facts of Particulars 1 and 2 and denied the remainder of the Allegation.

Application to Amend Allegation 
2. Mr Lloyd made an application to amend Particulars 1 and 2 by inserting the words “and/or Trust equipment” after the word “vehicle” on line 1 of both Particulars and deleting the words “to competitors and the attending general public” on line 2 of both Particulars and substituting the word “support”. He advised that the amendments served to clarify the Allegation and did not alter the nature of the Allegation. He also advised that the Registrant had been put on notice of the proposed amendments on 18 May 2020. Mr Jotangia confirmed that the Registrant had no objection to the proposed amendment.

3. The Panel considered the submissions of Mr Lloyd and Mr Jotangia together with the advice of the Legal Assessor. The Panel agreed to grant the application as it was satisfied that the amendment better reflected the evidence and did not cause any injustice to the Registrant.

Background
4. The Registrant is a Paramedic who has been employed by North West Ambulance Service NHS Trust (“the Trust”) since December 2000 and at the relevant time was working as a Specialist Paramedic in the Hazardous Area Response Team. On 8 November 2018, it was brought to the attention of the Trust that members of staff, one of which was the Registrant, had provided medical cover at a sporting event on 3 November 2018 without the Trust’s knowledge or authorisation. AR, Sector Manager, subsequently undertook an internal investigation into this matter, during which the Registrant disclosed that he had also provided medical cover at the same sporting event the previous year, again without the Trust’s knowledge or authorisation.

5. On 23 November 2018, the Registrant made a self-referral to the HCPC in respect of the ongoing investigation into his conduct. On 29 May 2019, following the conclusion of the investigation, the Trust held a disciplinary hearing in respect of this matter.

Decision on Facts
6. The Panel heard live evidence from two witnesses on behalf of the HCPC: AR, a Sector Manager who was appointed as the Investigating Officer and Colleague 1, a Paramedic, both of whom were employed by the Trust. The Panel also heard evidence from the Registrant.

7. The Panel found AR to be a credible witness who did her best to assist the Panel. She was an experienced Paramedic and an independent Investigating Officer who had conducted a thorough investigation on behalf of the Trust and who exhibited documentary evidence, including records of interviews she had conducted in the course of her investigation and shift records.

8. The Panel found Colleague 1 to be a credible and reliable witness whose evidence was clear. The Panel found that she answered questions put to her in a straightforward manner. The Panel was of the view that she had no reason to mislead the Panel.

9. The Panel heard very limited oral evidence from the Registrant. He gave live evidence on two very discrete points and was not cross examined. In his evidence he disputed two conversations which Colleague 1 referred to in her statement as having taken place on 3 November 2018 prior to the event. In considering his limited oral evidence and his written statements which included reflective pieces, the Panel was of the view that throughout his evidence, he attempted to minimise the severity of his actions and, in his live evidence, to undermine Colleague 1. While he has accepted the factual basis of Particulars 1 and 2, the Panel was of the view that he failed to appreciate the seriousness of his actions. Where his evidence conflicted with that of Colleague 1, the Panel accepted Colleague 1’s evidence.         

Particular 1 – found proved
10. AR gave evidence that she was asked by the Head of Service for Greater Manchester to undertake an investigation after it was brought to the attention of the Trust that on 3 November 2018 four members of staff had provided medical cover at a sporting event, namely the Manchester Youth Karate Open Championships, without the knowledge or authorisation of the Trust and utilised Trust resources when doing so. She stated that it was reported that the Registrant was one of the members of staff and that he had been responsible for sourcing the other three members of staff who worked at the event and that the Trust equipment used included an emergency ambulance. She gave evidence that in the course of that investigation, it came to light that the Registrant had also provided medical cover at the same event the previous year, on 4 November 2017, again without the knowledge or authorisation of the Trust. She advised the Panel that the Registrant volunteered this information during the fact-finding meeting.

