Miss Debbie Porter

Profession: Paramedic

Registration Number: PA33695

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 17/05/2021 End: 17:00 14/06/2021

Location: This hearing took place virtually

Panel: Conduct and Competence Committee
Outcome: Suspended

Please note that the decision can take up to 5 working days to be uploaded onto the HCPTS website. Please contact one of our Hearings Team Managers via tsteam@hcpts-uk.org or +44 (0)808 164 3084 if you require any further information.

 

Allegation

(as amended on Day 1 of the hearing, namely, 17 May 2021)

Whilst employed as a registered Paramedic for South Western Ambulance Service NHS Trust:

1. On 20 August 2018, you did not provide appropriate care to Patient A, in that you:

a. Did not take into account information provided by Person B regarding Patient A’s presentation.

b. Did not conduct an adequate clinical assessment, including:

i. A cardiovascular assessment;
ii. A respiratory assessment;
iii. An assessment of the patient’s abdomen; or
iv. An ECG.

c.  When the oxygen saturation/SP02 reading of 83% was indicated, you:

i.  Did not provide the Patient with oxygen;
ii.  Did not conduct any further assessments.

d.  Did not convey Patient A to hospital.

2. In relation to Patient A, you did not keep adequate records, in that you:

a.  Amended Patient A’s oxygen saturation reading/SP02 to 98%, which was not accurate;

b. Did not record a reason for amending Patient A’s oxygen saturation/SP02 reading;

c. Did not record any faults with the mobimed device;

d. Recorded a second blood pressure reading that had not been taken;

e. Recorded Patient A had normal skin colour, when this was not the case;

f. Did not record any differential diagnoses.

3. On 21 August 2018, you added additional details to your statement regarding Patient A in relation to a faulty mobimed device which were not referred to in your original statement.

4. Your actions as set out in paragraphs 2a), 2d), 2e) and/or 3 were dishonest.

5. Your actions as described in paragraphs 1, and/or 2 and/or 3 and/or 4 constitute misconduct.

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

 

Finding

Preliminary Matters

Service

1. The Panel was satisfied that the Notice of Hearing dated 11 February 2021 contained the date and time of the hearing as well as the nature of it (a remote hearing). This was served on the Registrant to her last known email address, as permitted under the HCPC’s emergency Covid procedural legislation (S.2ZA of the Health and Care Professions Council (Coronavirus) (Amendment) Rules 2021). The Notice content and date of service were also in accordance with Rules 3 and 6(1) and (2) of the HCPC (Competence and Conduct Committee) (Procedure) Rules 2003 (the Rules). Moreover, the Panel noted that the Registrant had responded on 31 March 2021 and 6 April 2021 indicating that she was aware of this hearing.

Proceeding in the Absence of the Registrant

2. The Panel heard Ms Lykourgou’s application to proceed in the Registrant’s absence. It accepted the Legal Assessor’s advice and paid regard to the HCPTS’ Practice Note on Proceeding in the Absence of a Registrant. The Panel took into consideration that the Registrant had emailed the HCPC on 31 March 2021 and again on 6 April 2021 stating that she would not be attending the hearing nor would she be represented. The Registrant provided an explanation as to why she would not be attending. The Panel noted its discretion to proceed in the absence of the Registrant when the Registrant indicated that she would not be attending the hearing under Rule 11 of the Rules, provided that the HCPC has made all reasonable efforts to serve the Notice of Hearing on the Registrant. The Panel determined that the HCPC had successfully served the Notice of Hearing in accordance with the Rules.

3. In addition, and in exercising its discretion with utmost care and caution, the Panel noted that the Registrant has not applied for an adjournment and has indicated twice that she is not intending to appear at this hearing and has explained why she is not attending. The Panel concluded that the Registrant has chosen not to attend of her own volition. The Panel also concluded that if it adjourned this hearing, it would be unlikely that the Registrant would appear on the next occasion in any event.

4. Furthermore, in paying regard to the wider public interest in the expeditious disposal of all matters, the Panel concluded that the hearing should proceed as the witnesses were ready to give evidence, this matter is now of some age and it is a serious case requiring resolution as soon as possible. This would not only be in the public interest, but also in the Registrant’s interest in not having the matter lingering for a longer period than is necessary.

5. For these reasons, the Panel determined to proceed in the Registrant’s absence.
Application to Amend the Allegation

6. On 12 October 2020, the Registrant was informed by email and post of the original allegation. On 15 October 2020, she was further informed by email and post that there would be a request by HCPC to amend the Allegation at the commencement of the final hearing of her case

7. Ms Lykourgou requested that the Allegation be amended at the commencement of the final hearing. The Panel, having heard the submission on this and having accepted the Legal Assessor’s advice, determined that the amendments were only an exercise in organising the Allegation into a logical sequence. In the Panel’s judgement, this made it an easier document to address. In addition, the Registrant had good notice of the proposed amendments and has raised no objection. Furthermore, the Panel noted that the Registrant has responded to the proposed amended Allegation. Therefore, the Panel determined to permit the amendments on the grounds of being fair and not prejudicial to the Registrant.

The original Allegation

Whilst employed as a registered Paramedic for South Western Ambulance Service NHS Trust:

1. On 20 August 2018, in relation to Patient A, you:

a. Failed to deliver appropriate patient care; and/or

b. Manually amended the patient’s electronic readings; and/or

c. Failed to record the decisions for changing the readings.

d. Did not take into account information provided by Person B regarding Patient A’s presentation.

e. Did not conduct an adequate clinical assessment, including:

i. A cardiovascular assessment;
ii. A respiratory assessment;
iii. An assessment of the patient’s abdomen;
iv. An ECG.

f. When the oxygen saturation/SP02 reading of 83% was indicated, you:

i. Did not provide the Patient with oxygen;
ii. Did not conduct any further assessments.

g. Did not convey Patient A to hospital.

2. In relation to Patient A, you did not keep adequate records, in that you:

a. Did not record any faults with the mobimed device;

b. Recorded a second blood pressure reading that had not been taken;

c. Recorded Patient A had normal skin colour, when this was not the case;

d. Did not record any differential diagnoses.

3. On 21 August 2018, you added additional details to your statement regarding Patient A in relation to a faulty mobimed device which were not referred to in your original statement.

4.Your actions as set out in paragraphs 2b), 2c) and/or 3 were dishonest.

5.Your actions as described in paragraphs 1, and/or 2 and/or 3 and/or 4 constitute misconduct.

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

The amended Allegation

Whilst employed as a registered Paramedic for South Western Ambulance Service NHS Trust:

1. On 20 August 2018, you did not provide appropriate care in relation to Patient A, in that you:

a. Failed to deliver appropriate patient car; and/or Did not take into account information provided by Person B regarding Patient A’s presentation.

b. Manually amended the patient’s electronic readings; and/or [Moved down] Did not conduct an adequate clinical assessment, including:

i. A cardiovascular assessment;
ii. A respiratory assessment;
iii. An assessment of the patient’s abdomen; or
iv. An ECG.

c. Failed to record the decisions for changing the readings. [Moved down] When the oxygen saturation/SP02 reading of 83% was indicated, you:

i. Did not provide the Patient with oxygen;
ii. Did not conduct any further assessments.

d. Did not convey Patient A to hospital.

2. In relation to Patient A, you did not keep adequate records, in that you:

a. Amended Patient A’s oxygen saturation reading/SP02 to 98%, which was not accurate;

b. Did not record a reason for amending Patient A’s oxygen saturation/SP02 reading;

c. Did not record any faults with the mobimed device;

d. Recorded a second blood pressure reading that had not been taken;

e. Recorded Patient A had normal skin colour, when this was not the case;

f. Did not record any differential diagnoses.

3. On 21 August 2018, you added additional details to your statement regarding Patient A in relation to a faulty mobimed device which were not referred to in your original statement.

4. Your actions described as set out in paragraphs 1b 2a), 2d), 2e) and/or 3 were dishonest.

5. Your actions as described in paragraphs 1, and/or 2 and/or 3 and/or 4 constitute misconduct.

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

HCPC’s application to rely upon the reports of Dr Morrison, Consultant Cardiologist, as expert evidence

8. The Panel heard from Ms Lykourgou in relation to her application to rely on the reports dated 2 and 9 October 2019, of Dr Morrison, Consultant Cardiologist, as expert evidence.

9. Ms Lykourgou submitted that the test for the admission of such evidence was whether or not its admission would assist the Panel in its determination of the Allegation.

10. Ms Lykourgou submitted that Dr Morrison’s evidence, albeit in written form only, as the HCPC did not intend to call him to give oral evidence, was relevant and would greatly assist the Panel, as his specialism as a Consultant Cardiologist was highly relevant to the issues to be determined by the Panel in the Allegation against the Registrant. She stated that this was a serious case involving the unexpected death of a relatively young patient after the Registrant had been involved in his care as a Paramedic.

11. Ms Lykourgou stated that Dr Morrison’s evidence “dovetailed” with that of the existing expert in the case, Mr Brogan, the Paramedicine expert. In a number of areas in his report dated 25 May 2020, Mr Brogan had deferred to the expertise of Dr Morrison and she submitted that it would make the Panel’s task more complete if Dr Morrison’s reports were to be admitted.

12. Ms Lykourgou also submitted that, despite these two reports being prepared for HM Coroner in this case, that did not negate their importance in assisting the Panel in its remit in this Fitness to Practise hearing.

13. In answer to the Panel’s questions, Ms Lykourgou also stated that she could not find any caselaw that demonstrated that an expert had to give consent to their report(s) being used in a different way to the original purpose.

14. Ms Lykourgou further submitted that there were five primary reasons why Dr Morrison’s reports should be admitted in evidence in support of the HCPC’s case:

i) It put the medical evidence in context to assist the Panel in determining which account of Patient A’s presentation they might prefer, as there were conflicting accounts between Person B, the Registrant and Colleague 1 as to whether Patient A was cyanosed when the Registrant attended. Ms Lykourgou stated that this may also assist the Panel in determining whose accounts they find most credible on other issues as well; for example, whether the Registrant had accused Patient A of over exaggerating his symptoms and if he had pleaded to see a doctor;

ii) It may also assist the Panel in assessing the reliability and weight attributable to other medical evidence relevant to the Registrant’s clinical performance, in particular that of RG;

iii) Dr Morrison’s description of best practice would also assist the Panel to determine whether the Registrant’s conduct amounts to misconduct by falling far below the standard expected of a competent Paramedic.

iv) The contents of the reports will assist the Panel in determining how plausible the Registrant’s account is from her documentation in determining whether her account of how and why the mobimed figures were altered was due to dishonesty.

v) The admission of the reports will also assist with the question of whether Patient A might have survived if different measures had been taken by the Registrant which might be relevant to the issue of impairment on public interest grounds. It may also be a relevant consideration for sanction, with the level of culpability being relevant to the level of risk posed by the Registrant.

15. Ms Lykourgou also submitted that she intended to submit Dr Morrison’s reports as hearsay evidence and was confident that the Panel could give them the weight it considered appropriate.

16. In response to the Panel’s questions and to the Legal Assessor’s advice in relation to the absence in Dr Morrison’s reports of the usual expert’s Declaration and Statement of Truth and curriculum vitae, Ms Lykourgou stated that, although it would be ideal for Dr Morrison’s reports to have included these, the Panel could see his experience as set out in his reports and that, in any event, any omission or deviation from the norm would not be fatal to her application, as the application was based solely on the test of whether the evidence would assist the Panel.

17. In reaching its decision, the Panel accepted the Legal Assessor’s advice and paid regard to the HCPTS’ Practice Note on Opinion, Evidence, Experts and Assessors.

18. The Panel noted that the Registrant had been informed that the HCPC intended to raise this issue in an email sent to her on 16 March 2021. On 9 April 2021, in being sent the bundle supporting this application, she was informed of the date of the HCPC’s first application on this matter, being 30 April 2021. The Panel noted that the application was refused by another panel on the grounds that it did not have sufficient information to make the decision and ordered this Panel to be seized of the application as a Preliminary matter on the first day of this hearing. By 30 April 2021 and also by the first day of this hearing, the Registrant had not responded to the application, despite having been invited to do so no later than 7 days before the application to be initially heard on 30 April 2021.

19. Thus, the Panel was satisfied that the Registrant had good notice of this application and has chosen not to respond to it. In addition, the Panel noted that the Registrant had addressed some aspects of Dr Morrison’s reports to the Coroner in her response to the Allegation. The Panel was mindful at all times to ensure that there was fairness to the Registrant in its approach to this application, notwithstanding her absence from the hearing and her silence on this application. In reaching its decision the Panel exercised the principle of proportionality, giving equal weight to the balance of fairness to both the HCPC and to the Registrant.

20. The Panel read the reports of Dr Morrison, dated 6 and 9 October 2019, that formed the subject matter of the application. It noted that the expert report of Mr Brogan, whose report was in the main hearing bundle produced by the HCPC, had made several references to the reports of Dr Morrison, as prepared for HM Coroner. The Panel agreed that the reports of Mr Brogan and Dr Morrison seemed to dovetail in some aspects of the evidence, but not all of it.

21. To the extent that Mr Brogan, in his report, had deferred to Dr Morrison’s evidence, in the Panel’s judgement, this would create a lacuna in the conclusions reached by Mr Brogan if the Panel did not have access to Dr Morrison’s reports, but the Panel determined that this should be in the form of evidence within the HCPC bundle, as part of the Coroner’s documentation within the existing HCPC bundle.

22. The reports of Dr Morrison were an intrinsic part of the Coronial process and the Inquest and, as such, hold the status of being expert reports for the Coroner, but not as expert reports for the HCPC. The Panel concluded that in order to have complied with its own Practice Note on Experts, if the HCPC had wished to bring Dr Morrison into these HCPC proceedings as an HCPC expert, adopting him as its own expert witness, as it did with Mr Brogan, the HCPC should have approached Dr Morrison, furnished him with an instruction letter and asked him to prepare a report specifically for this hearing. This would not only have been in accordance with the HCPTS Practice Note on Expert evidence, but also would have allowed Dr Morrison to comply with his own regulatory requirements as a medical expert.

23. The Panel concluded that any potential gap in the analysis by Mr Brogan caused by the absence of Dr Morrison’s reports would not be satisfactory for the Panel in its determination of the issues in the case. The Panel determined that such merging of the relevant parts of the evidence of both Mr Brogan and Dr Morrison, where Mr Brogan had deferred to and/or agreed with Dr Morrison’s opinion, was going to be of assistance to the Panel.

24. Therefore, for these reasons, the Panel concluded that it would permit the evidence of Dr Morrison to be included in this hearing and placed into the existing HCPC bundle as supplemental pages. The Panel concluded that Dr Morrison will not be an HCPC expert witness, but, rather, retain his status as the Coroner’s expert. In the Panel’s judgement, this decision will allow the Panel to be assisted in dealing with any relevant matters in a way that is both clear and fair.

Application by the HCPC to admit the evidence of Person B, SB, and four Paramedic witnesses, EM, RW, SB and NG, as Hearsay evidence

25. Ms Lykourgou submitted that the following fell within the application she was making:

1) Person B, Patient A’s wife who witnessed the treatment administered by the Registrant to Patient A.

