Rafal Piotrak

Profession: Paramedic

Registration Number: PA45314

Interim Order: Imposed on 16 Jun 2021

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 07/06/2021 End: 17:00 16/06/2021

Location: Virtually via videoconference

Panel: Conduct and Competence Committee
Outcome: Suspended

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Allegation

Allegation, as amended:

1. During the course of your employment as a Paramedic with the East Midlands Ambulance Service NHS Trust, you:

a. On 14 August 2018, attended an emergency call to Patient 1 and you did not:

i. Reassess the patient’s symptoms during the secondary survey until prompted to do so;

ii. Conduct a neurological investigation into Patient 1’s symptoms;

iii. Offer pain relief until the patient was in the Ambulance;

iv. Take Entonox to the scene;

v. Flush the cannula after removing the infusion set.

b. On 14 August 2018, attended an emergency call to Patient 2 and you did not:

i. Take an adequate history from Patient 2;
ii. Assess the patient’s

a) Chest and/or
b) abdomen and/or; gastro intestine and/or

c) Genitourinary system;
iii. Identify and/or explore a potential differential diagnosis;
iv. Complete a secondary survey at discharge.
c. On 14 August 2018, attended an emergency call to Patient 3 and you did not:
i. Check the Patient’s radial pulses; and/or gain an initial blood pressure check prior to carrying out a BEFAST assessment;
ii. Check the patient’s temperature; and/or

iii. Gain undertake an initial blood pressure check without prompting prior to carrying out a BEFAST assessment;

iv. Conduct a blood pressure check prior to standing the patient up and requesting the patient to take a few steps;

v. Identify and or explore a potential differential diagnosis without prompting;
vi. Conduct an abdominal assessment until prompted to do so;
vii. Carry out a bilateral blood pressure assessment until prompted to do so;
viii. Carry out a standing blood pressure check until prompted to do so.

d. On 2 June 2018, attended to Patient 4 and you did not:

i. Take an adequate medical history; and/or
ii. Undertake a 12 lead ECG.

e. On 2 June 2018, attended to Patient 6 and you did not identify a change to Patient 6’s heart rate and/or did not take steps to try and identify possible causes of this.

f. On or around 2 June 2018, admitted to guessing ECG rhythms.

g. Did not consistently provide adequate patient handovers to hospital staff.

h. On 13 August 2018, did not complete a Paramedic Clinical Assessment to an adequate standard.

2. Did not consistently demonstrate effective language and communication skills when communicating with patients.

3. The matters set out in paragraphs 1 – 2 constitute a lack of competence.

4. By reason of your lack of competence your fitness to practice as a Paramedic is impaired.

Finding

Preliminary Matters

Service & Proceeding in Absence

1. A Notice of Hearing dated 16 April 2021 was emailed to the Registrant at his registered address. There is a delivery receipt of this. The Registrant has been put on notice of the date, time and nature of this hearing. The Panel accepted the advice of the Legal Assessor and found that good service had been effected.

2. The Council applied to proceed in the absence of the Registrant. The Panel accepted the advice of the Legal Assessor. The Panel having found that good service had been effected went on to take the following into account in accordance with the Practice Note: Proceeding in the Absence of the Registrant:

a. The Registrant has emailed the Council and confirmed that he was aware of the hearing date of 7 June 2021. A chain of correspondence “confirming 7 June 2021” with emails from the Registrant on 24 March and 31 March indicating that the 7 June 2021 was suitable for him for a final hearing have been provided.
b. On 4 June 2021 the Council forwarded to the same email address which the Registrant had used, a link to this final hearing for today. No explanation or response to this email has been provided. Accordingly, the Panel considers that the Registrant has voluntarily absented himself.
c. While the Registrant has engaged on a limited basis with the Council, he has not engaged at every stage of the process.
d. He has not indicated that he wanted to be represented albeit has had this opportunity.
e. There is no request for an adjournment.
f. There are seven witnesses who are ready to give evidence.
g. There is a general public interest in proceeding without delay, particularly given the impact on the memories of witnesses, and that this case deals with matters which date back to 2018.

3. In all these circumstances the Panel is of the view that the Registrant is voluntarily not engaging, given that he has confirmed the suitability of 7 June as a date for the final hearing, and has not requested any change to this as he might have done. The Panel determined that there is no advantage to any adjournment, given that there is no guarantee that this would secure the future attendance of the Registrant and serve a useful purpose. The Panel would take steps to ensure that the Registrant was not unduly disadvantaged and decided it was fair and just to proceed in his absence.

Amendment of the Allegation

4. Mr Ferson applied on behalf of the Council to amend the Allegation as set out above. These proposed changes were indicated on 1 February 2021 and sent to the Registrant. The proposed changes were categorised as relatively minor in nature and not changing the gravamen of the case.

5. The Panel accepted the advice of the Legal Assessor and considered each of the amendments in turn. It concluded that there were three categories of change:
a) In Particular 1.b.i the words, “take an adequate history for Patient 2,” is an addition and not just a change of wording or expression. The Panel was of the view that while this still fits within the spirit of the Allegation it is substantially different from the specifics that are otherwise listed in terms of physical examination in relation to Patient 2. However, it is clearly necessary that both a physical examination and an adequate history is taken, in order to make any appropriate differential diagnosis, and the latter failure already featured within the Allegation. In these circumstances, the change was not considered to impact the gravamen of the case.
b) The addition of failure to take a “temperature” was another addition which the Panel considered was more than a change of syntax or style. However, the Panel was of the view that this amendment fell within the spirit of the case in that it is part of the observations in terms of baseline checks which should be undertaken. Accordingly, the Panel were content that it should be added.
c) The remainder of the changes were minor in nature and do not impact the gravity of the case. They appeared to make the Allegation clearer in nature and set out the case that the Registrant is required to answer more specifically. The Panel was aware that the Registrant had been put on notice of these changes for some time and had not objected to them. In these circumstances, the Panel was content that the changes should be made.

Background

6. The Registrant had been a paramedic in Poland and had moved to the UK to take up employment with East Midlands Ambulance Service NHS Foundation Trust (EMAS) at the time of the allegation.

7. Upon starting his employment with EMAS he completed his 6-week development course and progressed to mentored shifts on the road. The Registrant had three mentors during his transition period, all of whom reported concerns regarding his performance. The Registrant’s probation period was extended and an Action Plan was implemented in February 2018.

8. In May 2018, the Registrant was placed under an 8-week formal capability plan and was provided with additional support. On 16 July 2018 the Registrant became registered as a Paramedic with the HCPC.

9. A capability meeting took place on 25 July 2018, following which the Registrant continued to receive support, but concerns were still raised in respect of his performance.

10. On 10 September 2018, the HCPC received a referral from EMAS regarding the Registrant’s fitness to practise.

Hearing

Witnesses

11. The Panel heard from the following witnesses:

a. LB, Paramedic, EMAS,
b. GO, Duty Operations Manager, EMAS
c. KT, Clinical Support Manager, EMAS
d. MJ, Paramedic, EMAS,
e. MW, Clinical Operations Manager, EMAS,
f.  DF Paramedic, EMAS,
g. AD, Clinical Practice Tutor, EMAS.

12. LB gave evidence under affirmation. She adopted the evidence as set out in her witness statement. She had taken on a new role as a Specialist Paramedic giving up her role as Manager in October 2020. She indicated that she came to know the Registrant in July 2017 when he was recruited by EMAS from Poland where he had qualified as a paramedic. She indicated that she was his Clinical Support Manager at the time. The Registrant was required to have 300 hours of supernumerary work with a mentor. As he progressed with his role and settled in, she then began to do shifts with him, and identified that there were gaps in his skills and knowledge, notwithstanding the training he received from EMAS. She indicated that the Registrant was found to be, “not up to scratch”.

13. She indicated that the Registrant did not raise any difficulties, until his mentors did. The impression that she gained was that he did not want to indicate that he had any failings, potentially exacerbated by his English language limitations, and his personality, given that he was described as a “quiet gentleman”. She said that the role of mentors was to supply guidance on EMAS procedures, rather than have to teach clinical assessment, which should not have been necessary for a qualified paramedic. She did provide the Registrant with a more experienced mentor and a computer to take home which resulted in some improvement.