11. The Panel also heard evidence from Colleague 1 that she was a Student Paramedic in November 2017 and that she attended the karate event on 4 November 2017 as she thought it would be good experience, especially as it meant that she would get to spend a whole day with a Senior Paramedic. She gave evidence that she met the Registrant and the other members of staff at the event and that it all looked very professional as all of the equipment was already set up. She stated that there was no indication during the 2017 event that NWAS were not aware of their involvement and that it would not have sat right with her had she known that NWAS had not approved it.
12. The Registrant admitted the facts of this Particular. His evidence was that he volunteered this information in the course of the Trust’s investigation.

13. The Panel accepts the evidence of AR which is supported by documentary evidence in the form of records of interviews and also by Colleague 1 who attended the event with the Registrant. It is also supported by the Registrant’s admissions. The Panel therefore finds the facts of Particular 1 proved on the balance of probabilities.

Particular 2 – found proved
14. AR gave evidence that her investigation involved gaining an account from Tom Goodwin, a Senior Paramedic Team Leader who was on duty at the Ambulance Station and witnessed the Registrant taking the ambulance from the station on 3 November 2018. She advised that she also took statements from Colleagues 1, 2 and 3, all of whom attended the event on 3 November and from the Registrant. She stated that she also considered a character reference from IS, the event organiser and the shift records for the four members of staff involved. She gave evidence that the key concern in relation to the Registrant’s actions was that the Trust did not have any knowledge of the sporting events on 4 November 2017 and 3 November 2018, nor had they authorised the provision of medical cover at these events, and therefore the cover provided was outside of its governance structures. In addition, the Registrant had attended the events in his uniform and with a Trust vehicle so it was reasonable for the organiser to believe that he and his colleagues were attending on behalf of the Trust, which they were not. Her evidence was that it was felt that the Registrant’s actions in this context went against the Trust’s vision and values, its behaviour framework and the NHS constitution. She told the Panel that had there been a major/significant incident, the ambulance was likely to have been required and that Patient Record Forms (PRFs) must be completed for any patient contact, however minor.

15. Colleague 1 gave evidence that on 3 November 2018, she met the Registrant and the other members of staff at the ambulance station instead of at the event. She stated that the conversations that followed triggered her to think that something was not right with the situation. She gave evidence that the first time that she started to feel uncomfortable was when the Registrant told them that if anyone asked them what they were doing, they should say that they were providing cover at the football. Her evidence was that the Registrant then said something to the effect of “it would cost a fortune to have NWAS cover the event”.

16. Colleague 1 gave evidence that shortly after this, she saw and overheard a conversation between the Registrant and TG, the Station Team Leader, in the garage in which TG said something along the lines of “I don’t remember this ambulance being taken for football today” and the Registrant responded that they were taking the ambulance to football at Manchester United. She stated that upon hearing this, she felt uncomfortable that the Registrant had lied to the Station Team Leader about what they were doing and questioned why he would do so.

17. Colleague 1 gave evidence that she subsequently told the Registrant that she was not comfortable with the situation and that she could no longer work at the event. She said that she was scared and found it really difficult to tell him how she felt and that she felt what they were doing was potentially fraudulent, taking an ambulance, equipment and drugs (including access to controlled drugs) from NWAS. She stated that she did not want anything to do with the event and that she was worried about her HCPC registration as she had only recently got it. She said that after leaving the ambulance station, she drove home in tears.

18. The Registrant gave live evidence that the conversation referred to by Colleague 1 in paragraph 15 above did not take place. He also said that Colleague 1 was not present when he had the conversation with TG as she had left by then. His evidence was that he had responded to TG confirming that they were taking the ambulance to the soccer dome (and not to Manchester United) which was the location of the karate event. 

19. The Panel was of the view that in his evidence, the Registrant was attempting to minimise his actions and also to undermine Colleague 1. The Panel preferred the evidence of Colleague 1 in relation to these conversations as, in the Panel’s view, she had no reason to attempt to mislead the Panel. In addition, the Panel concluded that, given it was not disputed that while at the ambulance station, Colleague 1 decided not to attend the event and that she was upset and left, there had to have been a reason for her to behave in that manner and that the conversation she had overheard triggered that reaction.   

