Mrs Emma Stevens

Profession: Paramedic

Registration Number: PA18595

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 08/03/2021 End: 17:00 12/03/2021

Location: This hearing will take place virtually

Panel: Conduct and Competence Committee
Outcome: Caution

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Allegation

During the course of your employment as a Paramedic with the East of England Ambulance Service NHS Trust (“the Trust”):

1. On or about 5 March 2014, when attending an emergency call at the home of Patient A, you:

a. Failed to take an adequate history to assess the nature and progression of Patient A’s illness;

b. Failed to:

i. undertake a physical examination to an appropriate standard that would have recognised the severity of Patient A’s condition; and / or

ii. observe/ appreciate the significance of Patient A’s breathlessness;

c. Allowed an Emergency Care Assistant (ECA) to inspect the patient’s throat;

d. Failed to observe that Patient A was cyanosed;

e. Failed to recognise the significance of oxygen saturations of 86%;

f. Failed to repeat an oxygen saturation measurement once the nebuliser had finished;

g. Reported that the patient improved post nebulization when clinical documentation does not support this;

h. Failed to perform a 12 lead ECG;

i. Failed to recognise the significance of the sepsis markers;

j. Failed to follow EEAS and/or JRCALC guidelines on the management of sepsis;

k. Failed to convey the patient to hospital, despite indication that sepsis was present;

l. Failed to complete the non-conveyance form or document in the records your reasons for not doing so;

m. Failed to make a complete and accurate written record of your findings.

2. The matters set out in Particular 1(a) to (m) constitute misconduct and/ or a lack of competence.

3. By reason of your misconduct and/ or lack of competence, your fitness to practise is impaired.

 

Finding

Preliminary Matters

Application to amend the allegation

1. Ms Lykourgou applied to amend the particulars of the allegation as follows (amendments shown in bold):

During the course of your employment as a Paramedic with the East of England Ambulance Service NHS Trust ("the Trust'):

1.On or about 5 March 2014, when attending an emergency call at the home of Patient A, you:

a. Failed to Did not take an adequate history to assess the nature and progression of Patient A's illness;

b. Failed to Did not:

i. undertake a physical examination to an appropriate standard that would have recognised the severity of Patient A's condition; and/or

ii. observe/ appreciate the significance respond appropriately to of Patient A's breathlessness;

c. Allowed an Emergency Care Assistant (ECA) to inspect the patient's throat which was beyond the scope of her practice;

d. Failed to Did not observe that Patient A was cyanosed;

e. Failed to Did not recognise the significance and/or take appropriate action in light of Patient A's of oxygen saturations of 86%;

f. Failed to Did not repeat an oxygen saturation measurement once the nebuliser had finished;

g. Reported in the Patient Care Record that the patient improved post nebulization when clinical documentation the Patient's vital signs and presentation did does not support this;

h. Failed to Did not perform a 12 lead ECG;

i. Failed to Did not recognise the significance take appropriate action in the presence of sepsis markers;

n. Failed to Did not follow EEAS and/or JRCALC guidelines on the management of sepsis;

o. Failed to Did not convey the patient to hospital, despite indication that sepsis was present;

p. Failed to Did not complete the non-conveyance form or document in the records your reasons for not doing so non-conveyance;

q. Failed to Did not make a complete and accurate written record of your findings.

2. The matters set out in Particular 1(a) to (m) constitute misconduct and/ or a lack of competence.

3. By reason of your misconduct and/ or lack of competence, your fitness to practise is impaired.

2. Ms Lykourgou said that the Registrant was given notice of the HCPC’s proposed amendments in a letter dated 24 January 2020. She submitted that the amendments clarified the HCPC’s allegations against the Registrant and better reflected the HCPC’s evidence. She submitted that no prejudice was caused to the Registrant by the amendments.

3. Mr Attenborough on behalf of the Registrant indicated that the HCPC’s application to amend was not opposed.

4. The Panel took advice from the Legal Assessor. The Panel considered that the amendments sought were to clarify the particulars and ensure they accurately reflected the HCPC’s case. The amendments did not substantively change the allegation or extend its scope. The Panel was satisfied that no unfairness or prejudice would be caused to the Registrant who had had adequate notice of the proposed amendments and did not object to them.

5. The Panel therefore determined that it was appropriate for the proposed amendments to the allegation to be made.

Documents

6. The Panel received a bundle of 448 pages from the HCPC and a bundle of 11 pages from the Registrant.

Background

7. On the date of the incident in question, the Registrant was employed as a Paramedic by East of England Ambulance Service NHS Trust (“EEAS”).

8. On 5 March 2014, the Registrant attended an emergency call at the home of Patient A. The HCPC allegations arise from the events of that day. The background to the HCPC’s case is summarised as follows:

9. Patient A was a previously fit and healthy 37-year-old male. On the evening of 3 March 2014, he complained of a sore and scratchy throat. His partner, Person B, noticed that his voice had changed, sounding strange and was muffled. She purchased some over the counter medication but Patient A slept badly. The following day he went to work and then the gym but on arriving home he could not settle for the night. He said he thought his throat was closing up when he lay down.

10. By 0200 on 5th March 2014, Patient A’s condition was no better. At 05.30, Patient A could take it no longer and Person B drove him to hospital at around 06.15. They went to reception and were seen by a nurse. They told the nurse that Patient A could not swallow and his throat was closing up. The nurse said that his blood pressure and temperature were normal and that as he could talk and breathe, an appointment was made for Patient A to see the out of hours GP.

11. The couple walked round to the out of hours surgery in the fracture clinic next door and were seen by a doctor straightaway. They went through the symptoms of an extremely sore throat, trouble swallowing and breathing, that Patient A’s voice had altered, his throat was closing up and it was making a clicking sound. Patient A was wiping around his mouth with a tissue. He had a high temperature and his throat was red and inflamed. The doctor said he had a bad throat infection and he recommended over the counter medicine. The couple left feeling as if they were time wasters.

12. At 07.30, Person B gave Patient A soluble Nurofen and left for work at 08.15. At 10.00 Patient A called Person B. He was in a panic saying that he couldn’t breathe. Person B called 999 for an ambulance and left work immediately to return home.