• Her HCPC witness statement dated 13 November 2020;

• The record of conversation between MH and Person B dated 3 October 2018;

• The witness statement of Person B dated 18 November 2019 prepared for the Inquest;

• The supplementary statement of Person B dated 13 November 2019 for the Inquest; and

• The transcripts of Person B’s 999 calls dated 20 August 2018.

2) SB, a Medical Device Technician who tested the mobimed device used by the Registrant.

• His HCPC witness statement dated 10 August 2020;

• His email dated 22 August 2018; and

• His witness statement dated 25 February 2019 for the Inquest.

3) The witness statements of the ambulance crews who attended Patient A’s house following the Registrant’s initial attendance:

• EM, an ECA - witness statement for the Trust dated 21 August 2018;

• RW, a Paramedic - witness statement for the Trust dated 21 August 2018;

• SB, a Paramedic - witness statement for the Trust dated 27 August 2018; and

• NG, a Lead Paramedic - witness statement for the Trust dated 20 August 2018.

4) Ms Lykourgou gave reasons for the witnesses not being called. She stated that Person B was too upset to be involved any further in the events surrounding her late husband and that it was proportionate for the HCPC to have decided not to call SB or the four other Paramedic witnesses, who had attended on Patient A on the second call out.

5) Ms Lykourgou submitted that it would be fair to admit the hearsay evidence in this case because:

• It is all relevant to the allegations the Registrant is facing;

• Person B and SB’s evidence in particular, is highly probative to the HCPC’s case;

• There is minimal prejudice to the Registrant through the admission of this evidence; and

• The Registrant was sent the bundle to the address she provided and was given an opportunity to arrange representation for herself, to present alternative evidence, and to object to the admission of any evidence the HCPC sought to rely on. No objection was made.

6) If it is admitted, the Panel will have the opportunity to ascribe whatever weight should be attributed to the hearsay evidence.

7) If the evidence is admitted a high degree of weight can be attributed to this evidence due to:

• The contemporaneous nature of the evidence to the allegations to be determined;

• The hearsay evidence is cross-supported by the witness statements and oral evidence the Panel will consider; and

• There is no evidence that the accounts provided are fabricated or unreliable.

The Panel’s decision on hearsay

26. In reaching its decision, the Panel accepted the Legal Assessor’s advice and exercised its judgement as to whether each category of the proposed hearsay evidence amounted to sole and decisive evidence and whether it was relevant and fair to permit it to be admitted as hearsay evidence, in accordance with the caselaw.

27. The Panel concluded that the four Paramedic witnesses would not be sufficiently relevant to the issues under scrutiny, since these witnesses gave evidence about their actions when they attended on Patient A very close to one hour after the Registrant and Colleague A had left the premises. Thus, the only matters that they could legitimately address related to Patient A’s condition when he was in an extremely perilous state of health, and some considerable time after the Registrant had seen and assessed him.

28. The Panel also took into consideration that the witness statements had not been made for the purpose of this HCPC hearing, but, rather, for the Trust’s investigation into Patient A’s death and the HCPC had not approached the four witnesses to obtain witness statements specifically for the purpose of this hearing.

29. Thus, in the Panel’s judgement, it would not be fair to permit these statements to be attributed the status of an HCPC witness statement under the hearsay provisions and they would be excluded from the Panel’s deliberations hereafter.

30. In relation to the evidence of SB, the Panel considered that his evidence was not the sole and decisive evidence on the issues he covered, as RG had also tested the Mobimed and handheld oxygen saturation device, as was clear from RG’s witness statement. The Panel also considered that SB’s evidence was relevant as it addressed the Particulars of Allegation 2a), 2b), 2c) and 2d).

31. Thus, the Panel concluded that it would be fair to permit the evidence of SB to be adduced as hearsay evidence, as there was their evidence (RG’s) to counterbalance it and SB’s evidence was relevant. The Panel would be able to give it the weight it considered appropriate when it deliberated on the facts and would take into account that SB would not available to be questioned by the Panel in the Registrant’s absence.

32. In relation to the evidence of Person B, the Panel considered that her evidence in relation to, for example, Patient A’s facial colour, including his lips, his breathing and whether the Registrant assessed Patient A’s abdomen, was the sole and decisive evidence. The Panel noted that Colleague 1 was also present but her written evidence on these matters was not decisive and on occasion opaque as to detail. Hence, in the Panel’s judgement, the only person, other than the Registrant who was present at all material times was Person B.

33. The Panel considered her evidence on matters that related to several of the Particulars of Allegation that the Registrant was denying, to be pivotal, and therefore, relevant. Although Person B’s evidence was the sole and decisive evidence on a number of matters relating to the denied Particulars of Allegation, the Panel concluded that its relevance outweighed any risk to the Registrant. The Registrant had engaged to a certain extent in this process, had good notice of this application and had not objected to it, and also had been able to set out her defence to the Allegation clearly in writing. Thus, the Panel determined that her position would not be disadvantaged. The Panel concluded that the Registrant was in the same position as Person B; namely, neither Person B nor the Registrant would be available to be cross examined or questioned by the Panel. In addition, in the Panel’s judgement, the fact that the Registrant was not present at this hearing added nothing to this application, as the HCPC must prove its case on the balance of probabilities and it is not for the Registrant to disprove it.

34. Therefore, for these reasons, the Panel determined that it would be fair to permit Person B’s evidence to be adduced as hearsay evidence.

35. However, the Panel did not consider those parts of Person B’s evidence as contained in all the documents that were not the official HCPC witness statement of Person B dated 13 November 2020 and referred to by Ms Lykourgou, were eligible for consideration in this hearsay application. Those parts of Person B’s evidence flowed from her witness statement and consisted of exhibit material in the HCPC’s bundle. This was material that was openly disclosed to all parties, read by the Panel and it will take it into account in the normal way in relation to documentary evidence.

36. In tandem with Person B’s witness statement, the Panel will give the linked exhibit evidence the weight it considers appropriate at the proper time, taking into account that Person B’s evidence could not be tested by questioning, that this is a serious Allegation with potentially grave consequences for the Registrant if proved and that the Registrant is absent from this hearing.


Background:

37. The Registrant is a Paramedic who was employed by South Western Ambulance Services NHS Foundation trust (the Trust) covering Bristol, North Somerset and South Gloucestershire at the time of the alleged incident. She was a Band 6 Paramedic at the time of the events, with approximately 7 previously blemish-free years’ experience at the Trust, having originally commenced employment with the Trust as a non-paramedic in April 2002. The Registrant had registered as a Paramedic on 28 September 2011. The Registrant’s role, as a Band 6 Paramedic included responding to all types of emergencies and to provide urgent care to patients. She had also been responsible for the supervision of junior members of staff such as Emergency Care Assistants (ECAs) and Student Paramedics when they would be assigned to work with the Registrant as part of an ambulance crew. The Registrant’s Line Manager was GH, the Trust’s Operations Officer.

38. On 20 August 2018, at 14.19 hours the Registrant attended a 999 call with Colleague 1, an ECA. The Registrant was the lead clinician on the scene. They attended to Patient A, a 31 year old male, who had a history of diarrhoea and vomiting for twelve hours. The call log stated that the crew had been informed that Patient A had been ‘shaking since 2am’,’ was dizzy and faint’, had presented with a twelve hour history of diarrhoea and vomiting, was not completely alert and had ‘messed himself’. The Registrant assessed Patient A and deemed it appropriate to leave him at home and advised the patient to self-administer Immodium, to maintain fluid intake and to call the GPs the following day if symptoms persisted. In any case Patient A and Person B were advised to call 999 if the symptoms worsened. Therefore, having given this advice and the advice having been understood by the family, the Registrant discharged Patient A.

39. The Trust received a further 999 call at 16.01 hours from Patient A’s wife, Person B. Person B stated that Patient A had started to feel worse at 15.35 hours and had collapsed to the floor at 15.40 hours. When the second ambulance crew arrived, they found that Patient A was unconscious and apnoeic and they diagnosed that he was in cardiac arrest. Emergency resuscitation measures were performed but, sadly, Patient A died, confirmed at 16.21 hours. The Police and the Coroner were informed as this was an unexpected, but not suspicious, death. A Coroner’s Inquest was held into the death of Patient A from 2 to 5 December 2019.

40. MH, Paramedic Operations Officer for the Trust and RG, Quality Lead at the time and now Clinical Lead for the Trust both conducted separate and parallel internal investigations into the concerns around the initial call out to Patient A by the Registrant. MH’s investigation was a disciplinary investigation to determine whether the readings relating to Patient A’s oxygen saturation levels had been amended. RG’s investigation focused on the clinical care that the Registrant provided to Patient A and was part of the Trust’s Root Cause Analysis.

41. MH was appointed as Investigating Officer of the index incident in August 2018 by SJ, the Trust’s County Commander and DM, the Trust’s Deputy County Commander. MH conducted a disciplinary investigation relating to the events that took place on 20 August 2018. He produced an Investigation Report, dated 5 December 2018, with the relevant appendices. His final report was submitted to Trust’s Human Resources Services in November 2018. This included a chronology of the events of 20 August 2020. MH had no direct involvement with the clinical Root Cause Analysis investigation.

42. RG, with MH, interviewed the Registrant on 5 October 2018 to clarify the contents of her original statement dated 21 August 2018. She was asked to comment on the change of oxygen saturations as any information about this was absent from the original. She then amended her statement, signed and dated it on the same date, 21 August 2018.

43. On 5 October 2018, RG and MH interviewed the Registrant together to ensure that they had the information they needed for their respective investigations. It was usually the case within the Trust that any conduct investigation would await the outcome of a Root Cause Analysis investigation, as one of the recommendations might have been to conduct a conduct investigation, for example.

44. A photograph of Patient A, taken by the patient’s wife, Person B, after the Registrant and Colleague 1 had left the premises on 20 August 2018, was shown to the Registrant during the investigation meeting on 5 October 2018. She confirmed it was accurate of how the patient had looked during the incident, although the Registrant commented that the photograph made Patient A look worse as his eyes were partly closed in this photograph and they had been open when she was present.

45. As the concerns relating to alleged altered clinical observations were clear at the time to both RG and MH, they concluded that the two investigations could run parallel at the early stage of the process.

46. RG also interviewed Colleague 1 and asked her to produce a second statement, her first having been made by her on 21 August 2018. She produced a second statement, but after consultation, RG and MH decided that Colleague 1 should answer three further questions, which she did on the telephone with RG later on 5 October 2018. This was recorded and transcribed into a written document. In addition, Colleague 1 also confirmed that the same photograph of the patient shown to the Registrant, was a true representation of how the patient had presented, but she later amended that comment in her witness statement to the HCPC dated 11 May 2020, when she stated that the photograph was not a true representation of how Patient A had looked when she and the Registrant had attended to him.

47. On 3 October 2018, RG and MH had interviewed Person B, Patient A’s wife, who was present on 20 August 2018 when the Registrant and Colleague 1 had attended at their home. This meeting was under Duty of Candour to advise that a Serious Incident had been declared by the Trust. RG and MH made notes of the interview and also took possession of the photograph that Person B had taken of Patient A after the Registrant and Colleague 1 had left the scene at 14.41 hours on 20 August 2018. Another photograph of Patent A when he was well, taken before these events had taken place, was given by Person B to RG and MH. These two photographs were used by the Trust as a comparison of how Patient A had looked before and after the events in question. Person B confirmed that the photograph of the patient, taken by her after the first ambulance crew had left, was a true representation of how the patient had presented. The difference in the two photographs confirmed to RG and MH that the detail provided on the 999 call (which coincided with the auto-populated information from the ePCR) demonstrated a patient who was profusely cyanotic and acutely unwell.

48. The Registrant had been placed on restricted practice on 21 August 2018 but this was lifted on 22 August 2018 after statements had been taken and after the Trust had made a decision about the Registrant’s ongoing practice. However, after the Coroner’s involvement into the death of Patient A, the Trust decided to place the Registrant back on restricted practice to ECA status on 21 September 2018. After the investigation meeting of 5 October 2018, the Trust decided to suspend the Registrant from all duties until the outcome of the disciplinary process, which had been decided was necessary.

49. The Registrant’s disciplinary hearing took place on 7 January 2019. The allegation was of gross misconduct, in that the Registrant had failed to deliver appropriate patient care and had falsified readings in respect of a patient that she had discharged on scene. The decision letter of the disciplinary hearing was sent to the Registrant on 16 January 2019.

50. On 14 May 2019, the Registrant self-referred to the HCPC. She stated that she had undergone a phased return to work from 17 January 2019 when her suspension was lifted by the Trust, and, by 14 May 2019, had resumed all her Paramedic duties.

The HCPC obtained the following witness statements from:

• RG, whose witness statement was dated 20 April 2020;

• MH, whose witness statement was dated 13 June 2020;

• Colleague 1, whose witness statement was dated 11 May 2020;

• Person B, whose witness statement was dated 13 November 2020; and

• SB, the Trust’s Medical Advice Technician Team Leader, whose witness statement was dated 10 August 2020

• The HCPC also obtained an expert report from Mr Brogan, a Paramedicine expert, whose report was dated 28 March 2020.

 

Witness Evidence:

MH’S written evidence

51. MH’s remit was to conduct a disciplinary investigation to determine whether readings relating to Patient A’s oxygen saturation levels had been amended by the Registrant on the Electronic Patient Care Record (‘ePCR’). The ePCR is the electronic Patient Care Report and is the confidential patient record that is generated for every patient that the Trust attends. It records the patient’s history, all assessments (including observations and Electrocardiograms) and captures the outcome of the care episode. It is to be completed by the paramedic crews on each call-out.

52. In summary, MH’s report, dated 5 December 2018, sets out a chronology relating to the events of 20 August 2018. He identified that the Registrant had allegedly manually overridden in the ePCR Patient A’s oxygen saturation levels from 83% and 87%, respectively, to 98%. MH also stated that normal oxygen saturation levels should be between 94% and 100%.

MH concluded as follows:

• This patient was acutely unwell with clear signs of hypoxia and cyanosis and confirmed by physical signs and symptoms and diagnostic assessments. This was not reflected in …. (the Registrant’s)… clinical assessment and decision making.

• The evidence shows manual amendment of the SpO2 values with an explanation that is inconsistent with other evidence obtained.

• The evidence shows that there has been a potential insertion of patient information which is falsified – such as abdominal assessments and blood pressure reading.

• …. (the Registrant)…  stands by her initial statement and does not admit to the alteration of patient records throughout the investigation.

• …. (the Registrant)…  initially completed a clinical session with an Operations Officer and also provided a reflection……following the incident which demonstrated adequate learning had taken place.

• The investigation was reopened following the initial restriction of practice due to further investigation by RG, Quality Lead as a result of a request for a Coroner’s Report.”

RG’s written evidence

53. RG, was Quality Lead at the time of the events concerning this case and is now Clinical Lead for the Trust. He is also a registered Paramedic. He was asked to conduct a Root Cause Analysis of the events of 20 August 2018. RG provided a witness statement to which he exhibited the final draft version of the Root Cause Analysis Investigation Report dated 29 November 2018. The Report concluded as follows:

“Patient A did not have a history of known cardiac issues or chest pain and the crew were correct to suspect Patient A’s primary complaint was one of acute diarrhoea and vomiting. Patient A’s initial vital signs suggested he was acutely unwell and in need of emergency intervention.