14. However, in May 2018 formal capability processes commenced in relation to the Registrant. This impacted his confidence and performance and he indicated that he did not feel up to the standards expected of him in the UK. She tried to test the Registrant’s knowledge and capability in scenario setting questions, away from the pressure of real-life situations, but said that the time she spent with him indicated that he did not have the underlying knowledge to provide emergency care treatment, and that this was not about English language fluency or comprehension but simply not being able to demonstrate the competency required. She said that the international paramedic course was meant to be about providing support rather than teaching core competencies. She said that she thought that EMAS had provided a good level of support, but that the Registrant had nonetheless struggled.

15. She said that the Registrant explained that in Poland he was part of a three-person crew always, with a doctor being one of that crew, whom he would support. She indicated that she did not consider that his cannulation skills were sufficient. She added that while three months should have been enough time to be allowed to practice without a mentor, he had commenced work with EMAS in July 2017 and was only put on a capability process in May 2018, after being given opportunities to improve. She could not be precise about whether his failed clinical assessment on 13 August 2018 contributed to his observed performance during his operational assessment shift on 14 August 2018, but indicated that he was not working at the level of a paramedic or technician.

16. GO gave evidence under affirmation and adopted his written statement. He conducted an Observational Shift with the Registrant on 14 August 2018, which was the first time he met the Registrant. He was concerned about the treatment of Patient 1, who had dialled, “999” after a sudden onset of pain in her back. He explained that a patient’s positioning can alleviate or worsen their symptoms. This was basic training for any ambulance crew member and would be learnt early on in their career. Failure to reassess a patient after moving their position could make their symptoms worse, rather than aid recovery. His prompting was to aid his mentee by stimulating interaction to address the patient’s comfort.

17. He indicated that after this prompt, the Registrant was good with his questioning of the patient, asking the patient whether she found that her pain changed with her change of position and whether being moved to the stretcher had caused her pain to worsen. However, he would have expected this basic line of questioning to be followed unprompted, and for the Registrant to think “outside of the box,” to enable the crew to rule out as many causes of the pain as possible.

18. In relation to pain relief, he said that while the Registrant offered to treat the patient with Entonox, which was the correct thing to do, that this only occurred once the patient was in the ambulance rather than at the scene. He indicated that it is normal when attending to a call that involves pain to take a defibrillator, oxygen, resuscitation bag and pain relief to the scene from the ambulance vehicle, because the aim of a paramedic is to mitigate distress as quickly as possible. However, the Registrant did not bring the pain relief bag to the workplace, therefore delaying the time until they were able to offer the patient pain relief. What the Registrant did do correctly, was offer the patient Entonox, and when refused, to offer paracetamol. Entonox should have still been brought to the scene.

19. Once Patient 1 was in the ambulance, the Registrant cannulated the patient in order to administer the paracetamol. His technique in inserting the cannula could not be faulted it was said. However, it is good practice and important to flush the cannula with saline solution after administering medication to ensure that the cannula is clear of blood and can continue to be used, as well as ensuring that all the medication administered is flushed through the cannula. The procedures for correctly administering medication can be found in many of the training manuals used, e.g. Ambulance Care [and] Practice; the Registrant did not flush the cannula after removing the infusion set, therefore the cannula was back-filled with blood, rendering the cannula useless. It is important to flush the cannula as if it is not clear then the hospital staff will need to re-cannulate the patient on arrival at the hospital. This both increases the time until the patient can be administered the required medication and it can also distress some patients, for example those who have a phobia of needles.

20. He said that he felt that Patient 1 had represented a good opportunity for the Registrant to demonstrate his safe practice and confidence, as this was a non-time-critical patient. He indicated that he appreciated that observation shifts can be nerve-wracking, as someone is watching your practice, but felt an opportunity was missed for the Registrant, to show the necessary abilities.

21. For Patient 2, the crew was called by an urgent care vehicle that was on the scene and looking to discharge the patient, as they did not feel she required hospital treatment. An urgent care vehicle is unable to discharge a patient on scene without a clinician. The crew were therefore called to examine the patient and assess whether it was appropriate for the patient to be discharge on scene. This was an unusual case as it is uncommon for a patient with no history of a fall or traumatic event, such as a car crash, to have sudden hip pain and to experience their leg shaking. The Registrant did not take a thorough history from the patient. He asked no questions regarding arthritis, whether the patient was waiting to have surgery or whether they had a GP referral. The Registrant asked no questions that helped to answer what the hip pain could have been caused by. A thorough assessment would include: listening to the breath sounds of the patient to check if any unusual sounds are heard in the chest; feeling the abdomen to assess whether the patient felt any pain or discomfort when pressure is applied; the genitourinary system should be assessed via questioning; a gastrointestinal assessment should be conducted, which includes auscultation, palpation and visual inspection of the abdomen. He said that he did not recall the Registrant conducting any of these assessments on scene.

22. He also indicated that Patient 2 was presenting with a temperature but that the Registrant did not explore the potential causes of her temperature. When he asked the Registrant what the potential causes of a temperature were, he had no problem answering this question. However, when they returned to the patient, again the Registrant did no further investigation; he did not listen to the chest to rule out a potential chest infection; nor ask the patient whether she was urinating normally, to rule out a possible urinary tract infection; nor check the patient’s blood pressure before considering what the overall diagnosis could be. He said that the Registrant gave no indication to him that he had considered these differential diagnoses.

23. He said that the Registrant did make the right decision to discharge the patient on scene and he was correct to tell the patient that she should contact her GP to discuss her pain further. However, his assessment was not thorough enough to come to the decision to discharge on scene. To do this, the Registrant should have taken more time whilst undertaking the patient assessment and he should have gone down more varied lines of enquiry to ensure that he gained sufficient information to consider other potential diagnosis.

24. He went onto discuss Patient 3: a 79-year-old man who had a history of blackouts and had experienced periods of unconsciousness. When the crew were in the ambulance on the way to the scene, the Registrant said that he thought it sounded like a potential stroke. While he thought that this was a good working diagnosis to have in mind whilst attending to the patient, and that it was positive that the Registrant was thinking ahead; this translated into the Registrant ignoring differential diagnoses at the scene.

25. When presented with the patient who was pale, felt clammy to touch, and complained of worsening back pain, while he was visibly bloated, the Registrant performed some positive and negative tasks. He did assess the patient’s chest and elevate the patient’s legs when he was experiencing a period of bradycardia. Further, he correctly considered oxygen therapy for arrhythmia. However, he failed to take a radial pulse, to get a rough idea of the rate and rhythm of the patient’s heart rate and take a full set of observations of the patient, including temperature and blood pressure. His neglect in pursuing these other lines of enquiry was likely due to having stroke as a potential diagnosis in mind. It meant that he did not take a blood pressure reading before asking the patient to stand, which could have resulted in the patient falling, even though he did steady him, and hold him up.

26. Given the symptoms that the patient was presenting with, such as his distended abdomen and worsening back pain, he said he would have expected the Registrant to consider the diagnosis of an abdominal aortic aneurism. It was only after prompting the Registrant about potential differential diagnosis when the crew were back in the ambulance on the way to the hospital that he discussed the possibility of an abdominal aortic aneurism. Instead, he proceeded to undertake a BEFAST (Balance, Eyes, Face, Arms, Speech, Time) assessment to determine whether a patient is showing signs of having a stroke.

27. He should have first checked the radial pulse to ascertain heart rate, heart rhythm, quality of pulse and blood pressure. He should also have noted that the patient’s abdomen was noticeably distended and examined this initially rather than only doing so when prompted. As well as a distended abdomen, the patient had also been experiencing worsening back pain over the last couple of months which are two symptoms of an abdominal aortic aneurism. When a patient presents with these symptoms a bilateral blood pressure should be taken. Sudden drops in blood pressure can occur when a patient stands up, which can cause them to black out. It was only when LB suggested that the Registrant take a standing blood pressure that this was conducted.