13. When Person B arrived home the ambulance was already there and Patient A had let the crew inside. Person B described Patient A as having blue/mauve lips and dark circles under his eyes. The Emergency Care Assistant (ECA), Colleague D, was checking him over and the Paramedic, the Registrant, was standing back talking. Person B told them about the trip to A & E that morning.

14. Person B referred to Patient A having a lot of saliva in his mouth and she could hear it making sounds in his throat. Person B fetched a bowl for Patient A to spit this out and she recalls this as being blood tinged. The ambulance crew told her this was because of “grazing” of the throat.

15. Person B recalled a discussion by the ambulance crew about going to hospital. Person B was asked if she was staying at home and said that she was so they decided not to take him to hospital.

16. The crew put Patient A on oxygen. Patient A said he felt he could breathe a lot more easily. His lips became pink in colour. Person B gave him some soluble paracetamol and the ECA wrote up the notes. The crew left a copy of the notes and told Patient A to call back if anything changed. Patient A told Person B he felt scared and thought he would die.

17. At about 13.00, Patient A tried to take some soluble Nurofen, stood up and holding on to the TV, said “ambulance, ambulance”. Person B called 999 but as she was doing so Patient A lost consciousness, his eyes started to roll back and he fell to the floor. His face was purple. He did not make a sound after hitting the floor.

18. Person B placed Patient A in the recovery position, as bright red blood started pumping from his mouth.


19. The paramedics arrived quickly, this time a different crew. They tried to insert a breathing instrument into Patient A’s throat as they were trying to remove blood from his throat. They gave adrenaline and called for extra help. The Registrant and the ECA Colleague D arrived at the house again. Patient A was taken to Southend Hospital. Patient A was certified dead at 14.29 on 5 March 2014.

20. The cause of Patient A’s death was recorded in a post mortem report as “Acute Epiglottitis – Beta Haemolytic Streptococcus Group C as Causative Organism”.

The Registrant’s response

21. The Registrant admitted the facts alleged in Particulars 1(a), 1(b)(i), 1(c), 1(f), 1(h), 1(i), 1(j), 1(k), 1(l) and 1(m).

22. Particulars 1(b) (ii), 1(d), 1(e) and 1(g) were denied.

23. In respect of the alleged ground of impairment, it was indicated that the Registrant would admit that particulars 1(c), 1(l) and 1(m) constituted a lack of competence and the particulars 1(f), 1(h), 1(i), 1(j) and 1(k) constituted misconduct.

The HCPC’s case

24. The Panel heard oral evidence for the HCPC’s case from Person B and Witness SB. The Panel also heard expert evidence from Professor Charles Deakin MA MD MB BChir FRCP FRCA FERC FFICM.

25. Person B was the partner and fiancée of Patient A. Person B and Patient A had been due to marry in July of the year in which he tragically passed away, 2014. The Panel recognised how difficult and painful it was for Person B to give evidence at this hearing about the events leading up to Patient A’s death on 5 March 2014 even after 7 years.

26. Witness SB is an HCPC registered Paramedic. He is currently employed as Resilience Manager for EEAS. At the time of the relevant events he was employed in the role of Assistant General Manager for EEAST. SB undertook an investigation into the circumstances of the attendance on Patient A on 5 March 2014 and produced an investigation report dated 19 July 2014. During his investigation he interviewed and obtained statements from the Registrant and from Colleague D. He produced various relevant EEAS documents. The Panel noted that at the time of his investigation, SB had not been provided with a statement from Person B but had been provided by the Trust with details of her account and the cause of Patient A’s death had not been determined.

27. Professor Deakin is a full-time NHS consultant in Cardiac Anaesthesia and Critical Care at Southampton University Hospital since 1999 and has been Medical Director of South Central Ambulance Service (Hampshire Division) (part-time) since 2003. He is a member of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) which sets national standards for UK paramedic practice. Professor Deakin said that he has been involved in pre-hospital work and ambulance care at both a managerial and practical level for over twenty years.

28. Professor Deakin was instructed by Essex Police on 22 September 2015 to provide an expert opinion in respect of the Registrant’s actions in respect of the care of Patient A on 5 March 2014, the terms of reference being whether the Registrant’s action was “so far below what would reasonably have been expected that it would be deemed criminal”. In his oral evidence, Professor Deakin referred to this report, dated 15 November 2018. For the purposes of the HCPC proceedings, however, he was asked to give his opinion on whether the Registrant’s actions, if proved, fell short, or far short, of the standards expected of an HCPC registered Paramedic.

29. The Panel also received documentary evidence, including the EEAS witness statement of Colleague D and contemporaneous records including the PCR for Patient A.

Submission of no case to answer – Particular 1(g)

30. At the close of the HCPC’s case, Mr Attenborough made a submission of no case to answer in respect of the facts of Particular 1(g):

“Reported in the Patient Care Record that the patient improved post nebulization when clinical documentation the patient's vital signs and presentation did not support this”;

31. Mr Attenborough submitted that whilst the HCPC had adduced evidence to support two elements of the particular, no evidence had been adduced in relation to the third element, namely that the patient’s presentation did not support that the patient improved post nebulisation. Mr Attenborough submitted that the evidence of Person B clearly confirmed Patient A’s presentation did improve and referred to the PCR. He submitted that Person B’s evidence was that after receiving the nebuliser, Patient A’s condition did improve, albeit briefly, and he was able to breathe and swallow more easily. She thought it was about an hour later that he collapsed.

32. Mr Attenborough submitted that the HCPC had not adduced any evidence in support of this issue and therefore particular 1(g) must fall.

33. Ms Lykourgou responded that it was open to the Panel to find that there was sufficient evidence in support of the whole or part of the allegation. She referred to the PCR which showed that some of Patient A’s vital signs in relation to breaths per minute had not improved and were still very high. Although Person B referred to Patient A seeming improved after the nebuliser, it had not been put to her whether Patient A was able to talk, breathe or swallow more easily. Ms Lykourgou submitted that the Panel should find there was sufficient evidence upon which the allegation could be found proved. Alternatively, the Panel could find the submission proved only in respect of the presentation element and continue with the remainder of the particular.