This, along with the description of Patient A during the 999 call, the photograph provided by Person B, the first set of observations, the original reduced SpO2 values, his rapid deterioration to cardiac arrest and subsequent pathology findings, lead the IO to believe there was a missed opportunity to recognise how unwell Patient A was and act urgently to treat and transport him to hospital for further assessment and treatment.

There is a clear discrepancy between the evidence listed above and the findings of the ambulance crew and observations noted on the ePCR. This will require further investigation outside the scope of this report and is currently being dealt with by the Human Resources Department.

The care and treatment afforded to Patient A following his collapse from cardiac arrest was appropriate and in keeping with Trust and national guidelines.”

54. In his witness statement, RG documented how he had become aware of the incident and identified the documents he had used in the preparation of his witness statement and the Root Cause Analysis report.

55. RG stated in the witness statement that he had also looked at the vehicle tracking system for the ambulance that was used by the Registrant and Colleague 1, as Person B suggested that the Registrant and Colleague 1 had not been on scene for very long.

56. In relation to the allegation of falsification of the patient’s oxygen saturation levels, RG stated as follows in his witness statement:

“….There are two pieces of equipment that a crew may use to take a SpO2 reading from a patient. The first piece of equipment is a Mobimed Device. This is an electronic device which uses a wired probe that is placed over end of the patient’s finger and a light is omitted from one side of probe which is then received on the other side of probe. A reading is taken based on the amount of light received by the receiver. This information is then transmitted from the unit to which the probe is attached to the Mobimed Device and the screen on the Mobimed Device displays the SpO2 reading. This is a numerical figure and it appears on the screen automatically if the probe is attached and able to obtain a reading. If the Mobimed Device is able to produce a SpO2 reading, this reading will be recorded automatically on ePCR and records a timestamp. At certain intervals, the Mobimed Device will also automatically record data in the background.

The second device that can be used to measure a patient’s SpO2 level is a portable oxygen saturation probe. Most, if not all ambulance vehicles and rapid response cars carry this device. It is contained within the emergency response bag. The device works in the same way but it is a single portable unit and the SpO2 reading is displayed on the unit itself, rather than automatically on the Mobimed Device. This reading therefore needs to be manually entered onto the ePCR for that patient. Ideally, this reading should be recorded into the ePCR at the time when it is taken, but it is recognised especially with nature of the work we do that it is not always appropriate to do at the time, so the crew can input this data as soon as practicable. However, all steps should be taken to make sure that the SpO2 reading is accurate at the time of entry into the ePCR. A number of crews will therefore take notes on a notepad to make sure that when the information is entered into the ePCR, it is accurate. It is also common practice to write values on the back of your glove, although this is not encouraged. There is no preference as to which device crews should use; if, for example, it is necessary to take a large amount of kit into a property it may not be feasible to take the Mobimed and vital signs monitoring too, so an assessment may be carried out using manual equipment.

Within the Mobimed Device, there is a log which essentially tracks any input or changes to the information already on the ePCR. This information is logged in the background so we can review that information and see every entry made on the Mobimed Device…… By looking at that log, I could see that the original, automatically recorded observations were overwritten. …. (the Registrant)… is recorded as having made these changes and signed the ePCR. She has also acknowledged in her evidence to the Trust and to the Coroner that she completed the ePCR for Patient A.

The first SpO2 reading, taken at 14:31 hours was 83% and the second SpO2 reading, taken at 14:40 hours was 87%……These readings were automatically recorded. They indicated that Patient A was critically unwell. …. (the Registrant)… would have been aware of this as a result of her training as a Paramedic. She would also have had access to guidelines through the Mobimed system, to which she could have referred. However, both readings were then manually adjusted to a reading of 98%….. and this is the reading that was included within the first ePCR……The reading of 83% was altered to 98% at 14:41 and the reading of 87% was altered at to 98% at 14:43. This ePCR, completed by …. (the Registrant)…, states that Patient A’s SpO2 level at 14:21 hours and 14:40 hours was 98%. It is clear these values were manually inputted due to the fact anything that is automatically captured by the system is recorded as an automatic entry. The Mobimed Device appears to have been attached to Patient A from 14:26 hours until around 14:40 hours, when the last auto-captured entry was recorded. The ambulance ignition was started at 14:41:25 hours, indicating that this is when the crew left Patient A’s address. This chronology suggests that Patient A’s SpO2 readings were therefore manually adjusted after the crew had left Patient A’s address……the original values automatically recorded by the Mobimed Device, of 83% and 87%, were very concerning and combined with the other observations taken indicated that Patient A was critically unwell. This is clear from the clinical values recorded. Patient A required urgent oxygenation to correct the profound hypoxia he was presenting with……….…. (the Registrant)… should have been able to recognise that these readings were very concerning, as recognising normal and abnormal physiological vital signs is a fundamental part of any Paramedic’s training and practice.”

57. RG stated in his witness statement that, whilst there would be occasions when a Paramedic might manually amend readings automatically recorded by the Mobimed Device, such as a poor blood pressure cuff fit, this should be recorded by the Paramedic in the “exclusions” box on the ePCR, with reasons why this was done, and the Registrant did not do this.

58. RG stated in his witness statement that the Registrant had said in her 5 October 2018 interview that the Mobimed Device was not reporting the oxygen levels correctly in her view, as the signal was weak. RG explained in his statement that red indicated a weak signal with one bar, amber showed two bars and green, a strong signal, showed three bars. The strength of that signal was relevant to its strength in obtaining the readings. As a result, the Registrant had said that she felt the reading was not accurate, so she used the portable oxygen probe which she said gave a SpO2 reading of 98%. The readings were then amended in line with the readings taken from the portable probe. RG noted in his statement that Patient A’s SpO2 level was consistently low, around 83% to 87%, which gave a good indication that the reading was not erroneous. He stated that the Registrant would have been able to see that, over the period of time that the patient was being monitored, his oxygen saturation was consistently low, remaining between 83-87%.

59. RG acknowledged in his witness statement that it had not been possible to examine the portable oxygen probe that the Registrant had used, in order to confirm if it had displayed a SpO2 reading of 98%. However, MH tested the portable device and the Mobimed vital signs monitoring equipment following this incident and confirmed to RG that the equipment worked correctly. RG stated in his witness statement that the suggestion that the portable oxygen probe indicated that Patient A had a SpO2 reading of 98% was “not plausible, given Patient A’s presentation at the time. Based on the clinical readings taken, Patient A’s presentation, the Coroner’s report and the photograph taken by Person B…., we know that Patient A was presenting with central cyanosis. His lips were blue and this is a clear indication of central cyanosis.”

60. In his witness statement, RG addressed the alleged falsification by the Registrant of Patient A’s blood pressure readings. RG stated that he was concerned about the second reading because Person B’s evidence was that there had been no physical contact or physical assessment completed by the Registrant or Colleague 1 of Patient A. He stated the Mobimed captured two blood presuures readings of 110/71 at 14:21 and at 14:40 hours on 20 August 2018. RG stated that he was concerned by this as it would be‚ ‘very unusual‘ to have exactly the same recorded blood pressures when taken 20 minutes apart. When RG challenged the Registrant about this, she maintained that she had taken the second blood pressure reading from Patient A and she stated that she had inputted the second reading onto the ePCR manually.

61. In addition, in his witness statement, RG also set out what steps he thought the Registrant should have taken in relation to Patient A. This included recording accurate oxygen levels, vital signs, undertaking an ECG, performing a chest and abdominal examination, and a hospital transfer. In addition, RG was critical of the Registrant’s subsequent advice to Patient A and his family prior to discharging Patient A.

Colleague 1’s written evidence

62. In her witness statement, Colleague 1 referenced her 21 August and 5 October 2018 statements to the Trust and the answers she had given to RG and MH in their telephone call to her on 5 October 2018.

63. In addition, Colleague 1 referred to the photograph taken by Person B after the crew had left the premises and how Patient A looked when she and the Registrant attended on Patient A in comparison to the photograph. She stated that, in the photograph, “Patient A looks much worse than I recall due to his eyes being half closed. I feel that the photograph also does not accurately reflect his colouring”. She confirmed that this amended the statement she had given to the Trust on 5 October 2018, when she had stated that the photograph accurately reflected how Patient A had looked when she and the Registrant had attended to him.

64. Colleague 1 also stated in her witness statement the following in relation to Person B’s descriptions of Patient A in her 999 calls: “I cannot recall the exact job detail but Patient A was a male with 12 hours onset of diarrhoea and vomiting. The job detail also mentioned that the patient’s lips were grey/purple. I only recall this now as it was mentioned at the Coroner’s Inquest in December 2019…”

65. Colleague 1’s witness statement recorded that Patient A was lying down and not fully conversing as he was in pain and uncomfortable. His breathing seemed “fine” on a visual check. Colleague 1’s witness statement stated that she spoke to Person B to obtain personal information on Patient A and was checking the mobimed. The Registrant was with Patient A. Colleague 1 did not recall being shown a photograph of Patient A by Person B.

66. With respect to the actions of the Registrant, Colleague 1 in her witness statement stated that the Registrant had examined Patient A’s stomach by palpating it and feeling it, but she could not confirm this for certain. She could not recall what the oxygen saturation levels were at the time but stated that “with hindsight, I know there has been a query raised about the oxygen levels”.

67. Colleague 1 in her witness statement also stated that the Registrant made the decision to change to the mobile monitor from the mobimed to measure the patient’s oxygen saturation levels and that to the best of her recollection there had been nothing to suggest that the mobimed was not working correctly. She also stated that there was “a strong likelihood” that the mobimed had been used previously that day by the crew.

68. In regard to changing the oxygen saturation levels manually, Colleague 1 stated in her witness statement as follows:

“As far as I am aware, it is common practice that if you record a reading on one machine and if that reading is not considered to be at a good level which is a value above 94%, then you can switch to using a different machine to measure the same reading. This confirms if the first reading was correct. It is a double check. There are various reasons why readings do not pick up properly such as if the patient has poor circulation, so it is common practice to switch to a different machine to confirm the correct amount…"  She stated that she had not been alarmed by the difference in the oxygen saturation level readings taken on the two machines.

69. Colleague 1 stated in her witness statement that the Registrant had advised Patient A to “keep his fluids up” to avoid dehydration which was common with diarrhoea and vomiting, taking small sips often, to take paracetamol, to contact the General Practitioner should his symptoms persist and to obtain the medication from the pharmacy to help stop the diarrhoea. Colleague 1 also stated in her witness statement that she and the Registrant had ensured that Patient A, Person B, Patient A’s mother (who could not speak English) had understood the information that the crew had given them. In addition, in her witness statement, Colleague 1 stated that Person B had said that they were all happy and had understood the information.

Person B’s written evidence

70. Person B stated in her witness statement that she wished to provide additional information to the statement she had made for the Coroner’s Inquest. This centred around her belief that the Registrant had not been sufficiently concerned about Patient A’s condition and that the Registrant had downplayed the seriousness of it. She referred to the Registrant stating that Patient A might have been exaggerating his symptoms, that he might have had a “tummy bug” when challenged by Person B about Patient A’s blueish lips, and that the Registrant stated that there was nothing wrong with him.

71. Person B stated that she had shown the ambulance crew a photograph of Patient A in a normal state.

72. Person B stated in her witness statement that the Registrant did not seem to want to be at the premises, brushed off Person B, Patient A and their daughter and that the Registrant looked “fed up”, “appearing to reflect the thought ‘why am I even here?’.” Person B stated in her statement that the Registrant “did not look concerned or worried about Patient A and did not appear to be supportive or caring towards him.”. In her statement, Person B stated that the Registrant appeared to have made up her mind about Patient A’s condition before she arrived, that she appeared to be “….blinkered and not prepared to see and acknowledge Patient A’s actual presentation.”

73. In her witness statement, Person B also referred to the Registrant not examining Patient A’s chest or abdomen or asking about his pain.

SB’s written evidence

74. In his witness statement, SB stated that he was requested by MH to check the Vital Signs Monitoring (VSM) equipment inside vehicle 7724 (the vehicle used by the Registrant and Colleague 1 on 20 August 2018) to confirm if it was working and recording observations correctly. This included the ECG Machine, the SpO2 device and the Non-Invasive Blood Pressure (NIBP) Monitor. He stated that he found that the ‘VSM equipment and the consumable equipment’ were working correctly. In his witness statement, SB also explained the function of the logistics desk and he clarified the Symbio Patient simulator. In his statement, SB also confirmed that the blood pressure cuffs were working correctly, how he tested the Adult and Paediatric SpO2 probes, but he was unable to confirm if the vehicle used by the Registrant and Colleague 1 on 20 August 2018 was used by any other staff members during the period between 20 August 2018 and when he had completed the testing on the equipment.
 
Mr Brogan’s expert evidence

75. In his expert report on this case, Mr Brogan concluded as follows as set out in his report of 25 May 2020:

“My opinion
 
4.1.  Having reviewed the evidence served I have made the following observations, in line with my instructions:

4.2.  In reviewing the patient's presentation, with consideration for the description of Patient A’s presentation by his wife to the ‘999’ call assessor and the photograph she has provided of the patient that she took whilst awaiting the arrival of the ambulance, I agree with the findings of the internal investigation report. The description of Patient A given by his wife to the call assessor is in keeping with the photograph. I have noted that all parties agree that the photograph is a true representation, save for the Registrant identifying that the patient's eyes were open during her examination. It is clear from the photograph that Patient A appears to be acutely unwell, with cyanosis evident. In my opinion, the patient's presentation in the photograph would correlate with the symptoms identified and the observations that were automatically captured by the monitoring equipment. With this presentation and the automatically captured observations, this would indicate that the patient was hypoxic and required immediate assessment, treatment and conveyance to an appropriate receiving facility. In my opinion, the presentation of Patient A would be most in keeping with the auto captured observations by the ‘Mobimed’ and not as documented on the ePCR by the Registrant.

4.3.  In reviewing the evidence, I have found that the Registrant performed an assessment of responsiveness, using the AVPU pneumonic, Glasgow Coma Score (GCS), Capillary Bed Refill (CBR), Respiratory Rate (RR), Pulse (HR), Pulse Oximetry (Sp02), Blood Glucose Measurement (BGM), Blood Pressure (BP), and Temperature (Temp). I have found that several elements of assessment have been recorded, such as identifying that the patient had adequate perfusion and normal skin colour, which is clearly not in keeping with the photograph of Patient A produced. I have noted that the Registrant has documented performing an abdominal assessment, despite neither the Emergency Care Assistant (ECA) or Patient A’s wife recalling this in their statements. The Registrant documents this assessment, minus any assessment of bowel sounds, or any commentary on the nature, frequency, or temporal factors of the patient's bowel movements. I have also noted that the patient had a normal pulse, despite initially recording this at 110, where anything over 100 would be considered to be tachycardic. In my opinion, the observations that were automatically captured would be in keeping with the presentation, as seen in the photograph and described by the wife of Patient A.

4.4.  Based on the presenting symptoms of Patient A from the bundle of evidence, I would have expected the Registrant to have performed observations in keeping with standard Paramedic practice. Specifically, I would expect to see a primary survey consisting of identification of any or potentially life-threatening injuries or illness following a sequential format of danger assessment, responsiveness assessment, airway check, breathing check and circulation.
 