28. The Registrant’s handover notes provided very limited information on the patients. In debriefs, he indicated that the Registrant was very receptive to the feedback that he provided. He indicated that he was very positive and appreciative of the time and mentoring provided. He said that he could not fault the Registrant’s attitude. However, he likened the assessment to a driving test where good behaviours need to be observed. He concluded that the Registrant worked at the level of a technician rather than a paramedic, even allowing for the language barrier. He indicated that it was possible to have a conversation with the Registrant, albeit not a “free-flowing” one, and that while there were many positives observed, there were also deficiencies. He was disappointed not to have observed more positives and concluded that the Registrant’s performance required more support from the Clinical Support Manager

29. KT gave evidence under affirmation and adopted her written statement. She gave evidence in relation to matters that occurred prior to the Registrant’s registration on 16 July 2018 with the HCPC as a Paramedic. During the course of the hearing the HCPC became aware of this and proceeded to offer no evidence in relation to the particulars that predate the registration date. Therefore, the Panel could not take into account the evidence of KT.

30. MJ gave evidence under affirmation and adopted his written statement. While he had not been the Registrant’s mentor consistently, having not worked from November 2017 to February 2018, they had done 60 shifts together. His view was that the Registrant’s general performance was not “up to the mark”. He indicated that he did improve slightly but not to the extent that he could be left safely so as to be the lead paramedic in any ambulance crew.

31. He described the Registrant as “abrupt - but not as a result of a lack of compassion”; he elaborated that he considered that the Registrant was not familiar with the manner expected in the UK, which he characterised as being able to talk to a patient appropriately given their situation, and aiding mutual comprehension, professionally. He described his evaluation of the Registrant’s performance.

32. He spoke of the Registrant missing out information, both in eliciting relevant details from the patient, or those caring from them, and for passing on details that are provided to hospital staff when effecting a patient transfer. He said that he was uncertain of whether there was an element of language comprehension at play but there was also a lack of recognition of the importance of a thorough handover. Important details would be omitted he observed, e.g. a patient’s age.

33. He indicated that in his opinion the Registrant was below the level of student paramedic when assessed in 2018. He did not think that he was at the level of a Technician even at this time. He said that in his view, having himself qualified as a paramedic in February 2010, that what the Registrant required was a better understanding of English, plus to redo a student paramedic course from start to finish. He said that this perspective had been garnered through experience of mentoring since May 2010. He had undertaken a Level 5 Mentorship qualification in 2016 with EMAS and has mentored student paramedics and technicians through the EMAS qualification, albeit not Newly Qualified Paramedics. His impression was that given the Registrant’s background, six weeks of training school, followed by six weeks of mentorship should have been sufficient for him to be autonomous. This has not been the case.

34. He did clarify that he could communicate about non-clinical topics with the Registrant in English easily. Accordingly, his concern was not that the Registrant did not understand English but that he did not have a good clinical vocabulary, and did not appear to recognise the importance of some clinical information even when concepts were broken down to use less clinical language.

35. MW gave evidence under affirmation and adopted his written statement. He gave evidence in relation to matters that occurred prior to the Registrant’s registration on 16 July 2018 with the HCPC as a Paramedic. During the course of the hearing the HCPC became aware of this and proceeded to offer no evidence in relation to the particulars that predate the registration date. Therefore, the Panel could not take into account the evidence of MW.

36. DF gave evidence under affirmation and he adopted his written statement. He gave evidence in relation to matters that occurred prior to the Registrant’s registration on 16 July 2018 with the HCPC as a Paramedic. During the course of the hearing the HCPC became aware of this and proceeded to offer no evidence in relation to the particulars that predate the registration date. Therefore, the Panel could not take into account the evidence of DF.

37. AD gave evidence under affirmation and adopted his statement with one minor amendment. As a Clinical Practice Tutor for paramedics, he indicated that he was part of induction programme for the paramedics recruited from outside the UK in 2017. He was aware that some found the transition process difficult and would characterise the group in that way, rather than singling out the Registrant specifically. Some had language difficulties he acknowledged.

38. He did carry out one assessment with the Registrant in August 2018 and provided a report on this for LB. During the scenario, relevant signs and symptoms were provided by the Lead Assessor. The Registrant was expected to take the observations such as heartrate, temperature, blood-pressure from someone who pretends to be the patient, albeit there is nothing wrong with them. This simulation was supported by the Lead Assessor who provides information that should lead the paramedic to make a relevant diagnosis.

39. The Site, Onset, Character, Radiation, Associated symptoms, Time course, Exacerbation and Severity of the pain (SOCRATES) acronym is part of the pain assessment that would have been part of the training provided by EMAS induction and the expectation was that the Registrant would use this; he did not. While he did do some things correctly, such as ensuring the patient did not stand, he laid the patient with breathing difficulties down flat, rather than in a semi-recumbent position. This is knowledge that AD indicated that he would have expected the Registrant to have as a qualified paramedic.

40. The Registrant made many errors, including administering oxygen without taking baseline observations. He also did not measure temperature and glucose levels, which is essential to ensure that appropriate treatment is provided. He was also observed not to keep an eye on the patient’s heart rhythm. He did not notice promptly when the patient’s heart ceased to function as it should and it took him 90 seconds plus to recognise this, with another 90 seconds before CPR was commenced. The longer it takes for the heart to return to its normal rhythm, the greater the damage to organs and possible injury to the patient. He said that the Registrant should have known that CPR should be continued with minimal time away from the chest, with UK Resuscitation Guidelines being drawn from EU Guidelines, and little difference between them.

41. Other errors were noted. In the assessed handover the Registrant claimed to have administered a drug, along with its dosage, that he did not in fact do. The drug given and the dosage were both incorrect. He would have received feedback on this although the detail of this could not be recalled. AD said that he did not consider that English language comprehension or difficulties was pertinent to this error.

42. The mistakes made by the Registrant were numerous. Recognition of the potentially reversable causes of cardiac arrest, the four “H”’s (hypoxia, hypovolaemia, hypothermia and hypo/hyperkalaemia) and the four “T”’s (tension pneumothorax, cardiac tamponade, toxicity and thrombosis) were part of training that the Registrant should have had back in Poland before he came to the UK but were not demonstrated. The Registrant did not perform as well as a UK Technician or Emergency Care Assistant would have been expected to. He indicated that at the end of the assessment in August he did not believe that the Registrant was at the standard required for a paramedic at EMAS. He suspected that even if the Registrant had done the Technician Assessment, that he would not have passed it.

43. He concluded that the Registrant was, “not the worst of his intake by a long stretch,” but that it had become clear that, “the role of a paramedic in Poland was not the same as the role of a paramedic in the UK”. He said of the approximately 40 paramedics recruited in 2017, only two continue to work as paramedics in the UK, with another two having taken on the lesser Technician or Emergency Care Assistant roles. He said that EMAS may not have done their homework thoroughly in identifying what the role of a paramedic is in Poland, which clearly differs from that in the UK. There was a clear mismatch between expectation and reality for EMAS and the paramedics.

44. While the Registrant has not provided submissions for this hearing, he has set out his position in writing at an earlier stage. This communication had been shared by the Council with its witnesses and its contents are reproduced here in fairness to the Registrant. This is the contents of an email sent by the Registrant to the Council on 30 July 2019 at 13:31hrs:

“Hello, my Name is Rafal, I Just to work as a student paramedic in Scunthorpe, I like to tell I cannot come to hearing about my pin Number cos I have no money to travel to London, At the moment I working as a Ambulance Care Assistant with Amvale Lt, Medical private company. EMAS not give me a chance to be paramedic I needed more Time to improve my English and clinical skills its difficult to me to do that on short term. I cannot protect myself, emas leave me without any support, even working as a emergency care assistant I did suggest that but they dont, I like to be paramedic in future in UK but if I Will be well prepared for that. Im not agree for example my canniulation skills was poor, and couple diffrent skills, I expect EMAS send me to education Centre to improve my skills, I ask you to keep my pin Number please, At the moment I study Medical books in my spare Time, I give myself couple of years to improving and come back as a paramedic in UK, give me a chance I can prof my skills by anybody,
RAFAL PIOTRAK”

45. The Council provided written submissions on facts, grounds and impairment. In essence, these set out that the Council’s case was that the evidence before the Panel was sufficient to prove the facts for the following particulars of the Allegation. Further it was submitted that these facts amounted to a lack of competence and that the Registrant is currently impaired based on both personal and public components.