34. Mr Attenborough responded that the HCPC had chosen to allege “and” rather than “and\or” in respect of presentation and the “and” was conjunctive. He submitted it was not open to the Panel to sever that element and that the particular as a whole should fall.

35. The Panel took legal advice. The Panel was referred to HCPTS Practice Note on “Half-Time Submissions” and to the test in R v Galbraith [1981] 1 WLR 1039. The Panel bore in mind that the burden of proof is upon the HCPC to present sufficient evidence upon which the allegation could be proved and that the standard of proof on facts is the balance of probabilities. The Panel was advised it was a matter for the Panel as to whether it interpreted the “and” as conjunctive in particular (g). It was open to the Panel to accept the submission in respect of any element of the allegation and to decide to proceed with what was, effectively, a less serious allegation.

36. The Panel bore in mind that it had accepted the HCPC’s application to amend the particulars of the allegation at the beginning of the hearing. Some particulars made allegations in the alternative, as “and/or”. It appeared to be intended that the allegation in particular (g) was not in the alternative. The Panel concluded that such a change in the case the Registrant faced at this late stage was inherently unfair. It also accepted that the “and” in this case was to be construed as conjunctive and concluded that the allegation related to the patient’s condition holistically, namely the Patient’s vital signs and presentation.

37. On the above basis, the Panel concluded there was insufficient evidence upon which particular 1(g) could be proved and it determined to uphold Mr Attenborough’s submission of no case to answer.

The Registrant’s case

38. For the Defence case, the Registrant gave oral evidence and referred to her Trust witness statement dated 5 March 2014, the notes of her meeting with SB on 8 April 2014 and the notes of her EEAS interview with SB on 16 April 2014.

39. The Registrant told the Panel that she joined EEAS in 2002 as a technician, having previously been a medic in the RAF since 1997. She became a Paramedic with EEAS in 2006.


Submissions on facts

40. Ms Lykourgou drew the Panel’s attention to the evidence in support of each particular. She relied on the evidence of Person B, Witness SB and Professor Deakin. She submitted that that the evidence of Person B was highly credible in particular in respect of its consistency with the entries in the PCR. Ms Lykourgou referred to the documentation, in particular the PCR and the contemporaneous records of the Registrant and Colleague D. She submitted the HCPC had submitted evidence upon which the Panel should find all the remaining particulars of the allegation, including those which remained disputed by the Registrant, proved.

41. Mr Attenborough referred the Panel to the admissions made by the Registrant and addressed the evidence relating to the disputed Particulars, 1(b)(ii). 1(d) and 1(e). He told the Panel that the Registrant was of previous good character in her long career of 24 years, fifteen of which were as a qualified Paramedic and submitted that since the allegations brought into question her credibility the Panel should take account of her good character. He referred to the Registrant’s bundle which included letters in support of the Registrant’s character. Mr Attenborough submitted that the Registrant had made concessions during her evidence on two further particulars but had consistently maintained her position in respect of the denied particulars b(ii), (d) and (e). He submitted that the Panel should find these particulars not proved.

Panel Decision on Facts

42. The Panel accepted the advice of the Legal Assessor. The Panel bore in mind that the burden of proof is upon the HCPC and is not upon the Registrant. The standard of proof in HCPC proceedings is the civil standard, the balance of probabilities. This means in order to find a fact proved, the Panel must be satisfied it is more likely than not that it occurred.

43. The Panel remained mindful that it should reach its own decision, based on the evidence presented at this hearing, albeit it was aware of earlier investigations which had taken place into these events. The Panel bore in mind the Registrant’s previous good character in relation to her credibility on the disputed issues. It bore in mind that in respect of the hearsay evidence which had been admitted, it was a matter for the Panel to decide what weight could be attached to such evidence.

Allegation 1

44. In respect of the allegation, there was no dispute that on or about 5 March 2014 the Registrant attended an emergency call at the home of Patient A.

The particulars of the allegation

45. The Panel’s findings were as follows:

1(a) Did not take an adequate history to assess the nature and progression of Patient A's illness: Proved.

The Registrant admitted this particular.

Professor Deakin referred in his report of 15 November 2016 to the finding of the EEAS Report of 19 July 2014 that during history taking, the Registrant did not ask what clinical assessment had been undertaken by the A & E department earlier on the morning of 5th March 2014, or what specific diagnosis had been made by the out of hours GP.

Professor Deakin concluded in his report that the Registrant failed to perform a history to assess the nature and progression of Patient A’s illness.

The Panel noted the evidence of SB that at the time of his investigation he considered from examining the records that a reasonably detailed history had been taken in respect of Patient A. However, the Panel concurred with the opinion of Professor Deakin.

The Registrant had initially denied this particular. She told the Panel in evidence that Patient A was able to tell her and Colleague D on their arrival at the house on 5 March 2014 about events overnight and that morning. He was able to speak fairly well and was using full sentences.

The Registrant referred to the entry under “Medical History” on the Patient Care Record, initially stating that she believed she had obtained enough information to carry out her role. However, she changed her position during cross-examination by Ms Lykourgou and stated that she accepted the allegation. She told the Panel that now she would ensure that she obtained a detailed account of a patient’s presenting condition and history, and if a relative was present, she would ask the relative as well. She accepted she had not obtained a sufficiently detailed history in the case of Patient A.

The Panel accepted the Registrant’s admission and the opinion of Professor Deakin in support of this particular. The Panel was satisfied that this particular was proved.


1(b) Did not:
i. undertake a physical examination to an appropriate standard that would have recognised the severity of Patient A's condition; Proved


The Registrant admitted this particular, having initially denied it.

The Panel had sight of the record of the physical examination on the PCR. This noted “On examination the throat is inflamed. No airway compromise. Patient has been coughing clear sputum. Glands swollen. No cyanosis.”