4.5.  Following this, I would expect the Registrant to conduct a comprehensive history taking exercise, and, given the obvious acute presentation of Patient A, consider rapid intervention and transportation as the findings dictated, namely with pulse oximetry of 83%, I would expect the Registrant to have administered Oxygen in line with the relevant JRCALC guideline. When time allowed, I would then expect a physical examination of the respiratory, cardiovascular, and abdominal systems.

4.6.  In the examination of the respiratory system, I would have expected this to cover inspection, palpation, auscultation, and percussion of the chest as a minimum, with additional assessments as would be deemed appropriate. In the examination of the cardiovascular system, I would have expected this to cover inspection, palpation, auscultation, and percussion of the chest as a minimum, with additional assessments such as the assessment of clubbing, splinter haemorrhage as a desirable addition. In the examination of the abdominal system, I would have expected this to cover inspection, palpation, auscultation, and percussion of the abdomen as a minimum, with additional assessments as would be deemed appropriate within the scope of the Registrant.
 
4.7.  Thereafter, I would have expected the Registrant to complete clear documentation with relevant findings of any differential diagnosis and any pertinent negative findings and discounted differentials with appropriate justification. I would also expect the Registrant to have performed observations on the patient, namely, blood pressure, pulse oximetry, pulse, pupillary response, Glasgow Coma Scale (GCS) and 12 lead Echocardiogram (ECG). I would also have expected the Registrant to consider escalation/pre-alerting an appropriate receiving facility given the presentation of Patient A as acutely unwell and also with the infection control risk associated with diarrhoea. I would expect the Registrant to have adhered to the principles set out in the trust clinical guideline GC10, concerning patients with diarrhoea and vomiting. In this, in my opinion, the Registrant should have clearly documented their findings.

4.8.  From my review of the evidence, the following steps appear to have been missed by the Registrant: respiratory assessment, cardiovascular assessment, and 12 lead ECG. There is also prima facia some discrepancies between the automatic and manually overridden ePCR information.

4.9.  In considering the protocol for taking blood oxygen readings using a pulse oximeter/monitor with inbuilt pulse oximetry, I would expect the Registrant to select and apply an appropriate probe, giving consideration to the type of patient ie. adult or child, and the body area that that probe has been designed and tested for, in line with the manufacturer's guidelines for that product. I would then expect the Registrant to review the value given by the machine and consider this as part of the assessment of the patient. In this, I would expect the Registrant to give due consideration to any factors that may cause the reading to be deemed unreliable.

Areas that could cause concern as to the reliability of a reading could include faulty equipment or a reading that does not sit within an expected range (as would be detected by the Registrants experience, and based upon the history given by the patient), the environment in which the assessment is being completed and the patient's presentation; this is critical to then consider any possibility of a false reading being produced by, for example, Carbon Monoxide inhalation, the temperature of the patient's extremities, other morbidities that may affect the result eg. Raynauds syndrome. I would then expect the Registrant to document the value given by the monitoring equipment and then - if they felt this was inaccurate, unreliable, or questionable - record their analysis of the reading with full reasoning of the evidence they have considered that has led them to this conclusion, identifying if this has affected the way they have treated the patient, and documenting what treatment regime they then have followed. Moreover, I would then expect the Registrant to consider if they were able to ascertain a second reading utilising a different machine and document this, and their subsequent findings.

4.10. In reviewing the evidence bundle I have concluded that the Registrant did not follow this protocol when taking blood oxygen readings from the patient. Whilst the Registrant prima facia has applied the machinery correctly, there is no evidence in documentation as to any suspicion that the readings given by the first machine were considered to be inaccurate in any way. There is no identification of the use of the second machine until the addendum to the Registrants witness statement was produced.

4.11. In light of the blood oxygen readings, I have concluded that the Registrant should have conducted further assessments of the patient. I have formed this opinion on the basis of the observations that were recorded by the first machine, the failure to document the original result in the clinical documentation, comment on their findings as to the accuracy of these readings, and then clearly document the use of the second machine and the findings from this second measurement. In my opinion, the Registrant should have considered the cause of the presenting low oxygen saturations, coupled with the presentation of the patient. I agree with the comments of Dr Morris (sic), Consultant Cardiologist in his report for the Area Coroner of Avon. In my opinion, the case does not present in a manner that could simply be attributed to gastroenteritis. As identified in the report of Dr Morris (sic), the observations captured by the monitor – tachycardia and hypoxaemia. Whilst the ePCR identifies that the patient was Glasgow Coma Score (GCS) 15 and was marked as having capacity following a diagnostic capacity test, it appears from the evidence that the patient was displaying an altered level of consciousness. Given the observations captured, and the presentation of the patient, I would expect the Registrant to have completed a 12 Lead Echocardiogram (ECG). I agree with the remarks of Dr Morris (sic), in that it is likely, given the patient's presentation, that the ECG would have demonstrated tachycardia, with some ischaemic changes. In my opinion, it is likely that the ECG would have been abnormal.

4.12. In light of the blood oxygen readings, the Registrant should have provided further clinical treatment. In reviewing the evidence bundle I have concluded that the oxygen saturations captured automatically by the Mobimed monitoring equipment were accurate. I have formed this opinion considering Patient A’s presentation, the other baseline observations recorded, the photographic evidence of Patient A showing profound cyanosis, and the information garnered from the Mobimed system by SWASFT. In this case, the Registrant should have administered Oxygen to the patient as per the JRCALC guidelines as a minimum. Dependent on the further assessments that the Registrant ought to have undertaken there may also have been further treatments that may have been appropriate, however, without this information I am unable to comment on this further.

4.13. In light of the patient’s symptoms, condition, and having reviewed the evidence bundle provided, I do not consider the Registrant to have delivered appropriate care to Patient A. In my opinion, there were serious failings in the recognition of the acute and severe nature of Patient A’s condition which was then not acted upon appropriately. When considering the extent of the Registrant’s actions in relation to the contribution to the poor outcome of the patient, I believe there to be two considerations. As identified in the Serious Incident Report, Patient A had a significant and unstable coronary artery disease with almost complete occlusion of his left coronary artery. It has been identified that the pathologist concluded that the patient’s coronary artery disease could not have been identified by the Registrant and that the severity of the occlusion meant he could have died at any time – I agree with this finding. However, the patient was presenting in this case in a severely acute condition, which should have been identified, assessed, treated, and referred to an appropriate receiving facility. If this had occurred, this may have reduced the severity of the patient's condition, ultimately saving his life. Whilst I agree with the sentiment of the opinion of Dr Morrision given to the Area Coroner of Avon when he answers the question: “4.9 - Even if Patient A had been taken to Hospital would the outcome have been any different?” I cannot fully agree that the resuscitation provided in the Accident and Emergency department would have been significantly more favourable than the treatment Patient A received during the second 999 call. Indeed, the detection of the Patients underlying and unknown condition during a cardiac arrest in the hospital would be doubtful, however, if this was detected, the likelihood of any corrective procedure being performed during a resuscitation attempt would be dependent on the individual hospital trust and their staff. However, I agree that if the patient had been treated appropriately, the patient is likely to have survived to hospital, where imaging and blood testing could have assisted the attending medical staff to diagnose and potentially treat the underlying issues, in addition to the cause of this acute episode – the heart failure which could be treated with diuretics. In my opinion, the Registrant’s actions were a significant part in contributing to the poor outcome for Patient A.

4.14. In relation to how the ePCR values should have been recorded, the Registrant has identified in her reflection the procedure I would have expected to have been undertaken. I would expect the observation that is being relied on by the Registrant to be entered into the ePCR, with a full explanation of: the original value, the factors affecting the validity of the original value, the reasons why the Registrant is not seeking to rely upon the original value. I would then expect to see the recording of the new value that is being relied upon with an explanation as to how this has been captured and how this reading is now reliable. I would also expect the Registrant to report the concern with any failure of equipment, following their local reporting pathway.

4.15. In respect of whether the actions of the Registrant fell below the standard expected of a Registered Paramedic, whilst the unknown diagnosis of the cardiac disease could not have been detected by the Registrant, the presentation of Patient A could not have reasonably been diagnosed as simple gastroenteritis. It is clear that the Registrant failed to perform a complete history taking assessment as would be expected of a paramedic, in that she did not adequately identify presenting issues including giving sufficient gravity to the concerns presented by the wife and the physical appearance of Patient A created a ripple effect of failings, that meant a full and appropriate physical examination was not performed (including observations, such as a 12 lead ECG). As a result of this, the severity of Patient A’s presentation was not fully captured by the Registrant, leading to the Patient being left at home in a critical condition. This failing ultimately had a great effect upon Patient A’s condition to the point that he deteriorated, experienced a cardiac arrest, and died. HM Coroner of Avon has held that Patient A’s death was due to natural caused contributed to by neglect. The Coroner has held that the Registrant failed in eight areas, detailed in his findings in the evidence bundle. In addition to this, it was also held that the Registrant falsified results in the ePCR, on the basis that the values changed by the Registrant could not have been correct given the presentation of Patient A. I agree with these findings. As described by HM Coroner of Avon, the failures of the Registrant were held to be gross failures.

4.16. In all of the circumstances, the actions of the Registrant fell severely below the standard expected of a Registered Paramedic.”
 
The Registrant’s written evidence

76. In her self-referral form to the HCPC dated 14 May 2019, the Registrant included the following comments:

“I am providing the HCPC with this self referral in accordance with Standard 9.5. Unfortunately, there has been a delay in providing this self referral due to receiving conflicting advice as to if it was required. I apologise for not providing this sooner, but I hope you can appreciate the stressful time that I have been through which has led to this oversight on my part.

… I had used the mobimed device pulse oximetry which showed low oxygen levels, however I noted the system was not picking up a good trace. As my patient was not showing any other signs of low oxygen levels, I used the portable pulse oximetry device instead. This showed normal oxygen levels so I therefore amended the values that the mobimed system had detected. …

…Following the incident in August 2018, I completed a reflection of the incident and felt appropriate learning had taken place from that. I have included this reflection as part of my supporting documents for this self referral.

I have also attached the statement I provided the day after the incident, the letter confirming my suspension, the SWAST investigation report (without appendices), disciplinary outcome letter and the letter confirming the lifting of my suspension.”

77. On 31 March 2021, the Registrant sent the following as a response to the Allegation:

“RESPONSE TO ALLEGATIONS:

On 20th August 2018, you did not provide appropriate care to Patient A, in that you:

Did not take into account information provided by Person B regarding Patient A’s presentation – DISAGREE

I did take into account the information that was provided en route to the incident regarding the colour of the patient’s lips, however once I was on scene and had assessed Patient A I could see that he presented with a normal skin colour.  I was not shown the photograph of Patient A (Exhibit 6, appendix 10) by Person B, while I was on scene.  Person B did not speak to me about her concerns about his bluish lips while I was on scene and I definitely did not say anything about this being a normal symptom of a tummy bug.

The opinions of the independent consultant Cardiologist from the coroner’s inquest and the statement from the Paramedicine specialist both refer to the photograph that Person B took of the patient (Exhibit 6, appendix 11) and their reasoning on how Patient A should have been treated is heavily weighted on this.  In this photograph Patient A does look very unwell.  The report from the Paramedicine specialist included in the final bundle clearly states his opinion is based on the description of Patient A given in the 999 call AND the photograph provided that was taken whilst awaiting the arrival of the ambulance. However, Person B has confirmed in her witness statement that this photograph was taken after I had left scene.

I would also like to take this opportunity to point out that I did not say that the photograph (Exhibit 6, appendix 11) accurately reflected how Patient A appeared during my time on scene, as is reported in the witness statement from Mathew Hill. This is confirmed in my response to the disciplinary allegations (Exhibit 4, appendix 15).

Did not conduct an adequate clinical assessment, including:

A cardiovascular assessment; - AGREE

I agree that I did not complete a full and comprehensive cardiovascular assessment.  This is something that I highlighted and reflected on in my second reflection (Appendix C).

A respiratory assessment; - AGREE

I agree that I did not complete a full and comprehensive respiratory assessment.  This is something that I highlighted and reflected on in my second reflection (Appendix C).

An assessment of the patient’s abdomen; - AGREE PARTIALLY

As reported in the Patient Clinical record and in my statement, I did palpate the abdomen.  I believe this fact is being disputed due to Person B and Colleague A stating they did not see me do this.  I believe this is the case as I was stood in front of the sofa where Patient A was lying and they were stood behind me completing parts of the ePCR, therefore did not see me palpate the abdomen.  I do however agree that a full abdominal assessment was not carried out, as I did not auscultate or percuss the abdomen.  This has also been highlighted and reflected on in my second reflection (Appendix C).

An ECG. - AGREE

I did not complete a 12 lead ECG on Patient A as part of a full cardiovascular assessment due to the fact he was not complaining of chest pain.  However, like the points above, this is something I have reflected and learned from, during my second reflection (Appendix C).

When the oxygen saturation/SPO2 reading of 83% was indicated, you:

Did not provide the patient with oxygen; - AGREE

I did not give the patient oxygen.  This is because, after using the portable spO2 device which showed a reading of 98%, along with how Patient A was presenting, I did not deem it necessary. 

Did not conduct any further assessments. - AGREE

I did not complete a respiratory or cardiovascular assessment - please see allegation b)i), ii) and iv) above.

Did not convey Patient A to hospital. – AGREE

I did not convey Patient A to hospital. Based on the assessment I carried out for Patient A, I deemed it not necessary at that time.

In relation to Patient A, you did not keep adequate records, in that you:

Amended Patient A’s oxygen saturation/SPO2 reading to 98%, which was not accurate; - AGREE PARTIALLY

I did amend the oxygen saturation/SPO2 reading to 98% however I believed this was accurate as this was the reading the portable pulse oximeter gave me along with my visual assessment of Patient A.

Did not record a reason for amending Patient A’s oxygen saturation/SPO2 reading; - AGREE

I did not include a reason for amending the reading.  I should have done this and this has been included in both reflections that I have written (Appendix B and C)

Did not record any faults with the mobimed device; - AGREE

I did not record or report any faults with the mobimed device.  I should have done this and this has been included in both reflections that I have written (Appendix B and C)

Recorded a second blood pressure reading that had not been taken; - AGREE

I admit this is a mistake that I have made.  I thought the mobimed had recorded a second blood pressure when I pressed the button for it to do it.  However, it seems this was not the case, and the same blood pressure was entered for the 1st and 2nd set of observations.  This was not done intentionally or fraudulently, and I realised my error at the disciplinary investigation meeting.

Recorded Patient A had a normal skin colour, when this was not the case; - DISAGREE

I recorded Patient A had normal skin colour because he did have normal skin colour when I was on scene. 