46. The Panel accepted the advice of the Legal Assessor who provided legal advice on facts, grounds and impairment.

Legal advice on Facts

a. It is for the Panel to consider the evidence and announce its findings of fact in relation to the allegations.
b. The Panel will need to consider the evidence in relation to each of the allegations separately.
c. The allegations must be in an appropriate form as required by Article 22(5) of Health and Social Work Professions Order. That is they must be in writing, sufficiently identify the registrant, set out the nature of the allegation and the events giving rise to it, in sufficient detail to allow the registrant to respond.
d. The burden of proving each charge in dispute is on the HCPC. The registrant has to prove nothing, nor to disprove anything. Where there is doubt, it should be resolved in the registrant’s favour. The registrant does not have to incriminate themselves.
e. The standard of proof required is the civil standard of proof, that is, proof on a balance of probabilities. A fact will be established if it is more likely than not to have happened. It is the Panel to decide upon that.
f. The evidence in this case must be considered carefully. The HCPC case involves evidence given by seven witnesses and documentary evidence. The Panel must decide the case only on the evidence heard or is properly before it. The Registrant has not provided formal submissions for this hearing but has previously communicated with the HCPC. His position as communicated in 2019 was that he denies a wholesale lack of competence but appears to recognise that he needs further work before he can operate as a competent paramedic.
g. The Panel have heard what the HCPC witnesses have said. Some witnesses have acknowledged how they gained their “impressions”. The positive or negative characterisations of the Registrant from the witnesses does not change the fact that it is for the Panel alone to determine whether the Registrant was competent in their actions. Comments concerning demeanour etc. are for the Panel to consider whether relevant.
h. The Council has made clear that it is instructed to offer no evidence in relation in a number of the Allegations. These fall into two categories. In relation to Allegations 1.d-f the Council does not wish to proceed on the basis that these particulars fall outside of the period when Mr Piotrak was a HCPC Registrant. In relation to Allegation 1a(ii),1b(iv) and 1c(iv) the Council does not wish to proceed with these matters on the basis that it concedes that there is insufficient evidence for a finding of fact given the burden and standard of proof.

Legal advice on Grounds

i. The allegation concerns a lack of competence rather than misconduct. Misconduct is behaviour that falls short of what can reasonably be expected of a professional. However, a lack of competence is distinct from this and concerns a deficiency of knowledge, skill and judgement, usually repeated and over a period of time.
j. Lack of competence usually involves an unacceptably low standard of professional performance, judged on a fair sample of work, which could put patients at risk. For instance, where there is also demonstration of a lack of knowledge, skill or judgement showing that the Registrant is incapable of safe and effective practice.
k. Unless it was exceptionally serious, a single clinical incident would not indicate a general lack of competence. However, there are multiple instances listed within the allegations that call into question the Registrant’s competence.
l. The Panel will recognise that sometimes individuals make mistakes or errors of judgement. The starting position should be that a paramedic is usually a safe and competent professional but sometimes something may have happened that got in the way of them delivering safe care. Accordingly, the number and types of incidents alleged becomes crucial.
m. Concerns raised about the general competence of a paramedic should take into account the circumstances at the time. This may include the practising history of the Registrant and not just at the period of time when the concerns arose. This can assist with determining whether the concerns relate to a particular area or time or are more general in nature.
n. Where gaps are identified in the paramedic’s training, it is important to consider their nature. This is because healthcare professionals need to be able to address gaps and demonstrate that they are safe to practise.
o. It is important to consider how any gap occurred or came to light. If it raises a concern about the quality or availability of support and supervision at a particular setting or where there is evidence of unfair treatment, this should also be considered. This is required notwithstanding that the Registrant does not appear before the Panel in this hearing.
p. Assessments have been referenced along with the operational activity that has been observed. Both may be considered by the Panel. However, care should be taken not to simply adopt the assessment findings as equating to the statutory ground. The appropriate standards, the extent and degree of any failings should all be considered.
q. In terms of the standard that the Registrant was expected to be at, which much has been made of, the Registrant should be treated as being able to practise safely. The matters relate to a period where the Registrant was a registered paramedic. The standards that apply are the standards that would apply to any competent paramedic registered with the HCPC, in the role in which the Registrant was employed, irrespective of where they qualified.

Legal advice on Impairment

r. Essentially, deciding whether the Registrant is impaired is a matter for the Panel’s judgment, given the findings of fact that have been proved.
s. The legal regime is concerned with a Registrant’s current and future fitness to practise rather than with imposing penal sanctions for things done incorrectly in the past. The law requires the Panel to consider whether the fitness to practise of the Registrant “is” impaired as of today.
t. Accordingly, the Panel has to assess the current position looking forward not back. However, as the then Master of the Rolls, Sir Anthony Clarke, observed in the important case of Meadow [2006] EWCA 1390 “… in order to form a view of the fitness of a person to practise today, it is evident that the Panel will have to take account of the way in which the person concerned has acted or failed to act in the past.”
u. The purpose of a Panel is to regulate healthcare professions for the benefit of the public. If a lack of competence at a particular period was identified, the context of the Registrant’s behaviour must be examined. In circumstances where there has been identified a lack of competence at a particular time, the issue may be, whether that lack of competence has been remedied or not. The Panel may ask itself within the circumstances in which a lack of competence was identified whether there is context which indicates how this came about and whether that continues, such as to mean that his fitness to practise is impaired.
v. In considering the position today, the Panel is required to take account of such matters as the insight of the practitioner into the source of his lack of competence, any remedial steps which have been taken and the risk of recurrence. The Panel is required to have regard to any evidence about these matters which has arisen since the alleged lack of competence was identified.
w. Here, the Registrant has chosen to take no part in the substantive fitness to practise hearing, although properly served beforehand with the Notice of Hearing and all the evidence being relied on by the HCPC. That is his right. He has put in no testimonials, nor any character references, and has not challenged any of the evidence when it has been called by the HCPC. That, also, is his right. Those omissions, obviously, do not absolve the Panel from carrying out its duties in terms of making decisions and providing reasons for them.
x. Impairment considers both public protection and public interest. Public protection involves the public having access to safe paramedics who may treat them in emergency situations, when they may be at their most vulnerable. Any approach to the issue of whether a Registrant’s fitness to practice should be regarded as “impaired” must take account of the need to give substantial weight to public interest. In addition to the protection of the public, the public interest includes, amongst other things, the protection of patients, the maintenance of public confidence in the profession and the upholding of proper standards of conduct and behaviour.
y. The Panel should be clear that it carries out a sequential series of tasks. If first considers whether the facts are made out, considering each allegation separately. Thereafter, when considering the facts found proved, bearing in mind the burden and standard of proof, it must consider whether by reason of those facts, the statutory ground of a lack of competence has been met. It is only if the Panel considers that the statutory ground has been made out that it can move onto consider impairment which should be current.
z. Whatever decision the Panel reaches it will need to explain what factors have been taken into account, and how its decision has been reached.

Decision on Facts

47. The Panel considered the evidence before it, the submissions and legal advice it had been given. It applied the relevant practice notes and approached each matter in turn. A decision and the basis for this is provided in respect of each particular of the Allegation.

1. During the course of your employment as a Paramedic with the East Midlands Ambulance Service NHS Trust, you:
a. On 14 August 2018, attended an emergency call to Patient 1 and you did not:
i. Reassess the patient’s symptoms during the secondary
survey until prompted to do so;

48. GO provided evidence that once the patient had moved, it was important to conduct a secondary survey to reassess the patient’s symptoms. He said that it was important to do this so that a patient’s pain could be alleviated promptly, and failure to do so carried the risk of the patient remaining in pain longer than necessary. He did not see the Registrant doing this by asking any questions. He was asked if it appeared to him that the Registrant could have relied on his observation skills only. His response suggested that as no action, or record, to reflect such an observation was made, there was no evidence this has occurred. He also explained that the Registrant had been briefed at the start of the shift as to the need to verbalise his assessments as he was being assessed on the shift.