Professor Deakin’s report noted that it was Colleague D, the ECA, rather than the Registrant, who examined Patient A’s throat. He commented that the task was therefore left by the Registrant to a junior colleague whose clinical training did not extend to this level of assessment. He noted that a view of the back of the throat does not enable visualisation of the upper airway which, from the history and physical signs, appeared to be partially obstructed and inflamed. He would have expected a Paramedic to understand this. Professor Deakin’s conclusion was that the Registrant did not undertake a physical examination to an appropriate standard that would have recognised the severity of Patient A's condition.

SB’s evidence was that he did not conclude during his investigation that there was anything further that the Registrant could have done in the physical examination to ensure it was appropriate to recognise the severity of Patient A’s condition. He stated that he had been satisfied in addition that the crew had remained at the scene for some time to complete their evaluations, there was no rush to leave which did not suggest that the presenting complaint was dealt with any disdain at all.

The Registrant accepted this allegation in the course of cross-examination. She told the Panel that she had applied the monitoring device, taken Patient A’s blood pressure, listened to his chest, taken his oxygen saturations and pulse. These were recorded on the PCR. Two subsequent sets of observations were recorded, although times were not entered. She said these would have been undertaken at 10.25, 10.40 and 11.10. She believed the entries were accurate as far she could recall. She was working with Colleague D who entered the information on the PCR, which the Registrant said she glanced through before they left the house.

The Registrant said in questioning from the Panel that she now accepted that she should have looked at Patient A’s throat herself, looking for any redness, swelling or pus at the back of the throat. She said that she should have examined the patient again after treatment with the nebuliser and checked his temperature again and undertaken the ECG.

The Panel accepted the finding of the expert Professor Deakin in support of this particular. Having considered the evidence and examined the PCR itself, whilst noting the view of SB, the Panel preferred the opinion of Professor Deakin. The Registrant now accepted that the physical examination was not of an appropriate standard and the examination was undertaken by the ECA when it was beyond her scope of practice. The Panel found this particular proved.

ii. observe/respond appropriately to Patient A's breathlessness; Proved

The Registrant denied this particular.

Professor Deakin’s evidence was that the respiratory rate recordings undertaken when the Registrant and the ECA attended Patient A showed on all three observations a respiratory rate of 22bpm. Professor Deakin concluded that it was therefore clear that Patient A was significantly breathless, and also would have felt very breathless. He noted that with a respiratory rate at this level the patient would appear clearly breathless.

The evidence of Person B was that over the course of the morning of 5th March 2014 Patient A was expressing difficulty breathing. When Patient A called her at work asking for an ambulance he told her he couldn’t breathe and she could hear he was very short of breath.

The Registrant told the Panel that when she and the ECA arrived at the home, Patient A was anxious and panicking, but after a while calmed down. The Registrant said she assessed him by looking at his complexion, listening to his chest and ensuring he had good air entry. She did not conclude that he was seriously short of breath, but said that with an infection breathing may be increased. The crew were at the patient’s house for around an hour. The Registrant maintained that to her, the patient did not appear to be short of breath. When asked why she gave oxygen if the patient was not displaying shortness of breath, she said that she thought it might just have been to “calm him down”.

The Panel concurred with the opinion of Professor Deakin that, on the basis of the readings, it was likely that Patient A was breathless. This had been the reason for the emergency call for an ambulance. It was consistent with Person B’s observations. Whilst the Registrant disputed this, the treatment given to Patient A, oxygen therapy, was the appropriate treatment for breathlessness, albeit the Registrant’s evidence was that it was given for a different reason, “to calm him down”.

The Panel was satisfied that this particular was proved on the basis that the Registrant failed to observe that Patient A was breathless.

1(c) Allowed an Emergency Care Assistant (ECA) to inspect the patient's throat which was beyond the scope of her practice; Proved.

The facts of this particular were admitted by the Registrant.

The Registrant accepted that as the Paramedic, she had clinical responsibility for the care of Patient A. She accepted that she should have undertaken the examination of Patient A’s throat.

The Registrant confirmed that she was aware that Colleague D was an ECA who would not undertake clinical tasks. She was aware of the difference between an ECA and an Emergency Ambulance Technician who could undertake some clinical tasks.

The Panel noted the evidence of Witness SB, who stated that in the case of a mixed crew, a Paramedic and an ECA, he would usually expect a clinical examination to be dealt with by the Paramedic as the lead clinician.

Professor Deakin’s report was critical of the Registrant leaving this task to a junior colleague whose clinical training did not extend to this level of assessment.

On the basis of the Registrant’s admission and the evidence of Professor Deakin, the Panel found the particular proved.

1(d) Did not observe that Patient A was cyanosed; Proved.

Person B’s evidence was that she arrived home from work at approximately 10.30am, after receiving the call from Patient A and calling for the ambulance for him. The Registrant and Colleague D were already in attendance. Person B said that Patient A was sitting on the stairs. She went straight to him and held his hand. When she saw him, she panicked as he was very white, with large dark circles around his eyes and the area around his lips was mauve. Person B described this as noticeably different from his usual “pink-ish” coloured skin and rosy cheeks and also from how she had left him looking that morning when she went to work. Person B said that she could see that Patient A was very poorly. Person B did not recall any question or discussion with the crew about Patient A’s appearance but thought she was probably saying how poorly he looked. She told the Panel that once Patient A had received oxygen via the mask, his colour improved, but he was still pale and looked very poorly.

In the PCR record, Patient A’s skin colour was noted to be “normal” and not to be cyanosed.

In his report, Professor Deakin commented that Person B’s description was striking as a lay description. He said it described very well the appearance of someone with low oxygen levels, consistent with Patient A’s initial pulse oximeter reading, and the physiological response to being given additional oxygen, that is, the lips turning pink. Professor Deakin said this was such a good description that he had no reason to doubt it and he could only conclude that the Registrant and her colleague had missed this.

The Registrant denied this particular. She told the Panel that Patient A did not appear cyanosed at any time during the first visit. She said she had probably seen hundreds of patients with cyanosis. She described that a patient would look very white, their lips would be mauve or have a blue tinge. Their finger might be blue and there would be some shortness of breath. Cyanosis indicates a lack of oxygen in the body. The Registrant said that if Patient A had been cyanosed it would have been a serious concern and they would not have remained on the scene but would have gone to hospital. There would have been a concern about what was causing the lack of oxygen. She referred to the PCR which said the skin colour was normal and recorded that there was no cyanosis.