Did not record any differential diagnoses. - AGREE

I agree that there were no differential diagnoses recorded on the ePCR. They were considered during my patient history taking, however I have failed to record this on the clinical record. This is an error on my part and I have reflected upon this (Appendix C)

On 21 August 2018, you added additional details to your statement regarding Patient A in relation to a faulty mobimed device which were not referred to in your original statement. - AGREE

I did add the additional details to my original statement with regards to the amending of the spO2 readings.  I completed the initial statement and after it was reviewed by management, they approached me again and asked about the amendments to the oxygen readings.  This is when I gave the additional details as to why I had done it.  The time frame between completing my original statement and making the amendments was approximately 1 hour.  As for the reason why I did not include it in my original statement; I believe this was due to the extreme stress I was under and my emotional state at the time of writing the statement.  It was purely an oversight and not an intention to provide/add inaccurate or fraudulent information.

Your actions as set out in paragraphs 2a), 2d), 2e) and/or 3 were dishonest. - DISAGREE

At no point during this investigation, or my entire 18 year career, have I been dishonest with regard to my patient care.  The character references included with the final hearing bundle (Exhibit 24) attest this, and all have a reference to my professionalism as a Paramedic, the respect I have gained from colleagues and my attributes such as being trustworthy, loyal, caring and compassionate…”

The Coroner’s written documentation

78. Her Majesty’s Area Coroner for the Area of Avon, Dr Peter Harrowing (the Coroner) asked Dr William Morrison, Consultant Cardiologist at the Liverpool Heart and Chest Hospital NHS Foundation Trust, to write a report for him on the care and treatment that Patient A received from the Paramedics on the first occasion, referring to the involvement of the Registrant and Colleague 1 in Patient A’s care on 20 August 2018. In his first report dated 2 October 2019, Dr Morrison addressed Patient A’s past medical history and eleven categories of comments in answer to questions from the Coroner in his instructing letter to Dr Morrison. Dr Morrison’s conclusion was as follows:

“Conclusion and Issues…

This is a sad and very unfortunate case. I appreciate my comments are with the benefit of hindsight. I have a high regard for the ambulance service. They have to make decisions on scene. I work in a heart attack centre in Liverpool and as a consequence have close contact with Paramedics and Ambulance Teams. However, there appeared to have been several serious errors in Patient A's management.

• Patient A's symptoms do not appear to have been taken seriously, and there was an alleged comment that he may have been exaggerating his symptoms.

• There is variance and some disagreement in the accounts given by Person Band the Paramedic.

• There was lack of appreciation as to how ill Patient A was.

• Signs were missed or ignored.

• The initial observations were overwritten in order to put the observations in a better light. In addition there was failure to document the clinical rationale for such a significant alteration in the observations.

• ECG - was deemed to be unnecessary.

• Hospitalisation was also deemed to be unnecessary in spite of grave warning signs.

• Patient A received no real treatment. He was advised to take Paracetamol, sips of water and lmodium. What he required was administration of oxygen and hospitalisation.

• The golden hour was lost. In my opinion Patient A was let down by the initial Ambulance Team which led to his death.”

79. The Coroner held an Inquest that took place from 2 – 5 December 2019. He found that on 20 August 2018 ‘the Deceased, who was suffering with serious undiagnosed ischaemic heart disease, developed gastroenteritis’. ‘The medical cause of death was given as 1(a) Cardiac failure; 1(b) Ischaemic heart disease; 1(c) Coronary artery atheroma; II Gastroenteritis’. At the conclusion of the Inquest, the Coroner recorded that Patient A’s death was one of ‘natural causes contributed to by neglect’.

80. On 13 December 2019, the Coroner wrote to the HCPC raising serious concerns with regard to the Registrant’s fitness to practise.

Oral evidence heard by the Panel

81. RG, Quality Lead Paramedic at the relevant time and is now Clinical Lead Paramedic for the Trust. He gave oral evidence consistent with his witness statement and the relevant exhibits. In addition, RG’s oral evidence included the following:

He stated that the Registrant had missed cyanosis in Patient A. His oral evidence on this was that it suggested to him that Patient A was in a state of shock and dying when being attended to by the Registrant and Colleague 1, if one accepted the evidence of Person B (symptoms of central cyanosis, collapse and incontinence) and, later, knowing the cause of death.

82. RG also stated that he could not say if the Registrant had been given training in cyanosis, but that she had given a good explanation of it in her Trust interview, including assessing people with darker skin colour, which led him to believe that she had received cyanosis training. He also acknowledged that the Registrant had been “steadfast” in her opinion that Patient A had looked like he had a normal colour and knew from questions asked of her in her Trust interview to look for the colour of the patient’s lips, the pallor of their skin, and on prompting from him, to ask the relatives the patient’s normal colour.

83. RG stated that his remit in preparing the Root Cause Analysis was to take care to establish the facts, not to apportion blame and to take care not to form any unsafe conclusions. He stated that the Registrant had been “firm” that what she had done was appropriate during the Trust’s investigations.

84. With reference to the Registrant completing the documentation after leaving the premises, when the ambulance had already departed and may have been parked near Patient A’s premises, RG stated that, if the Registrant’s evidence was accepted, there was no rush in returning to base. Patient A was not in critical state requiring emergency treatment and it was often challenging for Paramedics to deal with the call and complete the paperwork at the same time. It was not uncommon for Paramedics to make a note of their observations on, for example, a glove or a notebook, and transpose these notes to the electronic record as soon as practicable afterwards.

85. In answer to the Panel’s questions, it was RG’s evidence that:

• When dealing with the 98% oxygen saturation possibly being a false high reading, RG stated that a fairly vast literature search he had conducted and his own experience had led him to conclude that there were no examples of blood oxygen levels being as low as 83% and 87% and then rising to 98% within 20 minutes, except carbon monoxide poisoning, which was not applicable in this case. He stated that he would not have been as bold as he had been in asserting this had it not been for what he had heard in the Coroner’s court from expert witnesses. He stated that he found it “implausible” for the change in the oxygen saturation levels to have happened as they were documented in this case. When probed further on this, to hypothesise without the Coroner’s court expert witnesses’ evidence and without the benefit of hindsight, RG maintained that he would “stop short of saying that it was impossible”, but he still found it “implausible” for these readings to be true readings, as the lower oxygen saturation percentages would have been visible to the Registrant for 8 to 10 minutes whilst she was still on the premises. The probe had not been disconnected from Patient A’s finger, as was obvious from the continuous graph reading (a virtually straight line) on the Mobimed and the Registrant had taken no intervention action to correct the oxygen level and/or to explore or recognise what she was seeing. RG’s opinion was that the Registrant had not acted with professional curiosity and that she lacked professional integrity, whether there was a problem with the machine as the Registrant had maintained, or that the patient’s oxygen saturation levels were as low as 83% and 87%; either way, she should have acted. He stated that he could “not comprehend” how one would be faced with that information and take no action.

• On being questioned about the photograph of Patient A looking ill, taken by Person B, RG stated that he understood that it had been taken by Person B after the Registrant and Colleague 1 had left the premises. He was asked about the likelihood of the patient deteriorating in the (maximum) period of the hour between the crew leaving the premises and the next crew arriving, in which time the photograph had been taken, acknowledging that the photograph had no time of when it was taken recorded on it. He stated that Person B’s descriptions of Patient A to the call handler/despatcher of Patient A having purple lips, hands and soles of his feet accorded with how Patient A looked in the photograph and was indicative of a patient in a state of pathological shock, with haemostasis, compensating, and in cardiogenic shock. He stated that it was “a one way street” unless one intervened. However, he agreed that if the Registrant’s evidence that Patient A looked a bit pale, sweaty and a bit poorly was accepted, he could say that “yes, absolutely” it is likely that someone could deteriorate that much in that time frame. RG also stated that the information sent to the crew relied on the dispatcher selecting it.

• RG also informed the Panel that the records of the calls being made by Person B and her descriptions of Patient A’s condition were triggered by certain questions routinely asked at the beginning of the call (firstly, is the patient breathing, secondly, is he conscious and, thirdly, to tell the call handler what had happened). RG was taken through all the call records where Person B had described Patient A’s condition. Patient A was initially recorded as being a male, conscious and breathing and his age was 31. RG then confirmed that, thereafter, the records in this case demonstrated a common thread throughout the timeline from when Person B first dialled 999 at 14:00:24 hours on 20 August 2018 to 14:10:41 hours when the Registrant and Colleague 1 entered the premises of Patient A, a period of just over 10 minutes. Person B had been informing the call handler/despatcher at various times within that time frame of the following: that Patient A was displaying symptoms of shaking since 2 am (for approximately 12 hours), dizzy, faint, diarrhoea and vomiting, not being well for a few days and worse at that time, abdominal and rib discomfort, growling and being in pain, faecal incontinence, purple lips, purple hands and purple soles of his feet. RG confirmed and clarified the records that indicated that another crew had been allocated, but had been stood down after the Registrant and Colleague 1 had been allocated the call to Patient A at 14:10:38 hours. RG identified that at 14:10:40 hours all the information from Person B’s calls had been transmitted to the Registrant’s vehicle and was received by her and Colleague 1 at 14:10:41 hours. However, RG stated that he had not had access to the physical document (the MDT) that the Registrant had seen and did not know if the message identification code that had been changed from the original crew’s to the Registrant’s, with a different number, contained the same information as the original crew had been sent, but at 14:10:54 hours there was a record that the message sent to the Registrant’s vehicle had been read. RG was confident that this indicated that she had the same information as the original crew had been sent and that included reference to the patient’s lips being purple. RG referred to the Registrant having given evidence at the Coroner’s Inquest that she agreed that Patient A’s lips were purple.

86. Colleague 1 was the ECA and crew member with the Registrant on Patient A’s call out on 20 August 2018. She had been qualified as an ECA for a few months. She gave oral evidence from her witness statement and the relevant exhibits. In addition, Colleague 1’s oral evidence included the following:

She was driving the ambulance on 20 August 2018 at all times (confirmed by RG in his evidence). Colleague 1 stated that as the driver she was concentrating on the directions to the property and did not take much notice of the information being received about the condition of Patient A. Colleague 1 had read some information initially and remembered it referred to a young male with diarrhoea and vomiting. She stated that she was not aware of thinking of blue lips in relation to Patient A, although it was possible blue lips were mentioned but she was inexperienced at that time. She stated that the Registrant did the observations of Patient A. Colleague 1 stated that she remembered that the Registrant told Patient A’s family that his temperature was slightly raised and that everything else was “within normal limits”.

In answer to the Panel’s questions, Colleague 1 stated that she could not remember any reference to Patient A’s colour changing or there being ‘concern’; only reference to diarrhoea and vomiting. Colleague 1 stated that the Registrant may have read out the information from the messages of the calls from Person B (the Terrafix). Cyanosis and hypoxia had been covered on her Induction course, but she stated that she “wouldn’t have joined up all the dots at that time.”

87. MH was the Paramedic Operations Officer for the Trust and the Investigating Officer for the Trust’s disciplinary procedure in relation to the Registrant. He gave oral evidence consistent with his witness statement and the relevant exhibits. In addition, MH’s oral evidence included the following:

Whilst MH’s original remit for his report was to investigate the alleged falsification of the oxygen saturation readings by the Registrant, other findings came to light after the investigation progressed. These included two identical blood pressure readings that were 20 minutes apart that were taken by the Registrant with one recorded after the Registrant’s vehicle had left the scene and whether she had performed an abdominal assessment on Patient A. MH stated that it would be appropriate to manually override the electronic system if the reading might be wrong by reason of the patient’s presentation or a visibly defective device, but it should be accompanied by a narrative account of the reasons why this had been done.

MH stated that the oxygen saturation of 83% had been auto-captured at 14.31 hours and 87% at 14.40 hours but manually overridden to 98% by the Registrant at 14.41 hours when she had left the premises. MH confirmed RG’s evidence about the significance of the Mobimed graph indicating that the Registrant had taken no intervention action in the 10 minutes from 14.31 to 14.41 hours, when it was visible to her on the Mobimed, to correct the oxygen level and/or to explore or recognise what she was seeing.

MH enlarged on the additional evidence he had seen to help form his views of the Registrant’s actions and that it included the photograph taken of Patient A by Person B. It was not time-stamped and he said that it had been taken before the Registrant and Colleague 1 had arrived at the premises of Patient A and Person B. It showed a “very unwell man”. When asked if the photograph had been taken after the crew had left the premises would his opinion be different, he stated that it would not. The photograph showed Patient A to be hypoxic and cyanosed and that he was “heading towards a cardiac arrest”. MH stated that the 999 call by a lay person, Person B, indicated from her descriptions that the patient was acutely unwell and that Colleague 1 had confirmed that the photograph was a true representation of how Patient A had looked. MH stated that if Colleague 1 was found not to be clear about this, he still felt that Patient A had been inappropriately discharged on scene and should have been taken to hospital, based on Person B’s descriptions to the call handlers of Patient A’s condition.

MH considered it “very unlikely” that Patient A’s blood pressure would be identical 20 minutes apart as normal body movements would result in an alteration of the blood pressure.

On questions from the Panel, MH stated that if the Mobimed was displaying an amber bar, he would expect the Registrant to have cross referenced the auto-captured readings with the patient’s condition and used a portable machine. He stated that it would have been “reasonable” to have manually overridden the earlier oxygen saturation readings, but he would have expected the Registrant to have given a narrative account of why she had done so. MH stated that if Patient A had been the colour maintained by the Registrant then a 98% blood oxygen saturation rate would be “credible”. However, he stated that, professionally, he did not think that Patient A was healthy. In relation to the photograph taken by Person B, MH stated that it showed Patient A with a pale complexion and mottled skin, but that if the Registrant had considered Patient A’s colour to be normal, then she should have asked the family about his normal skin colour and she had not done so.

MH explained that the National Early Warning Score (NEWS) for Patient A was automatically generated and the change from 6 to 2 reflected an improvement in Patient A’s blood pressure, pulse rate and oxygen saturation levels. At 2, sepsis would not have been indicated then, but would have been with a NEWS score of 6.

In re-examination, MH stated that in informing Person B that Patient A’s condition was normal, the Registrant was wrong. He stated that his view of the culpability of the Registrant had not changed in relation to her actions, the machines she had used that had been found to have been functioning correctly at the time and her amendment of the oxygen saturation readings.

88. Mr Brogan was the HCPC’s Paramedicine expert. He gave oral evidence, adopting the contents of his report, dated 28 March 2020 and the relevant exhibits. In addition, Mr Brogan’s oral evidence included the following:

Mr Brogan stated that he is a Paramedic expert in Emergency Medicine. Since writing his report for this case, he had been promoted and was now Head of Department at Aberdeen University.

He stated that he had not been influenced to any great degree by the reports of Dr Morrison. He differed from Dr Morrison’s view, for example, with respect to the likely survival of Patient A had he been transported to hospital by the Registrant, as there were many factors that Mr Brogan felt should have been discussed by Dr Morrison.

Mr Brogan stated that he held the opinion that the calls from Person B describing Patient A’s condition (blue lips, discoloured palms and soles of the feet) and the photograph taken by Person B after the Registrant and Colleague 1 had left the premises, demonstrated that Patient A was “acutely unwell with reduced consciousness and cyanosis around the lips”. Even without seeing the photograph, Mr Brogan stated that he would still conclude that Patient A was a “severely unwell patient”, as the tone of his skin colour indicated “profound cyanosis”.
 