Fact 1a(i) found proved.

ii. Conduct a neurological investigation into Patient 1’s
symptoms;

49. The HCPC offered no evidence in respect of this sub-particular.

Fact 1a(ii) is not found proved.

iii. Offer pain relief until the patient was in the ambulance;

50. GO gave evidence that the Registrant did not offer Patient 1 pain relief until they were in the ambulance. This was contrary to good practice and the procedures that operated at EMAS. It meant that the patient was at risk of being in acute pain without any relief for a longer period than necessary. He indicated that he only observed the Registrant following the correct procedure of offering alternative pain-relief, once the patient was in the ambulance. He had not done this at the scene when they first attended.

Fact 1a(iii) found proved.

iv. Take Entonox to the scene;

51. GO gave evidence that EMAS procedure was that Entonox should always be taken to the scene if pain had been a feature of the call out. He said that while it would not be necessary for each member of the crew to be assigned a role in terms of who carried what, the person taking the lead would be expected to ensure that the correct equipment was taken to the scene. The Registrant did not make sure this occurred. Entonox was only offered once the patient was in the ambulance, and while it was refused in favour of paracetamol, this approach would not have been known in advance. The risk was that necessary treatment would not begin in a timely manner leaving the patient in pain.
Fact 1a(iv) found proved.
v. Flush the cannula after removing the infusion set.

52. GO gave evidence that while the Registrant was clearly competent at inserting a cannula, after it had been inserted, he did not flush the cannula post removing the infusion set. This meant that a blockage could occur, with blood back-filling it, and rendering it useless. It also had the risk that a further cannula would need to be inserted when the patient arrived at hospital, rather than this single puncture sufficing. The Panel noted the Registrant has indicated in his email of July 2019 that he considers himself competent at cannulation. However, the Panel concluded that GOs was not critical of the Registrant’s insertion of the cannula, meaning that there is no inconsistency. The care of the cannula post insertion into the patient is what this particular of the allegation highlights.

Fact 1a(v) found proved.

b. On 14 August 2018, attended an emergency call to Patient 2 and you did not:
i. Take an adequate history from Patient 2;

53. GO gave evidence that the Registrant only asked about four questions of the patient. Thereafter he stopped asking questions and looked to his mentor. Given his inadequate questioning, he failed to elicit information that would have been relevant. He indicated that the Registrant, “asked no questions regarding arthritis, whether the patient was waiting to have surgery or whether they had a GP referral.” He concluded that the Registrant had not asked questions that could have assisted in identifying a cause of the hip pain.

Fact 1b(i) found proved.

b.ii. Assess the patient’s
a) Chest, and/or
b) abdomen and/or
c) Genitourinary system;

54. GO gave evidence that the Registrant failed to conduct: a) an assessment of the chest by listening to breath sounds; b) an examination of the abdomen by feeling the abdomen to assess whether the patient felt any pain or discomfort; and c) an assessment of the patient’s genitourinary system through questioning. He explained that the risk of not obtaining this information or carrying out these assessments could result in the patient being discharged on scene, which could be unsafe and “detrimental”.
Fact 1b(ii) found proved.
b.iii. Identify and/or explore a potential differential
diagnosis;

55. GO gave evidence that the patient was clammy and presenting with a temperature. The Registrant in failing to make sufficient enquiries or conduct the relevant assessment, e.g. to listen to the patient’s chest to rule out a chest infection, or to ask whether the patient was urinating properly to rule out a possible urinary tract infection, meant that, ‘something may be missed,’ he said, which could have implications for the patient’s treatment. Failing to consider all relevant material could be important in ultimately determining whether a patient is taken to hospital or not for urgent care promptly. He indicated that the Registrant demonstrated a single-minded focus on one aspect of diagnosis, such as an initial presenting complaint and had indicated that the Registrant should consider the ‘bigger picture’ in a more holistic approach, so that assessment and history together could inform potential diagnoses. GO gave evidence that indicated for a paramedic to be able to evaluate a patient appropriately, here are several component parts of assessment that would be required. For Patient 2, he indicated that he expected the Registrant to check the patient’s chest, abdomen, and genitourinary system. He indicated that in order to be able to provide the patient with appropriate medical treatment and explore differential diagnoses, both an adequate medical history and assessment of the patient’s physiology would be required. Given that the Registrant neither asked the relevant questions about medical history, nor carried out the necessary tests, he was unable to consider differential diagnosis

Fact 1b, (iii) found proved.

iv. Complete a secondary survey at discharge.

56. The HCPC offered no evidence.

Fact 1b(iii) is not found proved.

c. On 14 August 2018, attended an emergency call to Patient 3 and you did not:
i. Check the patient’s radial pulses;
ii. Check the patient’s temperature; and/or
iii. Undertake an initial blood pressure check without prompting prior to carrying out a BEFAST assessment

57. GO gave evidence that Patient 3 was an elderly gentleman who had a history of experiencing ‘blackouts’ or periods of unconsciousness. He said that his expectation of a paramedic attending Patient 3 would be to check the patient’s radial pulse, temperature and blood pressure, prior to any BEFAST (Balance, Eyes, Face, Arms, Speech, Time) assessment. The Registrant failed to conduct these checks. GO explained that these expectations, to obtain a full set of observations, were taught, “from day one,” in training and their importance would have been emphasised in any practical assessment during the Registrants’ training. He said that the risks of not obtaining these observations include the paramedic being unable to gauge whether their interventions are making the patient’s condition better or worse. Without this information the paramedic may also administer medication erroneously. He gave the example of certain medication raising or lowering a patient’s blood pressure and a base line observation being required to assess whether such medication is safe to administer or not.

58. In this case, given that sudden drops in blood pressure can occur when a patient stands up, as in the course of a BEFAST assessment, the Registrant’s failure to conduct a blood pressure check prior to standing the patient up risked the patient falling over or blacking out due to low blood pressure. While the Registrant did hold up the patient when he was standing to minimise the likelihood of this, GO indicated that the failure to check the patient’s blood pressure may have been because the Registrant ‘already had a stroke as a potential diagnosis in mind,’ and such he did not think he needed to take the blood pressure. He said that this was symptomatic of the Registrant pursuing a single approach rather than exploring all leads and trying to ascertain relevant information.

Fact 1.c.i.ii.iii found proved.

iv. Conduct a blood pressure check prior to standing the patient up and requesting the patient to take a few steps;

59. The HCPC offered no evidence in respect of this sub-particular.
Fact 1c(iv) found not proved.

v. Identify and/or explore a potential differential diagnosis without prompting

60. GO gave evidence that in the ambulance on the way to Patient 3, the Registrant had identified that the patient may be suffering from a stroke given the information he had received by that time. This was a good working diagnosis at the time. However, on attending the scene, it became clear that the patient was unlikely to be suffering a stroke as he was alert and talking upon attendance. He was also holding a cup of tea which appeared to indicate his motor function was normal. Although, it was pointed out that, “it can be easy to get tunnel vision,” when a paramedic has already come up with a potential diagnosis on the way to attending a patient, it is important when attending a patient to question the diagnosis based on the patient’s presentation.

61. GO indicated that having an open mind regarding a diagnosis also enables one to develop and change your treatment paths according to what is found upon your assessment. Given the patient’s symptoms, including a distended abdomen and worsening back pain, he stated that he expected the Registrant to consider the diagnosis of an abdominal aortic aneurism. He said that the Registrant had failed to consider a differential diagnosis until prompted.

Fact 1c(v) found proved.

vi. Conduct an abdominal assessment until prompted to do so;
vii. Carry out a bilateral blood pressure assessment until prompted to do so;
viii. Carry out a standing blood pressure check until prompted to do so.

62. GO gave evidence that the Registrant failed to carry out each check until prompted, despite: the patient displaying a distended abdomen; the possibility of a differential diagnosis; and the risk of sudden drops in blood pressure once a patient has been stood up. In respect of the expectation that the Registrant complete a bilateral blood pressure assessment, a number of witnesses were questioned on whether this may be a required observation if an aortic aneurism is suspected. A number of experienced paramedics who appeared as relevant witnesses were unable to answer the question with confidence, which raises the question of how usual this procedure is. However, as a matter of fact the Panel noted there was nothing to dispute GO’s evidence that the above checks had not been carried out.