The Panel noted the witness statement of Colleague D, the ECA, dated 5 March 2014, which stated that Patient A was not cyanosed or pale. This was consistent with the account of the Registrant and given on the day of the incident. The Panel was mindful however that this was hearsay evidence. Colleague D had not given oral evidence to the Panel and so could not be questioned or cross-examined on this issue. The Panel concluded it could accordingly give less weight to this evidence.

The Panel found Person B’s description compelling. Her description was clear and consistent. Whilst the day in question was now seven years ago, Person B had, not surprisingly in the tragic circumstances, a clear recollection of how she found Patient A on her return home after calling the ambulance. The Panel noted the opinion of Professor Deakin that Person B’s account was striking for a lay description of cyanosis. In particular the Panel noted Professor Deakin’s evidence that a patient with the initial oxygen reading which was recorded for Patient A would be likely to be cyanosed. The Panel preferred the evidence of Person B and accepted Professor Deakin’s opinion that this was consistent with the Patient A’s clinical presentation in terms of the concerning level of his initial oxygen saturations.

The Panel found proved that the Registrant had failed to observe that Patient A was cyanosed.

1(e) Did not recognise the significance and/or take appropriate action in light of Patient A's oxygen saturations of 86%; Proved.

Professor Deakin’s report noted the first reading of oxygen saturations of 86 on arrival indicated the patient’s oxygen levels were “very significantly deranged”. He observed that as the reading was recorded by the ECA and was checked without amendment by the Registrant, this suggested the Registrant considered it was accurate. The later higher readings and general improvement noted were only whilst the patient was breathing supplementary oxygen. In Professor Deakin’s opinion, the Registrant failed to appreciate the significance of such a low oxygen saturation reading.

The Panel noted the evidence of SB that he could not think of anything else that could be done in response to the low oxygen saturation level recording: the Registrant had taken a history, taken into account the patient’s initial presentation, administered oxygen and then made a decision to administer salbutamol via a nebuliser.

The Registrant denied this particular. The first recording, on arrival, was 86%. The Registrant said this did not concern her, as the low reading did not match Patient A’s appearance. She would have expected him to be pale, short of breath and possibly showing some signs of cyanosis. She said that he was not confused and was completely coherent. The Registrant said she concluded that the probe may not have been attached properly because Patient A was moving around a lot and so the reading may not have been accurate. She did not think that the machine was faulty She said they got Patient A to calm down and gave oxygen therapy. The subsequent readings of 96 and 99 were when Patient A was given oxygen therapy and then the nebulizer. The Registrant said that Patient A was a lot calmer and more relaxed, but otherwise his presentation had not changed.

The Panel accepted the evidence of Professor Deakin. It accepted that oxygen saturations of 86% on air indicated significant derangement and this should have been evident to the Registrant. She did not appear to question the reading which the Panel found difficult to understand. The further readings taken on that morning were whilst the patient was receiving assisted oxygen therapy and so did not provide reassurance that there was improvement in the patient’s condition. The Panel was satisfied that this particular was proved.

1(f) Did not repeat an oxygen saturation measurement once the nebuliser had finished; Proved.

The facts of this particular were admitted by the Registrant. She accepted that a further oxygen saturation measurement should have been carried out when the nebuliser was finished. The Registrant told the Panel that Patient A remained connected to the monitor while she and Colleague D were in attendance, but no recordings were documented in the notes.

The EEAS Report, as referred to by Professor Deakin, commented that in the absence of a further measurement it would not have been known if Patient A’s oxygens saturations on air fell back to the dangerous levels of the first recording. Professor Deakin was critical of the absence of a further measurement.

The Panel accepted the Registrant’s admission and the conclusion of Professor Deakin in support of this particular and found it proved.

1(h) Did not perform a 12 lead ECG; Proved

The facts of this particular were admitted by the Registrant. She was unable to tell the Panel why no 12 lead ECG was carried out.

Person B confirmed that she did not see an ECG being given to Patient A during the first attendance by the Registrant and Colleague D.

Professor Deakin’s report noted that the JRCALC guidelines recommended that a 12 lead ECG is undertaken for anyone with breathlessness, which in his opinion was present in Patient A’s case. He noted the Registrant’s earlier comment that they (the crew) realised they had not carried out an ECG after leaving the scene “due to the fact a nebuliser was given”. Professor Deakin stated he was not sure why use of a nebuliser would preclude an ECG. In his view, not having performed a 12 lead ECG was a clear breach of the JRCALC guidelines.

The Panel accepted the Registrant’s admission and the opinion of Professor Deakin in support of this particular and found it proved.

1(i) Did not take appropriate action in the presence of sepsis markers; Proved.

The facts of this particular were admitted by the Registrant.

The Panel accepted the finding of Professor Deakin in support of this particular. He noted that based on the EEAS investigation, four sepsis markers were present and were documented in the PCR: suspected infection; heart rate over 90; respiratory rate over 20 and Hyperglycaemia in the absence of diabetes (greater than 7.7mmol/l). The Report stated that these markers were not acted upon.

Professor Deakin observed that according to definition in the EEAS guidance, sepsis was present and the recommended action was to administer oxygen at 12-15l/min and prompt conveyance to hospital. Professor Deakin noted this guidance was not acted upon and no reason was given by the crew as to why they took actions which conflicted with this advice.

The Registrant said that she had the EEAS guidance in the form of the two-sided laminated card in her pocket and she referred to it, but only to one side. Based on this guidance, she told the Panel that she concluded that Patient A had simple sepsis as other factors indicating a more serious level were not present: Patient A was not unconscious, his skin was not mottled and he was able to answer questions. She accepted however that the markers of sepsis were present and the appropriate action was not taken.

The Panel was satisfied in the light of the evidence of Professor Deakin and the Registrant’s admission that this particular was proved.

1(j) Did not follow EEAS and/or JRCALC guidelines on the management of sepsis; Proved.