In Mr Brogan’s opinion, the contents of Person B’s 999 calls were “very supportive” of a patient with cyanosis. In his opinion, the original figures on the Mobimed were accurate. In the absence of the photograph, which, he stated, did make it easier to see what Patient A had looked like, Mr Brogan stated that Person B’s description correlated with the auto-captured Mobimed, as opposed to the Registrant’s manual overriding transcriptions. In addition, Mr Brogan stated that he considered it “extremely unlikely” that Patient A’s condition had changed from being cyanotic when Person B was calling in, had improved whilst the Registrant was present in the premises and then had changed back to Patient A being cyanotic again. He said that he “could not think of a reason” for that to occur.

Having concluded that blue lips could not be attributed to a “tummy bug”, Mr Brogan discussed the action that should have been taken by the Registrant (transportation to hospital after performing a cyanosis assessment, including capillary bed refill tests and pain assessment). Mr Brogan stated that in his opinion the Registrant had not responded appropriately to Patient A’s pain, as pain is highly subjective and requires a full interrogation of the patient by the Paramedic, including timing, location, characteristics and severity of the pain.

In Mr Brogan’s opinion, the Paramedic must take a holistic approach to all patients, with “the biggest flag” in this case being that the patient was so unwell that the Person B had dialled 999. Even with a working diagnosis of diarrhoea and vomiting, the Registrant should have exercised “due diligence” and conducted a full and proper assessment of Patient A to justify a discharge at home. In Mr Brogan’s opinion, the Registrant had not done this.

Mr Brogan stated that he had concern about the Registrant having “coached” Patient A’s respirations back from such a high level. He could not see how that was possible.

Mr Brogan accepted that the Registrant had performed some aspects of abdominal assessment, but she had followed the “yes/no” boxes on the record and had not provided any free text to give more detail of her assessment and findings, as he would have expected with this patient’s presentation.

Mr Brogan gave his advice that the issue of Paramedics relying on the information being fed to them by the call handlers/despatchers was “a contentious subject” within the profession and he described it as a “hot topic”. The positive aspect was that the Paramedic would have information to form a working diagnosis to aid him/her with how to approach the patient when first meeting them. However, Mr Brogan stated that the contrary view within the professional discussions on this topic tended towards the danger of Paramedics being led down a different or irrelevant path by the call handler/despatcher information when the Paramedic would be assessing the patient, as Paramedics were only human. The Paramedic could become “blinkered” by the information and could disregard the situation on arrival, which could be very different from the information from the 999 calls. This latter point is recognised as potentially risky.

In Mr Brogan’s view, for these reasons, it was vital for a Paramedic to keep their “professional curiosity” at the “forefront” of their minds and to use the control room information “with extreme caution”. Mr Brogan described that professional curiosity would include using the tool of obtaining a differential diagnosis or diagnoses. He felt that the Registrant “had not looked outside” the initial nature of the incident, as evidenced by her fairly superficial assessments; for example, the patient’s abdomen. In his opinion, the Registrant had failed to link the three body systems of cardiovascular, respiratory and abdominal. Had she done so, she might have performed a 12 lead Electrocardiogram (ECG) test, as it is well recognised that pain can radiate from one part of the body to another, making the source of the problem more difficult to ascertain.

Mr Brogan stated that, in his opinion, a high respiration rate (tachypnea) could have indicated either hyperventilation by the patient due to, for example, anxiety, or it could have indicated a medical cause. Mr Brogan stated that Patient A’s lowest oxygen saturation level reading being 83%, which was very low in his opinion, and the patient’s raised temperature, pulse and respiration did not correlate with a Glasgow Coma Score (GCS) of 15 or with Person B’s descriptions of Patient A’s condition on the 999 calls she had made. Mr Brogan stated that the GCS is used to demonstrate the overall results of the assessments made, but it is an automatically entered reading. Hence, in this case, a GCS reading of 15 would reflect the altered oxygen saturation level (of 98%) and the blood pressure recordings of 110/70. In his view, the raised temperature, pulse, respirations and 83% and 87% oxygen saturation levels would not equate with the Registrant’s description of Patient A to Person B, when the Registrant was leaving the premises, of “normal”.

Furthermore, Mr Brogan stated that, in his opinion, if Patient A had been anxious and hyperventilating, a “coaching” of Patient A’s breathing, as the Registrant stated she had done, could not be an explanation for his 83% oxygen saturation level or his breathlessness. Mr Brogan stated that 83% was a “life threatening” reading and could not be explained by anxiety and hyperventilation. In addition, he stated that false high oxygen saturation levels readings are “very rare, although not impossible” and he gave an example of carbon monoxide poisoning that can cause a false high oxygen saturation reading. He stated that this had not been the situation in Patient A’s case.

Mr Brogan stated that the same automation process as with the GCS system would apply to the NEWS, which were recorded as 6 and then 2 for Patient A. Mr Brogan also explained that these two scores (6 high and 2 low) indicated the changed information in the same way as the GCS had recorded them. Mr Brogan identified that the difference for the Paramedic with the NEWS process is that it can point to a sepsis pathway, if appropriate. Mr Brogan stated that “quite possibly” sepsis should have been considered by the Registrant in Patient A’s case, as it would identify “information we are starting to see here.”

Mr Brogan emphasised that he understood that Paramedics occasionally write records up in the ambulance after leaving premises, usually due to the emergency nature of the call within the premises leaving no time, practically, for absolute contemporaneous notes to be written. However, in a situation, such as in Patient A’s case, where the patient had been discharged in his home, then, in Mr Brogan’s opinion, there would be no reason, such as emergency action taken within the premises, not to write the notes of findings immediately. He stated that recording matters such as blood pressure readings from memory, as the Registrant had stated that she had done, was not good practice, as there was a heightened risk for error. Mr Brogan stated that identical blood pressure readings, timed some time apart, indicating an identical blood pressure each time, was “possible but not common”. Mr Brogan also stated that it was inappropriate for a Paramedic to guess what an oxygen saturation level might be, if the Paramedic considered that the patient looked well, that other readings were low and that the Paramedic had disconnected the Mobimed finger probe.

When asked about whether a Paramedic should rely on readings from potentially faulty machinery or from the patient’s presentation, Mr Brogan stated that “patient presentation should prevail”.

In answer to the Panel’s questions, Mr Brogan stated that it was recognised within the profession that a Paramedic can be influenced by human factors. A Paramedic could be influenced by the control room information being fed to him/her and be “misguided” by it, leading to the Paramedic “discounting what is in front of you”. An example may be basing a working diagnosis from the Paramedic’s own experience and “not what is in front of you.” It included the Paramedic becoming “fixated” on information being fed to him/her and having a “blinkered mentality” to other factors being exhibited by the patient in the room. Mr Brogan also stated that there was also the "end-of-shift element”, where the Paramedic might be weary and/or have other, perhaps personal, reasons to want the shift to end. He also stated that the patient’s age could also be a factor playing into the human factor situation.

Mr Brogan agreed that in this case, there was information from the control room which included that Person B had stated to the call handler/despatcher that Patient A did not have a cardiac history, that he was of a young age, that he had diarrhoea and vomiting and had eaten a large take-away meal 12 hours beforehand. In those circumstances, Mr Brogan could see how all these factors were “working against what was in front of the Registrant”. He stated that if the Registrant had asked Person B if Patient A had a heart history, “the answer would likely to have been ‘No’”. Mr Brogan further noted that the Registrant had gone through Patient A’s past medical history with Person B and there had been a negative response (‘no’) recorded to the relevant section in the ePRC.

In re-examination, Mr Brogan acknowledged that properly trained registrants must pay regard to the HCPC’s Standards of Performance, Competence and Ethics (the Standards), even when confronted by the human factor element, including personal issues, but he also stated that: “…However, there is a greater understanding that we can’t do it all the time because we are human.”

89. In reaching its decisions on the facts, the Panel accepted the Legal Assessor’s advice. It read and took into consideration the HCPC bundle, including all the HCPC witness statements and the exhibits attached to each, as well as the Coroner’s documents. In addition, the Panel took into account the oral evidence of the HCPC witnesses who attended. The Panel also read and took into consideration, the Registrant’s evidence to the Trust dated 21 August 2018, her response to the disciplinary Allegations dated 5 October 2018 and the transcript of her evidence at the Inquest on 2 December 2019. It also took into account the Registrant’s self-referral documentation to the HCPC dated 14 May 2019 and the Registrant’s response to the Allegation dated 31 March 2021. The Panel also took into consideration the submission of Ms Lykourgou.

90. The Panel also noted the 17 references supporting the Registrant and noted that only one of which made reference to knowing the details of this hearing. The Panel also read and took into account, within the HCPC bundle, letters from grateful members of the public/service users about the Registrant’s performance and comments from Trust staff on the Registrant’s clinical performance and on her initial return to work after her suspension was removed. This included a supporting reference dated 28 August 2019 from GH, the Trust’s Operations Officer and the Registrant’s Line Manager. The Panel was careful to differentiate between references in support of the Registrant and the facts, and those that went only to mitigation.

91. The Panel noted that, as referred to above, the Registrant admitted the following Particulars of Allegation in Appendix A to her 31 March 2021 covering letter to the HCPC:

1b)i, 1b)ii), 1b)iv), 1c)i, 1c)ii), 1d), 2b), 2c), 2d), 2f), 3).
 
92. The Panel also read and took into consideration the various Guidelines contained in the HCPC bundle, as follows:


• The Trust’s Clinical Guideline for Coronary Symptoms dated 2 March 2018;

• The Trust’s Clinical Guideline for Diarrhoea and Vomiting dated 2 March 2018;

• The Trust’s Management of Clinical Records and Information Policy (including Clinical Photography) dated 7 April 2019;

• An extract from the JRCALC Guidelines regarding Abdominal Pain dated 2013;

• An extract from the JRCALC Guidelines regarding Oxygen dated 2013.

93. In addition, the Panel also noted the hearsay written witness statements of the following HCPC witnesses:

• Person B, Patient A’s wife;

• SB, the Trust’s Medical Advice Technician Team Leader.

94. The Panel gave the hearsay evidence the weight it considered appropriate in light of the fact that these witnesses were not present to have their evidence tested by cross examination and Panel questions.

The HCPC’s closing submission

95. Ms Lykourgou submitted that Particulars of Allegation 1, 2, 3 and 4 have been made out by the HCPC on the balance of probabilities. She referred the Panel to the oral and documentary evidence, which included the Registrant’s response to the Allegation and her admissions to some of the Particulars. In addition, Ms Lykourgou referred the Panel to the documentary evidence provided by Person B in relation to Patient A’s colour as pale, with purple lips and soles and palms. Ms Lykourgou also submitted that by reason of the Registrant’s absence, the Panel was deprived of hearing the Registrant’s responses to Ms Lykourgou’s cross examination questions that she would have put to her. These would have included:

1) why she left the house before completing the ePCR if she felt the patient’s case was not serious enough to go to hospital;

2) why she did not input any of the values she claims to have taken manually into the ePCR until after the crew had left the house;

3) why she did not them down anywhere;

4) whether she actually did complete a second set of observations with a manual oxometer, or whether she just entered the values she thought were suitable into the ePCR to justify her clinical decision to leave the patient at home;

96. Ms Lykourgou submitted that the Particulars of Allegation reflected that Standard 10 of the HCPC Standards of Conduct Performance and Ethics, relating to record keeping, had been breached by the Registrant’s conduct. Ms Lykourgou also submitted that Standard 8 has been breached; namely, to be open when things go wrong. Ms Lykourgou also submitted that the Registrant fell short of the HCPC Standards of Proficiency for Paramedics, in particular Standards 5, 8, 12, 13 and 14.

97. Ms Lykourgou finally submitted that if the Panel found that a breach of these standards would be a serious falling short of the ethical standards expected of a Registrant of the HCPC, then she invited the Panel to exercise its judgement to find that the Registrant’s actions amounted to misconduct.


The Panel’s decisions on the Facts

Particulars of Allegation

98. The Panel noted that, within the HCPC written and oral evidence, there was reference to a photograph taken by Person B of Patient A after the Registrant had left the premises allegedly showing him to be severely cyanosed. This photograph was not dated or timestamped. In these circumstances, the Panel gave limited weight to it. The Panel considered that this would be a fair and proportionate measure in its analysis of the case. The Panel was able to conclude that the written and oral evidence of the witnesses and of Mr Brogan had a significant amount of factual content and, in Mr Brogan’s case, expertise, to provide a clear and full analysis for the Panel, without the photograph being taken into account by the Panel.

1)a) - Proved.

99. The Panel noted that, although Person B was not present and could not be questioned about her evidence, nevertheless she had given a number of accounts of what she had observed about her husband’s presentation, all of which, in the Panel’s judgement, were consistent with each other and with the Terrafix record of her 999 calls. The Panel paid regard to the fact that she was reporting what she was seeing and that she was not a medically trained person. Person B’s various accounts were contained within the following documents:

1) her witness statement prepared for these proceedings dated 10 August 2020;

2) a statement she prepared for the Coroner’s inquest dated 18 November 2019;

3) a record of the MH/RG conversation with her dated 3 October 2018;

4) a record of the calls she made to 999 on 20 August 2018;

5) the Statement of Events record of those calls.

100. The Panel noted that the consistent description within these calls included Patient A’s purple lips, repeatedly alluded to when Person B described Patient A’s presentation. In the Panel’s judgement, the expert evidence of Mr Brogan had made it clear that a patient presenting with purple lips was a significant sign of cyanosis that should never be ignored by a Paramedic.

101. The Panel also noted Mr Brogan’s expert evidence that it would be highly unlikely for any patient to be cyanotic with the classic purple or blue lip colour change, to be coached back by calmer breathing techniques. This was what the Registrant said that she had carried out. Mr Brogan said it was not possible for a patient to present as cyanotic with purple lips and then to have normal lip colour and thereafter, to return to presenting as fatally cyanotic without oxygen intervention being undertaken.

102. The Panel concluded, on the basis of the Registrant’s written comments on this Particular of Allegation, there was no persuasive evidence before it to indicate that she had taken into account the relevant information from Person B to the ambulance service call taker, relating, in particular, to Patient A’s lip colour being purple.

103. The Panel accepted that the Registrant had reacted appropriately to Patient A’s pain symptoms, for example, but had not had the professional curiosity, as described by Mr Brogan, to advance any analysis of Patient A’s purple lips. Even if Patient A had been presenting with a more “normal” colour when the Registrant arrived, the Panel concluded that there was no evidence that she had questioned Person B on Person B’s earlier description of Patient A having purple lips. The Panel concluded, from Mr Brogan’s expert evidence, this was a vitally important sign and an obvious and significant matter for a Paramedic in the Registrant’s position at that time to take further, and she had not done so.

104. In the Panel’s judgement, had the Registrant adopted more probative questioning of Person B, especially with respect to her description of Patient A’s purple lips, the Registrant would have been able to construct a more holistic overview of the patient’s condition.

105. The Panel accepted Mr Brogan’s expert evidence that the Registrant lacked sufficient professional curiosity to pursue a more holistic approach, including the cardiovascular elements in relation to this patient. The Panel further accepted Mr Brogan’s expert evidence that this led to the Registrant’s misplaced emphasis on Patient A’s diarrhoea and vomiting history, as well as her unscientific approach to Patient A’s low oxygen saturation levels and her lack of understanding of how that may have related to the patient’s presentation.