Fact 1.c.vi,vii,viii found proved.


1.d. On 2 June 2018, attended to Patient 4 and you did not:
i. Take an adequate medical history; and/or
ii. Undertake a 12 lead ECG
1.e. On 2 June 2018, attended to Patient 6 and you did not identify a change to Patient 6’s heart rate and/or did not take steps to try and identify possible causes of this.
1.f. On or around 2 June 2018, admitted to guessing ECG rhythms.

63. The Panel have received confirmation that Mr Piotrak did not become a fully registered paramedic with the HCPC until 16 July 2018, as set out in an e-mail from CL, Hearings Team Manager, dated 9 June 2021. Mr Piotrak’s application was received in January 2018, however as it was an international application it took longer to process when compared to an applicant who had graduated from a UK approved course. On that basis, Mr Piotrak was not subject to the requirements of professional conduct and proficiency of an HCPC registered paramedic prior to 16 July 2018, the Council apply to offer no evidence in respect of the sub-particulars 1) d) to 1) f), as they fall outside of Mr Piotrak’s period of registration.

Facts 1.d-f not found proved.

g) Did not consistently provide adequate patient handovers to hospital staff.

64. This allegation is addressed by witnesses in the case. The Panel have heard that when a paramedic discharges a patient into the care of hospital staff the paramedic will give a verbal handover alongside the electronic Patient Report Form (“ePRF”). In respect of time-critical patients, the ePRF will be completed following the verbal handover.

65. Each of the relevant witnesses address the consistent inadequacy of the Registrant’s handovers to hospital staff. The Panel are only concerned with those handovers which took place after the 16 July 2018. GO indicated that in respect of the 5 patients he attended with Mr Piotrak on 14 August 2018, “Rafal Piotrak’s ePRF’s provided very limited information.” The Registrant’s mentor from March 2018 until the Registrant left EMAS, made clear that his ePRF’s were “terrible and did not improve,” indicating that he would, “always have to follow up Mr Piotrak's handover notes with the staff at A&E”.

66. Each of the relevant witnesses referred to the significant risks to the patient of providing an inadequate handover, including the potential administration of medication in circumstances where it was not required, and in the delay caused to the patient in ascertaining a full history.
Fact 1.g. found proved.

h) On 13 August 2018, did not complete a Paramedic Clinical Assessment to an adequate standard.

67. This sub-particular is addressed by AD in his witness statement. AD provided a detailed and considered account of the deficiencies in the Registrant’s performance during the assessment. He made clear that many of the failings he witnessed, including in identifying a patient having a cardiac arrest and conducting CPR promptly and properly, were fundamental failures. He made clear that he did not think that based on his performance that the Registrant would have reached the standard expected of an Ambulance Technician.

Fact 1.h. found proved.

Allegation 2: Did not consistently demonstrate effective language and communication skills when communicating with patients.

68. Each of the relevant witnesses testified as to the Registrant’s consistent failure to demonstrate effective language and communication skills. A number provided specific examples of how this manifested itself when he was communicating with patients. This is underlined in the assessment the Registrant underwent on 13 August 2018. Failures to “introduce himself to the patient,” or “gaining consent before performing an initial assessment or inserting a cannula” were considered to be poor communication. It echoed what GO indicated in his experience of the Registrant on 14 August 2018: “On arrival at the scene, Rafal Piotrak failed to introduce himself to the patient, I had to prompt him to do so. Not introducing yourself to a patient can affect the way that they feel around you. If the patient feels at ease around you, then they are more likely to provide a more thorough background story which in turn can help with assessing their condition. I would say that 95% of our job is communication with the patient, therefore making them feel at ease is very important.”

69. MJ, who remained Mr Piotrak’s mentor from March 2018 until Mr Piotrak left EMAS, made clear that the Registrant’s lack of communication skills which “decreased the efficiency at which he could attend to patients, happened every day, on most calls. He explained that the risk of this lack of communication was that there was the potential to fail to get, “the full clinical history, and the patient not being able to understand the treatment”.

70. Different witnesses did vary in how they characterised the Registrant’s English language skills. Some indicated that the Registrant’s conversational English was very good, and that he could participate in station banter, and demonstrated a good sense of humour and an understanding of jokes that were told. Others have indicated that communication was possible but allowances needed to be made because English was not the Registrant’s first language. However, all relevant witnesses agree that the Registrant did not have the necessary clinical vocabulary that was expected.

71. A combination of the Registrant’s command of English and his inadequate clinical knowledge meant that all the relevant witnesses were not able to indicate with confidence whether one or the other featured more strongly in his failure to communicate verbally with patients. However, where there was consensus was that the Registrant did not consistently communicate well with all patients, even if he was able to build a good rapport with some of them. The suggestion was that this may have been as a result of him failing to adapt his approach to take into account different patient types.

Allegation 2 found proved.

Decision on Grounds: Lack of competence

72. The Panel having found facts proved went on to consider whether those facts amounted to the statutory ground of a lack of competence. The Panel took into account the guidance provided and acknowledged that a lack of competence is distinct from negligence and misconduct. It recognised that a lack of competence: “connotes a standard of professional performance which is unacceptably low and which (save in exceptional circumstances) has been demonstrated by reference to a fair sample of the [registrant’s] work,” as set out in the case of R v Calhaem 2007 EWHC 2606).

73. The Panel took into account the principle as set out by Sir Stanley Burnton in the case of Andrew Francis Holton v General Medical Council [2006] EWHC 2960, where it was held that in assessing lack of competence, the standard to be applied was that applicable to the post to which the registrant had been appointed and the work he or she was carrying out. The public was entitled to expect that the work of a registrant who performed in any speciality was at the standard applicable to that post in that speciality.

74. The Panel considered that in this case it has heard from a number of different witnesses about the Registrant’s performance. The context of this case is important background. The Panel has heard that a number of people who qualified in Poland as paramedics were recruited to EMAS. However, there was no understanding by EMAS of the role of a paramedic in Poland. Information subsequently obtained, after the paramedics had been provided with supernumerary posts, has revealed this role to be very different to its English equivalent. Concerns regarding the Registrant’s competence to act as an autonomous paramedic in England do not single the Registrant out as AD explained that the Registrant was far from being the worst of this intake, and that for the majority of the recruits’ equivalence was not found.

75. Evidence has been heard that the Registrant was provided with an extended training programme, which lasted well in excess of the three months that would normally be offered to new recruits to EMAS. He was provided a number of mentors, each of whom, although adopting different approaches, made clear that they expended effort in trying to help the Registrant reach the required standards of a HCPC registered paramedic. The Registrant also received clinical management support from LB and KT.

76. The measures described indicate that EMAS provided substantial support to the Registrant, and that any shortcomings in his practise cannot be said to have arisen as a result of a lack of support or supervision. Rather it appears that the expected knowledge and skills, of both a language and clinical nature were not demonstrated. More than one witness has described how they found the Registrant’s professional performance to be unacceptably low in respect of a number of his patients.

77. The panel have reference in the allegations to various shortcomings in respect of three patients attended to during a shift on 14 August 2018. In addition, in respect of allegation 1) h), the Panel have had regard to the Registrant’s performance during his assessment on 13 August 2018, in respect of a simulated attendance on a patient. The Panel is mindful of the legal advice it has received to exercise caution in not simply adopting the findings of the assessment and equating this to a lack of competence and recognises that this is a separate assessment for the Panel to conduct.

78. The Panel has considered whether the evidence before it can be said to be a fair sample of the Registrant’s work, given that the facts found proved largely involves actions on two consecutive days only. Had these matters of 13 and 14 August 2018 been the only facts found proved, the Panel did not think that this would have represented a fair sample of the Registrant’s work. However, on the basis of the facts found proved concerning Allegation 1g and 2, which respectively dealt with communication and patient handovers, the Panel was of the view that this was not limited to simply two dates in August 2018 but spanned the period during which the Registrant worked at EMAS as a HCPC registered Paramedic.