The facts of this particular were admitted by the Registrant. Her evidence was that she carried a summary of the EEAS guidance, in the form of a two-sided laminated card, in her pocket. She referred to only one side of this. She accepted that the JRCALC guidelines were applicable, but she did not refer to them.

Professor Deakin observed that the recommendations of the EEAS sepsis tool were not acted upon and no reason given.

Professor Deakin referred to the UK Ambulance Service JRCALC 2013 Clinical Practice Guidelines (the “JRCALC guidelines”) on the management of sepsis. These are national guidelines for the Paramedic profession and the relevant version was in place from 2013. These guidelines would have indicated urgent transfer to hospital in Patient A’s case and were not followed.

The Panel found this particular proved on the basis of the Registrant’s admission and the evidence of Professor Deakin.

1(k) Did not convey the patient to hospital, despite indication that sepsis was present; Proved.

The facts of this particular were admitted by the Registrant. She accepted that markers of sepsis were present and would indicate that the patient should be taken to hospital.

The Panel accepted the evidence of Professor Deakin in support of this particular. He noted that the EEAS screening tool advised prompt conveyance to hospital. He stated that the screening tool was not acted upon and no reason given. Further, the JRCALC guidelines 2013 were in force at the relevant time and stated that sepsis is a life-threatening condition which indicated a time critical transfer to hospital. Professor Deakin was critical of the decision that it was acceptable for Patient A to stay at home and not to be transferred to hospital as an emergency.

The Panel noted that there was a dispute between the accounts of the Registrant and Person B as to the circumstances of Patient A not being taken to hospital. Person B told the Panel that there was no discussion with herself and Patient A. She said that the crew established that she, Person B, intended to stay at home to look after Patient A. Person B said that the decision about not going to hospital was made and Patient A was not given an option. She and Patient A were told to seek help again if Patient A’s condition deteriorated in the next 24 hours. Person B said that Patient A was not averse to going to hospital again, he just wanted to receive treatment and feel better. They trusted the advice of the crew because they were the professionals.

The Registrant’s evidence was that a discussion took place with Patient A and Person B in the living room and she was sure the option to take him to hospital was there, but Patient A was not keen on going back to hospital. The Registrant said she would always offer the option to go to hospital. Patient A was advised to contact his GP if there was no improvement or to call 999 if his condition got worse. The Registrant said that she accepted that this advice had been wrong, but said she was not aware of that at the time. She did not consider the option of asking the GP to visit at home and this was not standard practice at that time.

The Panel concluded that the allegation did not require the Panel to resolve the different accounts on this issue, as the allegation was based on the presence of sepsis markers. The Registrant now admitted that those markers were present and that they indicated that the correct action was transfer to hospital. Based on the admission and the evidence of Professor Deakin, the Panel found this particular proved.

1(l) Did not complete the non-conveyance form or document in the records your reasons for non-conveyance; Proved.

The facts of this particular were admitted by the Registrant. Witness SB’s evidence was that he could not be sure whether there was a specific form in place at the time in question, although he believed a form had been introduced since. However, he stated that if there was no form, the non-conveyance should be recorded in the PCR together with the rationale for the decision.

The Registrant did not believe that a non-conveyance form was in use at the time, but she accepted that the discussion and decision on non-conveyance should have been documented in the patient record and that she had not completed this or ensured that it was done.

The Panel concluded that this particular was proved.

1(m) Did not make a complete and accurate written record of your findings; Proved.

The facts of this particular were admitted by the Registrant.

The Panel examined the PCR which was the contemporaneous record of the visit by the Registrant and Colleague D on 5 March 2014.

The Registrant accepted that she did not complete the PCR. This was done by Colleague D, the ECA. Person B told the Panel that she recalled Colleague D writing things down while the Registrant stood back and was talking.

The Registrant accepted that there were missing entries in relation to timings, observations post-nebulisation and reasons for non-conveyance of Patient A to hospital. She accepted that the pain scores had not been completed. The Registrant further accepted in cross-examination that there was no record of her conclusion that the first entry of oxygen saturations of 86% was an inaccurate reading. In questions from the Panel, she accepted that there was no record of her conclusion that simple sepsis was present.

The Registrant referred in cross examination to having “glanced” at the PCR completed by Colleague D. She said that as the lead clinician, she should have reviewed the record more closely and picked up on the missing issues.

The Panel noted and accepted the opinion of Professor Deakin in support of this particular. He acknowledged the finding of the EEAS investigation that the clinical documentation was incomplete and lacked key information, including timings of observations and detail in relation to history and progression of the illness. His conclusion was that the Registrant failed to make an accurate written record of the findings.

The Panel reviewed the evidence and accepted the admission of the Registrant. This particular was found proved.

Decision on Grounds

46. Ms Lykourgou provided written submissions and addressed the Panel. She reminded the Panel that it must determine whether the proven allegations amounted to either misconduct or lack of competence. She set out guidance from relevant legal authorities. She reminded the Panel of the opinion of Professor Deakin and the evidence of Person B, who had told the Panel of the trust she placed in the Registrant in relation to the decision not to take Patient A to hospital. Ms Lykourgou submitted that by virtue of the omissions in the Registrant’s treatment of Patient A, the Panel could find the conduct represented a serious falling short of the standards expected of her and amounted to misconduct.

47. Ms Lykourgou further submitted that although the allegations concerned one incident on a single day, the extent of the Registrant’s failings could be found to constitute lack of competence.

48. Mr Attenborough did not make further submissions on the statutory grounds. The Panel bore in mind the Registrant’s earlier admissions of misconduct in respect of particulars 1(f), 1(h), 1(i) 1(j) and 1(k) and of lack of competence in respect of particulars 1(c), 1(l) and 1(m).

49. The Panel accepted the advice of the Legal Assessor. It bore in mind that whether facts amount to misconduct or lack of competence is a matter for its own judgment.

50. The Panel first considered whether the proven facts amounted to misconduct or to lack of competence, given that the HCPC put the allegation in the alternative. The Panel took account of the guidance from the authorities drawn to its attention by the parties and the Legal Assessor as to the meanings of misconduct and lack of competence.