20.  The Panel finds the facts of Particular 2 proved on the balance of probabilities, based on the evidence of AR and Colleague 1. Again, AR’s evidence is supported by statements and other documentary evidence in the form of shift records. The Registrant has also admitted the facts of this Particular.

Particular 3 – found proved
21. The Panel next considered whether the Registrant’s actions in using a Trust vehicle and Trust equipment to attend a Karate Competition and provide first aid support without the permission of the North West Ambulance Service NHS Trust on 4 November 2017 and 3 November 2018 were dishonest. In considering this issue, the Panel has applied the test set out in the case of Ivey v Gentings Casinos Ltd [2017] UKSC 67.

22. The Panel has first considered the Registrant’s actual knowledge or genuinely held belief in relation to the use of the Trust vehicle and equipment and the provision of first aid support without the Trust’s permission on both occasions. The Registrant has stated that his sole intention was to help a community-based organisation.  In his written statement produced for the Trust Investigation dated 14 December 2018, the Registrant has stated that prior to the event on 4 November 2017, he did not sign the vehicle check book, he did not sign the radios out in the book and he did not “sign on” with control as he knew at the time it was wrong. He also stated that no patient report forms were completed and would not have been done unless they had needed to call 999 for an ambulance. He advised that he had previously been involved in voluntary events and that he would always “sign on” with control and he knew the process to follow, which included asking permission for use of the vehicle and equipment. He also states that when the organiser asked if they could take photographs, he said no as he knew he should not have been there and that he did not tell the organiser the real reason for his reluctance.

23. In the same statement, in relation to the event on 3 November 2018, he states that he said yes without hesitation, although he knew what he had done the previous year was wrong. It is therefore clear to the Panel that the Registrant knew what he was doing was wrong, that he knew the process he had to follow in order obtain the necessary authorisations and that he failed to do so on both occasions.

24. The Panel next considered whether the Registrant’s actions in the light of that state of mind were dishonest according to the standards of ordinary decent people. The Panel has found that the Registrant was clearly aware that what he was doing was wrong and that he repeated his wrongdoing in 2018, having gone undetected the previous year. Paramedics are in a position of trust and attending the events in NWAS uniform and with an NWAS ambulance and other Trust equipment, members of the public would assume that the Registrant had the necessary permissions and insurance in place.  The Panel is of the view that, in these circumstances having presented himself as an authorised Paramedic, when in fact he was acting without the necessary permissions and insurance in place, ordinary decent people would consider his actions to be dishonest.

Decision on Grounds
25. The Panel next considered whether the Registrant’s actions found proved in Particulars 1, 2 and 3 amount to misconduct. The Panel is aware that this is a matter for its professional judgement. In reaching its decision, the Panel has considered the submissions of Mr Lloyd and Mr Jotangia and has had regard to the HCPTS Practice Note on ‘Finding Fitness to Practice is Impaired’. The Panel has also accepted the advice of the Legal Assessor.

26. The Panel is aware that the Registrant is an experienced Paramedic who had around 17 years’ experience at the time of the first event. The Panel has also found that he was clearly aware that what he was doing was wrong, that he was aware of the proper process to follow and that he repeated the wrongdoing in 2018 and on both occasions, there was a financial gain. The Panel has seen evidence that the Registrant donated his share of the payment to charity. However, the donations were only made after the matter came to light and at the time the payments were made, the Registrant retained the money. 

27. The Panel has concluded that the Registrant’s conduct found proved breached the following standards of the HCPC’s Standards of Conduct, Performance and Ethics:

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

In addition, Panel finds that the Registrant’s conduct found proved in Particulars 1 - 3 fell well below the standards expected of a Paramedic, who is in a position of trust, and as such amounts to misconduct. 
 