79. The Panel has considered that even on the two dates in August, a number of different patient situations arose which caused concern. There are three separate patients where the Panel found facts proved where there was a lack of competence. The Panel has taken into account that there is only a brief period of time during which Rafal Piotrak was registered with HCPC as a paramedic and worked for EMAS when his practice was under scrutiny. During these six weeks, there has been criticism about his performance when assessing patients, his communication with patients, and his communication in effecting complete handovers. In addition to the three clinical cases on 14 August there were also the results of the clinical simulated assessment on the 13 August. The Panel considered that while it would have not readily attached a lack of competence to a single clinical assessment in which there was a failure within a simulated setting, that there are three patients whom the Registrant failed to demonstrate the necessary standards with. Further, this combined with other particulars which span a six week period with relevant witnesses covering issues such as clinical communication, be this is verbally modifying his approach with different patients in order to build rapport in order to assess them, or to hand over patients to hospital staff verbally appears deficient. Together, these provide a fair sample of the Registrant’s work from which the Panel can assess his competence or lack thereof.

80. The clinical communication reflecting responsible autonomy that the Registrant should be able to demonstrate as fundamental tenets of the profession were not in evidence in July and August 2018. There was evidence that this was not just about two single dates but for numerous occasions, with omissions a regular occurrence. The Panel took into account the background to this case, which does not simply involve six weeks of registered practice when new in post, but 10 months of support, mentoring and assistance to gain confidence and competency prior to registration as a paramedic with the HCPC.


81. The evidence before the Panel has addressed the facts that it has found proved, but also been helpful in creating an impression as to what assistance the Registrant had been provided with, and how he performed on a daily basis when working. It was apparent that the Registrant himself and his paramedic colleagues all identified that he was not at the standards required of a HCPC registered paramedic in August 2018.

82. The Panel has taken into account that while the witnesses were not always able to provide chapter and verse of examples that occurred three years ago, without notes, that they have provided a fair picture of the Registrant’s performance in citing remembered occurrences, even if these lacked specific detail. There does appear to be extensive criticism concerning fundamental shortcomings in the Registrant’s performance and the facts found proved are indicative of a wider issue concerning the ability to work autonomously as a paramedic, as required in England.

83. The Panel has before it apparent recognition from the Registrant in his correspondence with HCPC in July 2019 that further work was necessary for his to reach the standards required of HCPC registered paramedic.

84. The Panel has been assisted in carrying out its assessment of the Registrant’s competence by the rules and standards ordinarily required to be followed by a HCPC registered paramedic. These are to be found in the HCPC’s Standards of Proficiency for Paramedics, published in 2014. Particularly relevant are the following:

1 - be able to practise safely and effectively within their scope of practice;
1.3 - be able to use a range of integrated skills and self-awareness to manage clinical challenges independently and effectively in unfamiliar and unpredictable circumstances or situations;
4 - be able to practise as an autonomous professional, exercising their own professional judgement;
4.3 be able to initiate resolution of problems and be able to exercise personal initiative;
8 - be able to communicate effectively;
8.1 - be able to demonstrate effective and appropriate verbal and non-verbal skills in communicating information, advice, instruction and professional opinion to service users, colleagues and others;
8.3 - understand how communication skills affect assessment of, and engagement with, service users and how the means of communication should be modified to address and take account of factors such as age, capacity, learning ability and physical ability;
8.5 - be able to select, move between and use appropriate forms of verbal and non-verbal communication with service users and others;
10 - be able to maintain records appropriately;
13 - understand the key concepts of the knowledge base relevant to their profession;
13.6 - understand the theoretical basis of, and the variety of approaches to, assessment and intervention;
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;
14.9 - 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;
14.17 - be able to demonstrate a logical and systematic approach to problem solving;

85. The Panel considered that they have evidence from different Paramedics who have all described that the Registrant lacks competence to practise autonomously. What has been set out by way of background is the efforts that EMAS took in order to provide supernumerary supervised work, training via a classroom and manuals, mentorship and other support by way of equipment loaned to practise on at home. The picture that has emerged is one where neither the Registrant nor EMAS has been content with the position that they found themselves in. EMAS has not been able to make a qualified paramedic familiar with their own processes quickly, and the Registrant was clear that he was not familiar with what was expected of him. The difference appears to stem from the fact that rather than different clinical skills being used in Poland, a paramedic there is part of an ambulance crew led by a doctor and will act under their instruction. Accordingly, the introductions, decision making, assessment, evaluation, and handovers that were required, do not seem to have been part of his role.

86. The Registrant’s position in 2019 set out that he expected more training in terms of becoming proficient with the standards expected in England. Notwithstanding the support that he received, he indicated that he felt unsupported in gaining the competence required. He spoke about attending a training centre and other paramedics have also mentioned that a UK based paramedic course would cover these basics of assessment, and handover. The biggest stumbling block for the Registrant has been his clinical communication skills, which are not necessarily language based, but stem from an unfamiliarity with the role of taking the lead in making decisions and acting on these.

87. Communication has been described as more than 90% of the paramedic role in the UK and this failure to be able to: a) modify ones approach to effectively engage with the patient, b) through questioning and testing, which may require some verbal interaction, assess physiology, c) act upon the findings and information received, d) communicate what is happening to the patient or others, e) describe adequately any difference between the call out descriptor and any presenting complaint, plus assessment and treatment carried out, is essential to the job.

88. Multiple testimony from different witnesses describes that the Registrant’s progress was slow. The phrase “one step forward and two steps back” was used to describe how progress over several patients on a single shift did not survive to the end of the shift. Taking into account all the information before it, the Panel finds that a lack of competence was demonstrated in the summer of 2018.

Decision on Impairment

89. The Panel having found that the statutory ground of a lack of competence is made out, has gone on to consider whether the Registrant’s fitness to practise is currently impaired. The Panel has taken into account the submissions received, the legal advice provided and the HCPC Practice Note on Finding that Fitness to Practise is Impaired. What follows is the Panel’s decision having exercised its professional judgment.

90. The Panel in looking at the Registrant’s fitness to practise today, has taken account of the way in which the Registrant acted in the past. It has not been assisted by information from the Registrant which addresses if deficiencies have been remedied, albeit his 2019 communication to the HCPC could be said to demonstrate insight that he was not operating at the level that was required in 2018 and that he hoped to remedy his shortcomings.

91. The Panel have borne in mind that its role is not to punish the Registrant for past misdoings but to protect the public. Accordingly, it looks forward not back. However, in order to form a view as to the fitness of a person to practise today, it is evident that it will have to take account of the way in which the person concerned has acted or failed to act in the past.

92. The Practice Note helpfully sets out the approach to be taken by Panels when determining whether a Registrant’s fitness to practise in impaired. This has been followed meaning that the Panel has taken into account a range of issues which, in essence, comprise two components:

i) the ‘personal’ component: the current competence, behaviour and circumstances of the individual registrant and;
ii) the ‘public’ component: the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession.

93. In terms of determining the personal element, the level of insight shown by the Registrant is central to a proper determination of this issue, along with his current competence and whether deficiencies have been remedied. The Panel in exercising its professional judgment to assess the Registrant’s insight have considered his correspondence with the HCPC in 2019. However, it notes that there has not been any meaningful update to that, given that the Registrant has not attended, nor provided any updated information or submitted any statements regarding his current professional practice.

94. The Panel has not been provided with any evidence of attempts to remediate the deficiencies in his practice. Time has elapsed since the Registrant was referred to HCPC but there has been no corresponding communication in terms of what improvements, if any, have been made in his practise during this intervening period. Accordingly, all the Panel has before it, is the assertion by the Registrant that some of his clinical skills, such as cannulisation, are not sub-standard and the more nuanced position set out by multiple witnesses to the Registrant’s deficiencies concerning how to communicate his ability to act autonomously and take the lead, despite intensive supervision and oversight.