51. The matters found proved in the case of Patient A concerned serious failings by the Registrant in respect of care given to the patient over one day, 5 March 2014. The Panel was of the view that this conduct involved acts and omissions which fell far short of expected standards of the Paramedic profession and met the first category set out in the case of R (on the application of Remedy UK Ltd) v GMC [2010] EWCA Civ 1245, namely “sufficiently serious misconduct in the exercise of professional practice such that it can properly be described as misconduct going to fitness to practise”. The Panel concluded that all the factual particulars found proved were properly characterised as misconduct, rather than lack of competence.

52. The Registrant’s conduct on the day in question concerned aspects of basic paramedic practice, including taking of adequate patient history, physical examination, taking observations and recognising their significance, recognising the severity of conditions and responding appropriately, identifying “red flags” and referring a patient on for further treatment in hospital or by a GP where indicated. These matters were interlinked and all led to the most serious adverse outcome for Patient A and his family. These matters brought the profession into disrepute.

53. Whilst misconduct was a matter for the Panel’s own judgment, it also bore in mind the opinion of Professor Deakin, the HCPC’s expert witness, that the Registrant’s actions on this day fell far short of the standard expected.

54. In reaching its conclusions, the Panel considered that the Registrant’s actions breached the following paragraphs of the HCPC Standards of Conduct, Performance and Ethics (2012):


1. You must act in the best interests of service users.
8. You must effectively supervise tasks you have asked other people to carry out.
10. You must keep accurate records.

55. The Panel considered that the Registrant’s actions in the case of Patient A fell far short of the standards expected of a registered Paramedic and would be considered deplorable by fellow professionals. The Panel concluded that cumulatively the matters found proved fell far short of the standard expected and amounted to misconduct.

Decision on Impairment

56. The Registrant gave oral evidence in relation to the issue of current impairment.

57. The Registrant told the Panel that she has remained employed as a Paramedic at EEAS since 5 March 2014. In 2017, she moved to ECAT (Emergency Clinical Advice and Triage Centre). Her role at ECAT involves triaging all types of call, working through an assessment protocol and identifying red flags. All calls are monitored and audited on a weekly basis. The Registrant stated that the pass mark is 90% and she has passed all audits and her scores have been in the high nineties. The Registrant told the Panel she now also acts as a mentor for Paramedics joining ECAT.

58. Mr Attenborough took the Registrant through each of the issues raised by the proven factual particulars in turn. The Registrant accepted that her performance in each matter was below standard on that day. She explained how she deals with each of those issues when faced with them now and how her practice differs from her practice on 5 March 2014. The Registrant told the Panel that she believes she is a different and better Paramedic now. When asked about the risks of not responding to these types of issue appropriately, in each case she responded that it could be catastrophic for the patient. When asked by the Panel about her reflection on the wider impact of her actions beyond Patient A, the Registrant said she wants to provide better care for patients and their families so that the care she gives is of the standard she would want for herself and her own family.

Submissions

59. The Panel heard submissions from Ms Lykourgou on behalf of the HCPC and considered her written submissions. She submitted that the main issue for the Panel was insight and risk of repetition and in her submission, despite the admissions made by the Registrant in this case, there remained concerns about insight in the light of her continuing position in relation to the issues concerning failure to identify cyanosis and the significance of the 86% oxygen saturation reading. She submitted this may be an indicator that the Registrant is still impaired in relation to the personal component.

60. In relation to the public component, Ms Lykourgou submitted that the Registrant’s actions in respect of Patient A brought the profession into disrepute. In relation to the impact upon public confidence, Ms Lykourgou reminded the Panel of the impact upon Person B and the family members who had attended each day of the hearing and that public confidence would be undermined if the Registrant were not found to be impaired on the public component.

61. Mr Attenborough on behalf of the Registrant submitted that the incident of 2014 was an isolated episode in a 24-year career. Since 2014, the Registrant has been promoted to senior Paramedic in 2015 and then moved to ECAT in 2017 where she has practised to a high standard, as confirmed by the range of support from her managers at ECAT, from colleagues and patients. She is now tested in relation to her recordkeeping in regular audits. She deals with calls in which she takes histories and makes decisions and these calls are monitored.

62. In his submissions, Mr Attenborough referred to letters supportive of the Registrant’s standard of current practice at EEAS in the documents. These included letters from Dr Tom Davies, Medical Director for EEAS to the HCPC dated 23 November 2018 and from Sandra Treacher, EEAS Senior Operations Centres Manager – Clinical Services who is the Registrant’s line manager at ECAT. She describes the Registrant as “a highly skilled Paramedic and an outstanding Specialist Clinician in Hear and Treat”. She describes the Registrant’s audit results as first rate and that she is the “go to” clinician for mentoring new starters.

63. There were further supportive letters from Christopher Allen, Leading Operations Manager, Stephanie Woolley, a Senior Paramedic who has been mentored by the Registrant, Karen Powers, ECAT Team Leader, Steve Ferrant, Paramedic and Leading Operations Manager at Southend Ambulance Station and Liam Walker, Regional Clinical Co-Ordinator at ECAT. There were letters from a Hospital Ambulance Liaison Officer (Paramedic) and the Chief Operating Officer, both thanking the Registrant for examples of her work with patients.

64. Mr Attenborough submitted that the Registrant explained in her oral evidence how she has addressed each issue in the charges in her current practice. She has shown insight and at this hearing admitted the bulk of the charges. She has shown remorse and distress for the impact on Patient A’s family. Mr Attenborough submitted that the Registrant’s past misconduct is unlikely to be repeated and the Panel should find that she is not currently impaired in respect of either personal or public components of impairment of fitness to practise.

Panel decision on Impairment

65. The Panel accepted the advice of the Legal Assessor. The Panel referred to HCPTS Practice Note, Fitness to Practise Impairment (December 2019). The Panel bore in mind that its decision must address the critically important public policy issues of protecting service users, declaring and upholding proper standards of behaviour and the maintenance of public confidence in the Paramedic profession.