106. Due to the Registrant’s failure to investigate further the information that she had already received, and which she acknowledged she had received prior to her arrival at the patient’s address in relation to Patient A’s presentation of purple lips, the Registrant set herself on an intractable and mistaken path of a solely gastro-intestinal related explanation of Patient A’s condition in relation to her care of him.

1)b)i), ii) and iv) - Proved and admitted. The Panel considered these separately.

107. The Panel was satisfied that the HCPC evidence from RG and Mr Brogan’s expert evidence accorded with the Registrant’s admissions to these three Particulars of Allegation.

1)b)iii) - Not proved.

108. The Panel noted that the Registrant stated in her written responses to the Allegation that she had performed an abdominal assessment of Patient A by palpating his abdomen. She stated that she had not performed auscultation or percussion on his abdomen. The HCPC did not provide sufficient evidence that an abdominal assessment had not been carried out by the Registrant on Patient A.

The stem of 1)b) - Proved

109. The Panel accepted Mr Brogan’s expert evidence, which was supported by the documentary evidence from Dr Morrison that the failures by the Registrant to assess Patient A’s cardiovascular and respiratory systems and her failure to perform an ECG on Patient A amounted to an inadequate clinical assessment of Patient A.

1)c)i) and ii) - Proved and admitted. The Panel considered these separately.

110. The Panel was satisfied that the HCPC evidence of Colleague 1, Person B and the ePCR accorded with the Registrant’s admissions.

1)d) - Proved and admitted.

111. The Panel was satisfied that the HCPC evidence of Colleague 1 and the Trust’s call records that Patient A had not been transported to hospital after the Registrant and Colleague 1 had left the premises accorded with the Registrant’s admission.

The stem of 1) - Proved.

112. The Panel accepted Mr Brogan’s expert evidence, as supported by Dr Morrisons’ opinion, that the facts found proved in Particulars of Allegation 1)a), 1)b)i), ii) and iv) and 1)c)i) and ii) and 1)d) demonstrated that the Registrant did not provide appropriate care to Patient A on 20 August 2018.

2)a) - Proved.

113. The Panel noted that both MH and SB had tested both the Mobimed and the handheld device and they were found to be functioning correctly, although the Registrant stated in her amended statement that the Mobimed had not been working correctly. The Registrant’s opinion was that the readings she viewed of Patient A’s oxygen saturation levels, being 83% and 87%, did not accord with her view of how Patient A was presenting at that time. The Panel accepted the expert evidence of Mr Brogan and the documentary evidence of the Mobimed readings showing a continuous line for 8 minutes, that it would have been impossible for the oxygen saturation probe of the Mobimed to have been removed in that 8 minute period, without an interruption to that continuous line.

114. As a result, the Panel accepted Mr Brogan’s expert opinion that Patient A had been displaying dangerously low levels of oxygen for that period of time in accordance with his purple lips and raised temperature, pulse and respirations. The Panel also accepted RG's evidence that it would be “implausible” for the readings of 83% and 87% to have been incorrect and the 98% to have been correct. Furthermore, the Panel noted that there was no independent evidence to demonstrate that the handheld device had recorded the 98% reading, in that, once removed from the patient’s finger, the device does not retain the data. Thus, the Panel concluded that the 98% recordings taken by the Registrant were unlikely to be accurate as they were not recorded anywhere contemporaneously. In addition, the record was noted by the Registrant several minutes after she left the premises.

115. The Panel accepted Mr Brogan’s further expert evidence that a Paramedic should have challenged the 83% and 87% SpO2 readings by further and detailed assessment of the patient. Instead, the Registrant, several minutes later, overrode those results with the data of 98%, which she said she had found on the handheld device. The Panel noted that the Registrant said in her view this was more consistent with the patient’s presentation at that time. The Panel accepted Mr Brogan’s criticism of this in the face of overwhelming clinical evidence that the patient was in a perilous clinical situation at that time. The Panel further accepted Mr Brogan’s expert evidence that it would be unacceptable for a Paramedic to transfer how she perceived the patient’s condition to be, when looking at him, into a written record of a percentage, in this case the 98% figure.

2)b), c), d), f) - Proved and admitted. The Panel considered these separately.

116. The Panel was satisfied that the HCPC evidence accorded with the Registrant’s admissions.

2)e) - Not proved.

117. The Panel noted that there was no HCPC evidence to demonstrate that at all times when the Registrant was present in the premises, the Patient A’s skin colour was not normal for him. The Panel determined that it was more likely than not that the Registrant genuinely saw and believed that Patient A’s skin colour was normal in her visit to the premises. In addition, the Panel noted RG’s response to a Panel question about this. He stated that, if the Registrant’s account of Patient A’s skin colour having looked normal to her as she left the premises, was accepted, it was possible that Patient A could have deteriorated to the level that he did, in the time period after the Registrant had left the premises and before Person B took the photograph.

3) - Proved.

118. The Panel was satisfied that the HCPC evidence of RG and MH accorded with the Registrant’s admission.

4) in relation to 2)a) - Not proved.

119. The Panel concluded that the Registrant had over-ridden the Mobimed readings of 83% and 87% to her preferred 98% on the basis of her visual assessment of Patient A’s condition and what she said she noted on the handheld device. In the Panel’s judgement, this was a careless, even negligent, act, but the Panel was not satisfied that the HCPC has produced any proof that it was a deliberately dishonest act by the Registrant. She has consistently stated that her belief was genuine, to the Trust, to the Coroner and to the HCPC; namely, that she was sure that the patient looked well enough to her eye to make her take a reading on the handheld device which she said was 98%. Moreover, the Panel noted that the Registrant manually overrode the automatic record at a time before Patient A had deteriorated and before Patient A sadly died. In the Panel’s judgement, the Registrant’s consistent account of what she genuinely believed at the time and her reasoning as to why she manually overrode the automatic readings provided a reasonable alternative explanation to that of dishonesty.

120. The Panel also took into consideration that the Registrant had, before these events, a blemish-free career as a registered Paramedic for 7 years.

121. In the Panel’s judgement, this reflected that her belief was genuine and this was a consistent thread in all her responses to the Trust, to the Coroner and to the HCPC.

122. For all these reasons, the Panel was satisfied that an informed member of the public, the ordinary decent person, would not consider that the Registrant’s action in relation to Particular of Allegation 2)a) was dishonest.

4) in relation to 2)d) - Not proved.

123. The Panel accepted the Registrant admission that she had recorded a second blood pressure that she had not taken and it accepted her written assertion in her response to the Allegation, as follows:

“I thought the mobimed had recorded a second blood pressure when I pressed the button for it to do it.  However, it seems this was not the case, and the same blood pressure was entered for the 1st and 2nd set of observations.  This was not done intentionally or fraudulently, and I realised my error at the disciplinary investigation meeting.”

124. In the Panel’s judgement, this was a careless, even negligent, act, but the Panel was not satisfied that the HCPC has produced any proof that there was deliberate conduct on the Registrant’s part pointing to it being more likely than not that she had been dishonest.

125. In the Panel’s judgement, the Registrant’s account of what she genuinely believed at the time and her reasoning for that belief provided a reasonable explanation for her actions.

126. The Panel also took into consideration that the Registrant had, before these events, a blemish-free career as a registered Paramedic for 7 years.

127. For all these reasons, the Panel was satisfied that an informed member of the public, the ordinary decent person, would not consider that the Registrant’s action in relation to Particular of Allegation 2)d) was dishonest.

4) in relation to 3) - Not proved.

128. The Panel concluded that the Registrant, as a matter of agreed fact, had been asked by RG to “clarify” her initial statement to the Trust to account for the discrepancy in the oxygen saturation readings (83% and 87% readings as against the 98% reading). Thus, she did so as requested by her employer. In the Panel’s judgement, had the Registrant wished to obfuscate the picture she presented in her original statement in relation to the various and inconsistent SpO2 readings, she would have done so then and not waited until instructed to do so by her employer. The Panel accepted the Registrant’s account in relation to the dishonesty allegation for this Particular of Allegation as more likely than not, and it was as follows:

“I did add the additional details to my original statement with regards to the amending of the spO2 readings.  I completed the initial statement and after it was reviewed by management, they approached me again and asked about the amendments to the oxygen readings.  This is when I gave the additional details as to why I had done it.  The time frame between completing my original statement and making the amendments was approximately 1 hour.  As for the reason why I did not include it in my original statement; I believe this was due to the extreme stress I was under and my emotional state at the time of writing the statement.  It was purely an oversight and not an intention to provide/add inaccurate or fraudulent information.”

129. In the Panel’s judgement, this reflected that her belief was genuine and this was a consistent thread in all her responses to the Trust, to the Coroner and to the HCPC.

130. The Panel also took into consideration that the Registrant had, before these events, a blemish-free career as a registered Paramedic for 7 years.

131. For these reasons, the Panel was satisfied that an informed member of the public, the ordinary decent person, would not consider that the Registrant’s action in relation to Particular of Allegation 3) was dishonest.


The Panel’s decision on Grounds:

132. The Panel concluded that the facts found proved were serious and put the health, safety and well-being of patients, the public and fellow Paramedic colleagues at risk of harm. In the Panel’s judgement, the facts found proved range across a number of failings both in relation to clinical care and record keeping. The Panel concluded that the intractable path that the Registrant followed was mainly due to her failure to pursue Person B’s earlier description of Patient A’s purple lips as evidence of cyanosis. This was due entirely to the Registrant having failed to take an holistic view toward patient care, both in her own mind and in relation to her assessments of Patient A. In addition, in the Panel’s judgement, the omission by the Registrant of recording that the Mobimed, which in her view was faulty, could have led to a potentially serious situation, both for Paramedic colleagues and service users thereafter.

133. The Panel accepted Mr Brogan’s expert evidence that the conduct of the Registrant framed within the Allegation fell “severely below” the standards expected of a registered Paramedic. The Panel determined that, equally, the facts found proved also demonstrate that the Registrant’s acts and omissions fell severely below the standards expected of a registered Paramedic. The Panel identified the following breaches of the HCPC’s relevant Standards of Conduct, Performance and Ethics (the Standards) dated 14 June 2018, and of the Paramedics’ relevant Standards of Proficiency dated 1 September 2014 in relation to the facts found proved:

The Standards

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

Standard 10: Keep records of your work. Keep accurate records

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

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

The Standards of Proficiency for Paramedics

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

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

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

Standard 10: be able to maintain records appropriately

Standard 12: able to assure the quality of their practice

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

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

14.3 be able to conduct appropriate diagnostic or monitoring procedures, treatment, therapy or other actions safely and effectively

14.6 be able to modify and adapt practice to meet the clinical needs of patients within the emergency and urgent care environment

14.7 know how to select or modify approaches to meet the needs of patients, their relatives and carers, when presented in the emergency and urgent care environment

14.9 be able to gather appropriate information

14.10 be able to select and use appropriate assessment techniques

14.11 be able to undertake and record a thorough, sensitive and detailed assessment, using appropriate techniques and equipment

14.12 be able to conduct a thorough and detailed physical examination of the patient using appropriate skills to inform clinical reasoning and guide the formulation of a differential diagnosis across all age ranges

14.15 be able to undertake or arrange investigations as appropriate

14.16 be able to analyse and critically evaluate the information collected

14.17 be able to demonstrate a logical and systematic approach to problem solving

134. Therefore, for the reasons stated, the Panel determined that the facts found proved amount to Misconduct.


Decision on Impairment:

135. In reaching its decision, the Panel paid regard to the HCPTS’ Practice Note on Impairment and accepted the Legal Assessor’s advice. The Panel used its own judgement and exercised the principle of proportionality balancing the overriding duty to protect the public and to uphold the wider public interest against the Registrant’s interest in being declared fit to practise. The Panel took into consideration the contents of the bundles before it, including the documents provided by the Registrant. The Panel also noted the submission of Ms Lykourgou on Impairment.

136. Ms Lykourgou stated that the criteria set out within the caselaw for Impairment had not been met by the Registrant on both the private and the public grounds, so as to allow the Panel to find the Registrant fit to practise. The Registrant had breached several of the fundamental tenets of the profession. Her serious failings and serious lack of judgement had undermined the public’s confidence in her and her profession. Ms Lykourgou submitted that the Registrant had been in a position of trust, treating vulnerable patients and her actions had caused the public to lose faith in her and the profession.

137. In addition, Ms Lykourgou reminded the Panel that the Registrant had not provided any recent CPD documentation or evidence of any recent courses taken, the last having been undertaken by the Registrant in 2018. Ms Lykourgou’s submission included the fact that the Registrant had not produced any recent reflective piece, in particular to deal with when oxygen therapy would be appropriate to administer and how to deal with cyanosis in people of colour.

138. The Panel had concluded that the facts found proved amounted to Misconduct and that the Registrant’s actions and omissions surrounding the events of 20 August 2018 were serious. In the Panel’s judgement, the Registrant’s identified failings both in relation to her clinical performance and to her record keeping fell seriously below the standards expected of a registered Paramedic. She failed to uphold her professional standards in several fundamental areas and breached a significant proportion of those fundamental tenets of the profession. In the Panel’s judgement, the Registrant, by her actions and omissions, put the health, safety and wellbeing of a vulnerable patient at risk of harm and she undermined the trust and confidence that the public was entitled to have in her as a registered Paramedic at the front-line of patient care and in her profession, which she brought into disrepute. The Panel considered that the Registrant’s acts and omissions also betrayed the trust and confidence of her Paramedic colleagues.

139. For these reasons, the Panel had no doubt that the Registrant’s fitness to practise was impaired at the time of the events.

140. The Panel concluded that the Registrant’s failings identified by this case were remediable, as they occurred around a single callout to the patient and concerned sub-standard clinical practice and record keeping that, in principle, could be addressed so as to prevent recurrence in the future. The Panel also noted that the Registrant had no known matters against her in the past, before these events, and none since 2018, as she had been returned to practice as a Paramedic by her then-employer, the Trust, in 2019 after training, reflection and supervision, without further complaint against her. Therefore, the Panel determined that her failings demonstrated within this case were remediable.

141. The Panel next considered if the Registrant had remediated her identified failings, and, if so, to what extent. The Panel concluded that the Registrant’s remediation would have to be full and robust to prevent the accumulation of errors that had taken place at her hands on 20 August 2018 ever taking place again in the future. The outcome for Patient A and his family was tragic and serious and the Registrant’s role in that was significant. Whilst there has been no determinative conclusion as to whether her acts and omissions that day directly caused Patient A’s demise, nevertheless the Panel was conscious that her catalogue of errors and her failure to adapt to the situation she found herself in and to have the required professional curiosity to change her overview of Patient A was a contributory factor in Patient A not being transported to hospital in a timely manner.

142. The Panel noted the Registrant’s reflective pieces dated August 2018 and January 2020 and the written evidence she produced of her CPD training at that time in 2019. The Panel also took into account that the Registrant had undergone the Trust’s training and supervision in 2018/9 and that she had been returned to unrestricted practice for a period of time in 2019, with no further failings or issues identified in that limited time. However, the Panel was also aware that the Registrant’s employment at the Trust had been curtailed after the Coroner’s Inquest, that although she was returned to unrestricted practice by the Trust in 2019, the Registrant stated in her 31 March 2021 response document that she had left the profession in October 2020.