Decision on Impairment
28. The Panel next considered whether the Registrant’s current fitness to practise is currently impaired by that misconduct. In reaching this decision, the Panel has considered both the personal component and the public component. In addition, the Panel has considered the submissions of Mr Lloyd on behalf of the HCPC, the submissions of Mr Jotangia on behalf of the Registrant and has had regard to the HCPC Practice Note on ‘Finding Fitness to Practise is Impaired’. The Panel also accepted the advice of the Legal Assessor.

29. In terms of the personal component, the Panel has considered the Registrant’s written statements, his reflective pieces, evidence of CPD and the positive character references and testimonials. The Panel is aware that the Registrant self-referred the matter to the HCPC and has fully engaged with the Trust and with the HCPC. He has also demonstrated some remorse for his actions in his written statements. The Panel is of the view that while this demonstrates some insight into his actions, he has not fully accepted the impact on others and does not appear to fully appreciate the potential for harm caused by his actions. In his evidence, he states that on both occasions he checked the rotas in advance and knew that there would be a number of spare vehicles and there would be no impact on operational needs or demand. However, he has failed to appreciate that if there had been a significant incident, the vehicles may have been needed. The Panel finds that he has failed to appreciate the seriousness of his errors and the potential impact on others, including the upset and distress on his junior colleagues whom he had recruited to assist him as well as the potential impact on patients, if something had gone wrong at the event, where there was ungoverned and uninsured medical provision.

30. In his written statement to the Panel dated 8 April 2021, the Registrant describes feeling proud following his interactions with the children at the event and feeling “that this would reflect well on the service and the Trust”. In his NWAS Reflective Practice Log the Registrant describes his actions as a “dip under the normal high standards I have continually produced throughout my career in the Ambulance Service”. Again, these demonstrate to the Panel a real lack of appreciation of the seriousness of the situation the Registrant was in and the potential consequences of his actions. The Panel felt that his reflections contained substantial self-justification. While he may be clinically experienced, he does not seem to fully understand the high level of honesty and integrity required to be a Paramedic which are fundamental tenets of the profession. The Panel is of the view that his level of insight is therefore limited.

31. The Panel has also considered whether his actions are remediable. The Panel does not consider this to be an isolated event, as submitted by Mr Jotangia. In the Panel’s view, these were carefully planned events and the Registrant had a year between them to reflect on his behaviour, the first having gone undetected, but he still repeated his dishonesty. In the absence of full insight, the Panel is of the view that the Registrant has not fully remedied his actions and there is therefore a risk of repetition.

32. The Panel has also considered the critically important public component which includes the collective need to maintain public confidence in the profession and in the regulatory process, the protection of service users and the declaring and upholding of proper standards of behaviour. The Panel is of the view that the Registrant’s misconduct would very seriously impact on public confidence in the profession. The Panel has found that the Registrant has taken a Trust vehicle and equipment without permission and repeatedly acted dishonestly in the full knowledge that his actions were wrong. He has also recruited junior colleagues to join in his dishonest venture, for which they all received a financial gain. The Panel has concluded that there is a serious risk of an adverse impact on public confidence in the profession and in the regulatory process, if a finding of impairment were not made in these circumstances.

33. The Panel has therefore concluded that the Registrant’s fitness to practise is impaired by his misconduct on both the public and personal components.

Decision on Sanction
34. The Panel has today heard further evidence from the Registrant and has heard submissions from Mr Lloyd and Mr Jotangia on the issue of sanction. The Panel has considered the sanctions available to it in ascending order of severity and has had regard to the HCPC Sanctions Policy. The Panel also accepted the advice of the Legal Assessor.

35. The Panel is aware that the function of fitness to practise panels is not punitive and that the primary function of any sanction is to address public safety from the perspective of the risk the Registrant may pose to those using or needing his services in the future. In reaching its decision, the Panel must also give appropriate weight to the wider public interest considerations, which include the deterrent effect on other registrants, the reputation of the profession and public confidence in the regulatory process.