95. The Registrant indicated in his e-mail on 30 July 2019, that he may need a ‘couple of years’ before reaching the required standard for a paramedic in this country. However, the panel are without any indication as to what stage the Registrant has now reached, or if any progress has been made at all. The role of a paramedic in this country is one where a Registrant would be required to take the lead in respect of communicating, assessing and treating patients. A paramedic may visit a person when they are at their most vulnerable and the potential consequences of his failings, on his patients, the reputation of the profession and the confidence that the public have in its regulator are all considerations that the Panel takes into account in making its decision as to current impairment.

96. In terms of the likelihood of a repetition of the Registrant’s behaviours, the Panel without evidence of improvement concerning his confidence, ability to act autonomously, and remedy the lack of competence in communicating with patients and making complete and appropriate handovers to hospital staff, cannot assess if these deficiencies have been remedied.

97. The Panel find both the personal and the public component to be engaged in this case. The Registrant, perhaps through no fault of his own, was unfamiliar with the expectations of the role that EMAS had in mind for him, but has conceded in effect that the standards were not one that he was able to meet in 2018. Further, that without evidence that there has been improvement and that progress has been made in meeting those standards, that the public’s confidence in the profession would be undermined if a finding of impairment were not made.

98. The Registrant did not have skill-based competencies that were required, such that this affected his ability to communicate effectively with patients in the course of his work as a registered paramedic or make safe handovers of patients to hospital. While some of his failures may have been exacerbated by his natural shyness, the inability to undertake assessment and communicate with patients or professional colleagues in hospital in effecting a handover are deficiencies which do not allow safe practice. Without knowing that these deficiencies have been remedied the Panel has little choice but to find current impairment.

The Panel finds that the Registrant is impaired by reason of his lack of competence.

Sanction

99. The Panel heard submissions on behalf of HCPC on the methodology it could take, in following that set out in the case of Fuglers LLP & Ors v SRA [2014] EWHC 179 (Admin). This covered a stepped approach in first assessing the seriousness of the lack of competence, its impact upon the standing and reputation of the profession as a whole. It concluded that the decision as to what sanction, if any, was a matter for its own judgment. It also received legal advice from the Legal Assessor. It has borne in mind HCPC’s Indicative Sanctions Policy.

100. The Panel was mindful that the purpose of any sanction was not to punish the Registrant but to protect the public, and to maintain public confidence in the profession, and the HCPC as its regulator, by the maintenance of proper standards of conduct and behaviour. It assessed the concepts of both the harm and culpability in this case.

101. It applied the principle of proportionality by weighing the Registrant’s interests with the public interest and by considering each available sanction in ascending order of seriousness.

102. The Panel first considered the aggravating factors in this case. The Panel noted that had the Registrant worked without supervision, there was a risk to patient safety on the basis that a complete patient assessment and patient handover would not have been communicated to the hospital staff. Further, this is a case in which the Registrant did not ask for help, or admit where he was struggling in relation to clinical findings, until expressly asked.

103. As mitigating factors, the Panel took into account that the Registrant was offered a post and recruited for a job by EMAS. They conducted a recruitment exercise where the difference between practise from a paramedic in Poland, and in England was not explained. The Registrant has exhibited some insight in acknowledging that the role and standards are different in England and Poland and that it would take him some time to reach those standards. All the witnesses indicated that the Registrant over the course of the year he worked at EMAS, he exhibited a positive attitude which demonstrated his desire to learn. The Panel also took into account that the Registrant has not had any previous fitness to practise concerns found against him.

104. The Panel considered that as a professional, the Registrant ought to have sought help when it was appropriate to do so. It took into account that his personality may not have assisted him with this, as he was described as “shy”. It took into account that there were no attitudinal failings and that the issues raised as a lack of competence could be remediated with more learning, experience and confidence gained.
105. Where the Panel is not helped is a lack of up to date information from the Registrant. The Registrant did indicate his desire and willingness to learn in order to reach the standards of a HCPC registered Paramedic which he acknowledged he was not at in 2018/9. However, it has no way of knowing whether the learning, experience and confidence that his Paramedic colleagues recommended has been obtained. It cannot assess his clinical English language vocabulary at this moment in time and whether his communication and confidence have improved so as to allow him to practise safely without restriction.

106. In determining the appropriate and proportionate sanction, the Panel had regard to its findings of fact. Having found that the Registrant’s fitness to practise is currently impaired due to a lack of competence meaning that safe practice without restriction is not possible, the Panel considered that it would be inappropriate to take no action, refer the matter to mediation, or issue a caution.

107. The Panel next considered whether a Conditions of Practice Order was appropriate and proportionate. The Panel was conscious that it has no information from the Registrant as to his working situation since July 2019 or whether he still wanted to pursue a career working as a HCPC Registered Paramedic as he had in 2019. Conditions of Practice have to be workable, practical, enforceable and verifiable and the Panel does not know whether the Registrant would engage with these conditions. The Panel further considered that Conditions of Practice would not sufficiently protect the public or be proportionate in this case.

108. The Panel next considered a Suspension Order which is likely to be appropriate where there are serious concerns which cannot be reasonably addressed by a Conditions of Practice Order, but which do not require the Registrant to be struck off the Register, given that striking off is not an available sanction to a lack of competence.

109. The Panel accepted that the public would be protected during any period of suspension and that the Registrant could continue to learn and improve his English language clinical vocabulary in roles for which registration with HCPC as a paramedic is not required. The Panel concluded that the appropriate and proportionate sanction was a Suspension Order for a period of 12 months.

110. Prior to the Suspension being lifted, a review will take place. At such a review it will be expected that the Registrant attends. A reviewing Panel would also be assisted by:

a. Written confirmation that the Registrant still wishes to pursue a career as a HCPC registered Paramedic;
b. Course certificates, showing the completion of training in clinical communication, addressing both patient assessment and effective patient handovers;
c. Certificates evidencing any other relevant Continuing Professional Development;
d. Any testimonials from those for whom the Registrants works in a clinical setting;
e. Reflections in writing, demonstrating his insight into his lack of competence, its potential effect on his patients and his profession.

Order

The Registrar is directed to suspend the registration of Mr Rafal Piotrak for a period of 12 months from the date this Order comes into effect.

Notes

Right of Appeal

You may appeal to the High Court in England and Wales against the Panel’s decision and the order it has made against you.
Under Article 29(10) of the Health Professions Order 2001, any appeal must be made within 28 days of the date when this notice is served on you. The Panel’s order will not take effect until the appeal period has expired or, if you appeal, until that appeal is disposed of or withdrawn.

Interim Order

The HCPC applied to proceed in the absence of the Registrant, and for an interim order to be imposed. The Panel took into account the legal advice provided, and considers that the Registrant while not present, had a) been put on notice in the Notice of Hearing sent to him on 16th April 2021 that an interim order could be made b) not given any indication of why he is not attending, and c) not provided submissions on this point despite being provided with the opportunity to do so.
The Panel had regard to what was fair in all the circumstances. Given that the Registrant has now had facts found proved against him, his fitness to practice impaired by reason of a lack of competence, and the Registrant’s practice has been substantively restricted, it follows that an interim order to cover any period of appeal is required.
The Panel makes an Interim Suspension Order under Article 31(2) of the Health Professions Order 2001, the same being necessary to protect members of the public and being otherwise in the public interest.
This order will expire: (if no appeal is made against the Panel’s decision and Order) upon the expiry of the period during which such an appeal could be made; (if an appeal is made against the Panel’s decision and Order) the final determination of that appeal, subject to a maximum period of 18 months.

 

Hearing History

History of Hearings for Rafal Piotrak

Date Panel Hearing type Outcomes / Status
07/06/2021 Conduct and Competence Committee Final Hearing Suspended
06/05/2021 Conduct and Competence Committee Interim Order Review Interim Suspension
23/10/2020 Conduct and Competence Committee Interim Order Review Interim Suspension
24/07/2020 Conduct and Competence Committee Interim Order Review Interim Suspension
30/01/2020 Investigating Committee Interim Order Review Interim Suspension
30/10/2019 Investigating Committee Interim Order Review Interim Suspension
31/07/2019 Investigating Committee Interim Order Review Interim Suspension
07/05/2019 Investigating Committee Interim Order Review Interim Suspension
14/11/2018 Investigating committee Interim Order Application Interim Suspension