143. The Panel considered that the Registrant’s second reflective piece, although revealing an improved breadth of insight into the events with, for example, remorse and regret expressed by her, nevertheless it was still incomplete. The Panel concluded that the January 2020 reflective piece was lacking in relation to the Registrant fully recognising her part in the seriousness of the errors she made on 20 August 2018, their consequences and how she would address those now to prevent recurrence in the future.

144. As a result, the Panel was able to conclude that it has not received any recent update on the Registrant’s reflection, now, about the events of 20 August 2018 and, within that, if she has undertaken any recent and relevant courses to fully address her shortfalls in clinical practice and record keeping. In addition, the Panel noted that the Registrant has not attended this hearing to potentially provide the Panel with an updated account of any remediation she may have continued and expanded upon. Although attendance at regulatory hearings to speak to remediation is not mandatory, it can be extremely helpful for panels to understand the level of remediation undertaken by a practitioner and, in this case, the Panel concluded that this was a lacuna.

145. Therefore, for these reasons, the Panel concluded that the Registrant’s insight into these events is not complete and lacks specific reference as to how she would prevent a recurrence of these events in the future. Without a complete picture of the level of the Registrant’s recent remediation, if any, the Panel was unable to conclude that she would be a safe and effective practitioner at this time. Thus, in the Panel’s judgement, the risk of repetition of these events remains.

146. The Panel determined that an informed member of the public would also come to the same conclusions. The Panel determined that an informed member of the public, including fellow Paramedic professionals, would be dismayed to find that the Registrant was deemed to be fit to practise now. In the Panel’s judgement, the informed member of the public and the Registrant’s fellow professionals would consider that the public would remain at risk of harm in absence of any reassurance by the Registrant’s evidence that she had addressed all the issues raised by this case with full insight into her actions and omissions. The Panel concluded that the trust and confidence that the public was entitled to have in the Paramedic profession, its standards and its regulatory process would be undermined in the eyes of the informed member of the public and in the eyes of the Registrant’s fellow professionals if the Registrant was to be declared fit to practise.

147. For these reasons, the Panel concluded that the Registrant’s fitness to practise is impaired on the grounds of public protection and in the wider public interest.

 

Decision on Sanction

148. In reaching its decision on sanction, the Panel accepted the Legal Assessor’s advice and paid regard to the HCPTS’ Sanctions Policy. The Panel noted that sanction is not intended to be punitive but it may have a punitive effect. It exercised the principle of proportionality, balancing the overriding duty to protect the public and to uphold the wider public interest against the Registrant’s interest in being able to practise in her chosen profession. The Panel took into consideration the Registrant’s accounts of her position in 2019, 2020 and 2021 from her emails and within her statements and exhibited documents. These included two reflective pieces dated August 2018 and January 2020, references and testimonials from colleagues, including her Line Manager at the Trust and her historic 2019 CPD documentation. The Panel also took into account that the HCPC had been informed that the Registrant had left the Paramedic profession in December 2020 and she had stated in her response document dated 31 March 2021 that she had no intention of returning to the profession in the future. The Panel also noted the submission of Ms Lykourgou.

149. Ms Lykourgou submitted that the HCPTS’ Sanctions Policy reflected that sanction should primarily protect the public. This included sending a message to the profession and upholding public confidence in the profession and in the regulatory process. She reminded the Panel of caselaw that demonstrated that the courts expect registrants to have insight and be willing to resolve the failings identified in their case. She submitted that where those elements were lacking, the sanction tended to follow the higher end of the spectrum available. Ms Lykourgou also referred to the overarching regulatory principle that the profession’s reputation should be placed above that of the consequences to the individual practitioner. Ms Lykourgou referred the Panel to her closing written submission for any aggravating factors. She suggested that any mitigating and aggravating factors should, in any event, be within the Panel’s judgement.

150. The Panel identified the following mitigating and aggravating factors in this case:

151. Mitigating factors:

• This was a one-off incident in a career lasting seven years;

• The Registrant consistently acknowledged most of her failings from an early stage;

• The Registrant expressed remorse, regret and an apology to Patient A’s family in her reflective pieces;

• The Registrant demonstrated some insight into her failings from an early time;

• The Registrant had undergone remediation by way of training and supervision organised by the Trust and had returned to unrestricted practice at the Trust by 2019;

• In her short time at the Trust in unrestricted practice during 2019, the Registrant had no further issues raised about her practice; and

• The Registrant produced positive references and testimonials reflecting that she was a trusted and valued professional

Aggravating factors

• The case was extremely serious, as it involved the Registrant’s failure to professionally adapt her practice to a patient, who was presenting with symptoms consistent with a serious underlying condition;

• By intransigently setting herself on a track that prevented her from undertaking a greater amount of routine and basic clinical tests on the patient, such as seeking further clarification from the patient’s wife and lacking sufficient professional curiosity with regard to the patient’s condition, the Registrant failed to capture a more informed overview.

152. The Panel first considered taking no action and mediation and imposing a Caution Order and, in turn, rejected each of these. In the Panel’s judgement, the seriousness of the matters found proved would not be adequately reflected by these outcomes/sanction, as they provided no method to check the progress of the Registrant on her journey, if she so chose, to full remediation. By reason of the extreme seriousness of this case, the Panel concluded that such outcomes/sanction would not properly protect the public and would not reflect the public’s confidence in the profession and in the regulatory process. The risks to the public’s health, safety and well-being would remain, and public confidence in the profession would be severely undermined, if this Registrant, without the full remediation identified by the Panel, would be permitted to return to unrestricted practice.

153. The Panel next considered imposing a Conditions of Practice Order.

154. The Panel had identified that the Registrant’s failings were remediable and, indeed, to some extent, for a short period of time in 2019, under the Trust’s supervision, they had been remediated so as to permit her to return to unrestricted practice at the Trust, without further complaint about her practice in that short time. The Panel concluded that the Registrant had demonstrated some insight so as to agree to commence the remediation at the Trust.

155. In addition, the Panel took into consideration that the Registrant had been the subject of an Interim Conditions of Practice Order for approximately 18 months to date (due to expire on 12 July 2021) and, whilst working as a Paramedic, had adhered to those conditions.

156. However, the HCPC had received notice that the Registrant had left her Paramedic employment in December 2020 and has indicated that she has no intention to return to Paramedic practice. The Panel has made important decisions on her case since the Interim Conditions of Practice Order was imposed. In light of the decisions the Panel has made, in the Panel’s judgement, the circumstances of the Registrant’s position is now more serious than before the final findings had been made. Furthermore, the Registrant, at this time, appears to be no longer able to continue on her remediation journey whilst in practice. Therefore, the Panel has concluded that workable, enforceable and meaningful conditions of practice, so as to be able to demonstrate her full insight and full remediation in order to mitigate against a risk of recurrence, would not be possible to construct.

157. Furthermore, the Panel was mindful of the provisions of the HCPTS’ Sanctions Guidance in which there is reference to conditions of practice…. “only being effective where the Registrant is genuinely committed to resolving concerns raised and the Panel is confident that they would do so.”

158. In the Panel’s judgement, by leaving the profession and by expressing an intention not to return to it, the Panel could not be confident that the Registrant was genuinely committed to resolving the concerns raised by this case. The Panel considered that it may be the situation in the future that the Registrant might change her mind and be willing to undertake what would be required of her by way of full remediation so as to prevent recurrence, but that time was not now.

159. The Panel noted that there were many mitigating factors in this case, but the aggravating factors, although fewer in number, were so serious that, in the Panel’s judgement, a Conditions of Practice Order would not adequately or proportionality reflect the inevitable public opprobrium of the Registrant’s failings and how they impacted directly on the patient, on his family, on the Registrant’s Paramedic colleagues and, on the profession, at large.

160. Therefore, for the reasons stated, the Panel determined that a Conditions of Practice Order was not appropriate or proportionate at this time.

161. The Panel next considered imposing a Suspension Order. The Panel concluded that this was the fairest and most proportionate sanction in this case, as a Suspension Order reflected the seriousness of this case and, therefore, was proportionate. The Panel concluded that this would send a message to the profession about the perils of failing to exercise professional curiosity in all cases. In the Panel’s judgement, Paramedics are at the forefront of the healthcare panorama and are in the frontline of healthcare provision in a variety of scenarios when they arrive on any scene. In the Panel’s judgement, the ability for Paramedics to exercise a flexible and adaptable approach to all patients is vital and professional curiosity must underpin this. 

162. The Panel also considered that the Registrant could use the duration of the Suspension Order to reflect further on her situation; if she would wish to return to Paramedic practice in the future, for example. The Panel noted that, if the Registrant decided to do so at an earlier time, she would be free to make use of the HCPC’s early Review process.

163. For these reasons, the Panel concluded that, as the sanction of a Suspension Order would remove the Registrant from the HCPC Paramedic Register for a defined period of time, it would provide the necessary protection for the health, safety and wellbeing of the public and it also would uphold public confidence in the profession and its regulatory process. In the Panel’s judgement, permitting the Registrant to be able to practice, even in a restricted manner, whilst having unresolved issues in relation to some of the facts of this case, would put the public at continuing risk of harm and would undermine public confidence in the profession and in its regulatory process.

164. The Panel determined that the duration of the Suspension Order should be for 12 months, as this would properly reflect the gravity of the case, as well as giving the Registrant time to reflect on her position.

165. The Panel considered whether to impose a Striking Off Order in this case, but considered that to be a punitive measure in light of its findings and, therefore, disproportionate.

166. Therefore, for these reasons, the Panel determined that the only proportionate and appropriate sanction should be that of a 12 month Suspension Order.

167. The Panel considered that a review panel might find the following useful:

• That the Registrant might wish to consider appearing in person before the review panel;

• That the Registrant might wish to send an updated and relevant reflective piece;

• That the Registrant might wish to provide updated and relevant CPD documentation;

• That the Registrant might wish to provide any updated references and testimonials from any employer, or others, all of whom should know the details of this case.


 

 

Order

Order: The Registrar is directed to suspend the registration of Ms Deborah Porter for a period of 12 months from the date that this Order comes into effect.

 

 

Notes

Interim Order:

Decision on Proceeding in Absence

1. The Panel heard Mr Millin’s application to proceed in the Registrant’s absence in order to enable him to make an application for an Interim Order now that the hearing had been concluded. The Panel accepted the Legal Assessor’s advice and paid regard to the HCPTS’ Practice Note on Proceeding in the Absence of a Registrant.

2. The Panel noted that it had determined that there had been good service of the Notice of Hearing under the HCPC’s procedure rules. It had been satisfied that the Notice of Hearing was dated 11 February 2021 and that it had contained the date and time of the hearing as well as the nature of it, in this case a remote hearing. The Notice email also contained an explanatory section that, at the end of the hearing, to cover any appeal period, an Interim Order can be sought by the HCPC. The Panel had also noted that the Registrant had responded on 31 March 2021 and 6 April 2021 indicating that she was aware of this hearing and that she would not be attending the hearing nor would she be represented and the Panel had noted that the Registrant had provided an explanation as to why she would not be attending. In exercising its discretion with utmost care and caution, the Panel noted that the Registrant has not applied for an adjournment for this stage of the hearing.

3. The Panel concluded that the Registrant has chosen not to attend this stage of the hearing of her own volition. The Panel noted that the existing Interim Conditions of Practice Order, imposed on 27 January 2020, will expire on 12 July 2021. The Panel further concluded that if it adjourned the application for an Interim Order, after sanction had been determined, in this case a 12 month Suspension Order, the Registrant would be free to continue unrestricted practice after 12 July 2021 until another hearing for the Interim Order application could be arranged.

4. The Panel determined that this could pose a risk to the health, safety and well-being of the public and, consequently, public confidence in the profession in this regulatory process would be undermined. Furthermore, in paying regard to the wider public interest in the expeditious disposal of all matters, the Panel concluded that the Interim Order application should proceed, as the Panel has made determinations on the Facts, Misconduct, Impairment and Sanction and, in the Panel’s judgement, the hearing requires immediate resolution.

5. For these reasons, the Panel determined to proceed with the Interim Order application in the Registrant’s absence on the grounds of public protection and in the wider public interest.

Decision

6. The Panel noted Mr Millin’s submission for an Interim Order. He requested that an Interim Suspension Order should be imposed on the grounds of necessity so as to protect the public and that it is otherwise in the public interest. Mr Millin submitted that this was supported by the Panel’s findings on all sections of the hearing, in particular the reasons it had given for imposing the 12 month Suspension Order. These included the serious nature of the case and the risk of harm to the public and to public confidence in the profession and the regulatory process. Mr Millin also submitted that if an Interim Order was not imposed by the Panel to cover the period of any appeal notice or the appeal itself, whichever the longer, the Registrant would be free to practise without restriction, which would put the public at risk of harm. Mr Millin also submitted that the Interim Order should be consistent with the sanction, and, therefore, that the Panel should impose an Interim Suspension Order.

7. In reaching its decision, the Panel accepted the Legal Assessor’s advice and paid regard to the HCPTS’ Practice Note on Interim Orders.

8. The Panel noted that following its decision on sanction, the existing Interim Conditions of Practice Order continues and will expire on 12 July 2021, after which the Registrant would be free to engage in unrestricted practice, and, before that time, would be able to practise in a restricted manner, contrary to the Panel’s sanction decision. Thus, another Interim Order to cover any appeal notice period or appeal period, whichever is the longer period, must be considered at this time.

9. The Panel concluded that the findings it has made on all stages of the case, culminating in the Sanction of a 12 months’ Suspension Order and its reasons throughout the stages, has firmly set out the Panel’s conclusions on the Registrant’s failures, the serious nature of the misconduct found proved and her present impairment that cumulatively, in the Panel’s judgement, required the sanction of a 12 months’ Suspension Order.

10. For the reasons set out in its substantive decisions, the Panel considered it is necessary to impose an Interim Order on the Registrant’s practice in order to protect the health, safety and well-being of the public in the period of time of any appeal notice or any substantive appeal, whichever the longer period of time. The Panel also determined, for the same reasons as set out in the Panel’s substantive decisions, that it was otherwise in the public interest to impose an Interim Order on the grounds of upholding public confidence in the profession and in the regulatory process.

11. The Panel concluded that an Interim Conditions of Practice Order would not be consistent with the sanction it has imposed of a 12 months’ Suspension Order. The Panel determined that imposing an Interim Conditions of Practice Order for any notice of appeal or any substantive appeal period would undermine the Panel’s decision on, and its reasons for, the sanction imposed in this case. 

12. For these reasons, the only appropriate and proportionate Order that the Panel could make is that of an Interim Suspension Order. The Panel determined that the maximum period of 18 months’ duration would cover any appeal period, should the Registrant decide to do so, as substantive appeals can take a considerable period of time to resolve.

13. In reaching its decision, the Panel accepted the Legal Assessor’s advice and paid regard to the HCPTS’ Practice Note on Interim Orders.

This hearing sat on the following dates: 17 – 21 May 2021, 7 – 11 June 2021 & 14 June 2021

 

Hearing History

History of Hearings for Miss Debbie Porter

Date Panel Hearing type Outcomes / Status
17/05/2021 Conduct and Competence Committee Final Hearing Suspended