36. The Panel has now heard much more evidence from the Registrant prior to reaching its decision on sanction. The Registrant provided oral evidence on the issues of insight, remorse, and remediation, matters which were not addressed in his earlier live evidence to this Panel. He also submitted further positive testimonials from colleagues, from which it is clear that he is considered to be a committed professional and highly regarded practitioner.

37. In the course of his evidence, the Registrant clarified that the dates on the reflective pieces he had previously submitted were incorrect and that he believed that the 8 April 2021 reflection may have been completed earlier. He explained that he had added the dates to some of the documents from memory and some dates were when he had printed the documents off. In the course of his evidence, the Registrant made it clear that his understanding of the seriousness of his dishonest actions and the potential consequences was far greater now than in 2018. He explained to the Panel that he was the main “financial earner” in his family and that he was also a carer for his mother. He accepted the findings of the Panel and expressed very clearly his remorse for his actions, the impact on his colleagues and on the reputation of the profession. It was clear to the Panel from his evidence that he now had considerably more insight than was demonstrated in his earlier reflective piece, such that in the Panel’s view, there was a low risk of repetition.

38. The Panel has also considered the mitigating and aggravating factors. The aggravating factors are:
• The Registrant’s actions were planned, repeated and involved dishonesty;
• He involved junior staff in his dishonesty without their full knowledge;
• His behaviour involved a breach of trust;
• There was potential for harm and;
• He only admitted his actions when detected.

39. The Panel also had regard to the following mitigating factors:
• He has engaged in the process;
• Prior to the 2017 incident, he had an unblemished career over 17 years and there have been no further referrals since he returned to his role as a Paramedic in November 2019;
• He has expressed remorse for his actions and apologised, where possible, to his colleagues;
• He has developed insight such that there is now a low risk of repetition.

40. The Panel first considered whether to take no further action and was of the view that this would not be sufficient to mark the seriousness of his conduct.

41. The Panel next considered a Caution Order. In terms of the Sanctions Policy, a caution may be appropriate where the lapse is isolated or of a minor nature, there is a low risk of recurrence and the Registrant has shown insight and taken remedial action. The Panel is of the view that a caution would not be an appropriate sanction as the lapse was not of a minor nature and there is not yet full insight. In addition, it would not address fully the need for remediation. The Panel is also of the view that it would not address the seriousness of the conduct found proved or the public interest considerations.

42. The Panel next considered a Conditions of Practice Order. The HCPC Sanctions Policy states that conditions are likely to be appropriate where the registrant has insight;  the failure or deficiency is capable of being remedied;  there are no persistent or general failures which would prevent the registrant from remediating; appropriate, proportionate, realistic and verifiable conditions can be formulated; the panel is confident the registrant will comply with the conditions; a reviewing panel will be able to determine whether or not those conditions have or are being met; and  the registrant does not pose a risk of harm by being in restricted practice.

43. The Panel finds that the Registrant’s conduct is capable of remediation and that he now understands the seriousness of his actions and the potential impact of his conduct on his colleagues, the public and the profession. This will help him remedy his conduct. The Panel understands that dishonesty is difficult, but not impossible, to remedy. In addition, there is no general failure as the Registrant has practised as a Paramedic since being reinstated in November 2019 without incident and appears genuinely committed to his profession. He has also expressed his willingness to comply with conditions and the Panel is of the view that appropriate, proportionate and realistic conditions can be formulated to address the matters found proved.

44. The Panel is aware that the Sanctions Policy states that conditions of practice are less likely to be appropriate in more serious cases, for example those involving: dishonesty and should only be considered where a panel is satisfied that the Registrant’s conduct was minor and out of character and capable of remediation and unlikely to be repeated.  Although Panel has found two acts of dishonesty involving a financial gain, the gain was modest and the Registrant was not aware that there would be any payment when he agreed to attend the first event. The Panel has considered the Registrant’s actions in the context of his career of 20 years as a Paramedic and the volume of positive testimonials from colleagues. In reaching its decision, the Panel accepts that his actions were out of character and notes that since his reinstatement the Registrant has been in unrestricted practice and no further concerns have been identified. 

45. The Panel next considered a Suspension Order. In terms of the HCPC Sanctions Policy, a Suspension Order may be appropriate where there are serious concerns which cannot be reasonably addressed by a Conditions of Practice Order, but which do not require the Registrant to be struck off the Register. the Registrant has insight and the issues are unlikely to be repeated. The Panel has found that the Registrant’s conduct can be addressed by conditions. The Panel has now identified a low risk of repetition, the Registrant has demonstrated further insight and understood the seriousness of his actions and is a very committed and competent Paramedic. Weighing the interests of the Registrant including the impact of such an order, against the public interest, the Panel is of the view that in these particular circumstances, a Suspension Order would be disproportionate.

46. The Panel has concluded that a Conditions of Practice Order would both protect the public and address the wider public interest considerations and that a period of two years would be sufficient to mark the seriousness of the Registrant’s conduct.

Order

The Registrar is directed to annotate the Register to show that, for a period of two years from the date that this Order comes into effect (“the Operative Date”), you, Mr Paul Anthony O'Neill, must comply with the following conditions of practice:

1. You must not carry out any pre-planned work as a Paramedic at any public events including sports events, concerts and events of a similar nature.

2. You must place yourself and remain under the indirect supervision of a workplace supervisor of Band 8 or above and registered by the HCPC. You must supply details of your supervisor to the HCPC within 14 days of the Operative Date. You must attend upon that supervisor as required and follow their advice and recommendations.

3. Within 1 month of your supervisor being notified to HCPC you must prepare a presentation for your supervisor explaining how you failed to uphold the values and ethics of the Paramedic profession and how you intend to put them into effect in the future.

4. You must meet with your supervisor monthly to discuss your learning and future development arising from the matters found proved by the Panel.

5. You must keep a dated log of your monthly meetings signed by your supervisor and submit this log to the HCPC 14 days prior to any review of this Order.

6. You must work with your workplace supervisor to formulate a Personal Development Plan designed to address the values and ethics of being a Paramedic in professional practice and share this with the HCPC, along with evidence of progress, at least 14 days prior to any review of this Order.

7. You must produce a new detailed written reflective piece setting out your continued learning from these incidents. You must ensure this contains all areas of learning including;
• The impact on those colleagues directly involved;
• The impact on the wider profession;
• The potential impact on NWAS and patients;
• The impact on the reputation of the profession.
• The steps you have taken towards full insight and remediation.
This should be accurately dated and submitted to the HCPC at least 14 days prior to any review of this Order.

8. You must promptly inform the HCPC if you cease to be employed by your current employer or take up any other or further employment.

9. You must promptly inform the HCPC of any disciplinary proceedings taken against you by your employer.

10. 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)

Notes

This Order will be reviewed before its expiry.

Right of Appeal
You may appeal to the appropriate court against the decision of the Panel and the order it has made against you. In this case the appropriate court is the Court of Session.

Under Articles 29 and 38 of the Health and Social Work Professions Order 2001, an appeal must be made to the court not more than 28 days after the date when this notice is served on you. The order made against you will not take effect until that appeal period has expired or, if you appeal during that period, until that appeal is disposed of or withdrawn.

Interim Order
The Panel thereafter considered Mr Lloyd’s application for an Interim Conditions of Practice Order for a period of eighteen months in terms of Article 31 of the health and Social Work Professions Order 2001. The application was made on the grounds that it was necessary for the protection of the public and was otherwise in the public interest. Mr Jotangia did not oppose the application.

Having considered Mr Lloyd’s application and accepted the advice of the Legal Assessor, the Panel agreed to make an Interim Conditions of Practice Order on the same terms, 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 Mr Paul Anthony O'Neill

Date Panel Hearing type Outcomes / Status
19/04/2021 Conduct and Competence Committee Final Hearing Conditions of Practice