66. The Panel considered whether the Registrant’s fitness to practise is currently impaired in respect of the personal and/or public components of impairment. The Panel considered these questions in the light of all the information known to it. The Panel applied its own judgment and bore in mind that not every finding of misconduct will indicate that there is current impairment.

67. At this stage of the process, the Panel took into account the evidence presented on behalf of the Registrant in relation to the issue of current impairment, which included her further oral evidence, the 11-page bundle of letters speaking to her current performance and information from her employer in the main hearing bundle.

68. The Panel’s starting point was that the findings of misconduct in this case were serious. Whilst the outcome of the events of 5 March 2014 is not a determining factor in the Panel’s decision, it was right to recognise the tragic outcome for the late Patient A and the impact of these events on his partner, Person B, and his family, which Person B told the Panel is still felt today.

69. In considering the question of the personal component of current impairment, the Panel was of the view that the misconduct in this case was potentially remediable. The Panel must consider whether there was evidence that the conduct had been remedied and was highly unlikely to be repeated. The Panel considered the oral evidence of the Registrant in relation to impairment and also considered the information presented within the hearing papers.

70. The Panel inevitably had to take into account that 7 years have now passed since the events in 2014. It has heard and seen evidence that in that time, the Registrant has practised as a Paramedic safely and without further adverse incident. The Registrant has remained in her employment with the same Trust by whom she was employed at the time of the incident. She has now moved to a different area, ECAT, and has progressed to a more senior role. She has had the support of the Trust throughout this time and is held in good standing by her employer. The Panel noted a letter from Dr Tom Davies, Medical Director at EEAS to the HCPC dated 23 November 2018 which referred to the supportive comments of her line manager and confirmed that the Registrant had remained working at EEAS since 2014 without any concerns as to her ability to practise as an HCPC registered Paramedic. The Registrant has produced letters of support from a number of senior managers speaking to her performance in the years following the case of Patient A.

71. The Panel saw evidence of the remedial work the Registrant undertook in the aftermath of these events which was set out in a letter dated 23 December 2015 from Tracy Nicholls, Head of Clinical Quality, to HM Coroner responding to the recommendation in relation to effective training of ambulance staff following the inquest into the death of Patient A. The letter referred to the Registrant having undergone a period of supervision and mentorship and her attendance upon a patient with sepsis markers when she was able to recognise the signs and use the sepsis screening tool appropriately.

72. The Registrant told the Panel in evidence how her practice has changed and improved. She explained how she has addressed the issues raised in the case, for example she referred to two occasions when she dealt with cases concerning the management of sepsis and provided a letter commending her actions.

73. The Registrant has told the Panel that she undertakes regular training in her current role at ECAT. Her work is subject to regular audits, as confirmed by the evidence of Sandra Treacher. These have a pass rate of 90%. No issues of concern have been identified and the Registrant has performed well in these audits.

74. In relation to the personal component of current impairment, the Panel was mindful that a registrant’s insight into their past acts or omissions is a critical factor, as it relates to the risk of future repetition. The Panel concluded that the Registrant has demonstrated remorse and has now acknowledged her past failings. She has engaged with the HCPC process and answered the allegations. She made a number of admissions to the allegations and made further admissions during the course of the hearing. Whilst Ms Lykourgou submitted there may be a concern over the Registrant maintaining her denial of the issues in the allegations concerning observation of cyanosis and recognising the significance of the oxygen saturations readings, the Panel is mindful (as per the case of Vali v GOC [2011] EWHC 310) that this does not necessarily equate to lack of insight. The Panel was satisfied that in her oral evidence the Registrant addressed what she has learnt about these issues and how she addresses them in her current practice.

75. The Panel was satisfied that the Registrant has taken remedial action and that over the last seven years, she has developed sufficient insight as a result of these events such that it is unlikely that her past actions will be repeated or that she poses a risk to patients in the future. The Panel did not find the Registrant’s fitness to practise impaired in respect of the personal competent of current impairment.

76. In respect of the public component, the Panel considered the need to protect service users, the maintenance of professional standards and public confidence in the Paramedic profession. The Panel did not find that the need to protect service users was engaged in this case, given its decision in respect of the personal component. It was satisfied that the Registrant has demonstrated that she has remedied her past clinical deficiencies over the last seven years.

77. The Panel did however consider that the second and third elements of the public component were engaged. Considering the guidance in the case of CHRE v NMC and Paula Grant [2011] EWHC 927 (Admin), and the HCPTS Practice Note, the Panel was mindful that it must take account of the wider public interest considerations.

78. Despite the passage of time, the Panel took the view that there has been an impact on the maintenance of professional standards and on public confidence in the Paramedic profession and the HCPC’s regulatory process. The Registrant’s actions brought the profession into disrepute. The Panel were concerned that when asked by the Panel, the Registrant showed limited awareness as to how this incident may have damaged the confidence of the public in the profession.

79. The Panel concluded that members of the public well informed of the circumstances of this case would be seriously concerned if the fitness to practise of the Registrant were not found to be currently impaired. The Panel concluded that public confidence in the profession and the regulatory process would be undermined if a finding of impairment were not made in this case. The Panel therefore concluded that the Registrant’s fitness to practise is currently impaired in respect of the public component of current impairment.

Decision on Sanction

Application to hear mitigation evidence in private

80. Mr Attenborough made an application for the next part of the hearing to take place in private. He intended to call the Registrant to give evidence at the mitigation stage and indicated that her evidence would concern matters relating to her private life which he submitted should be considered in private session.

81. Ms Lykourgou indicated an objection on the basis that Person B and members of Patient A’s family had attended throughout the hearing and may wish to hear all the evidence at the mitigation stage.


82. The Panel received and accepted the advice of the Legal Assessor. The Panel was reminded of the provisions of Rule 10(1)(a) of the Conduct and Competence Committee (Procedure) Rules 2003.The Panel was mindful of the important principle that HCPTS hearings take place in public in the interests of openness and transparency. That is the default position. However, the rule permitted the hearing or part of it to exclude members of the public on the grounds of the interest of justice, or for the protection of the private life of the Registrant. The Panel considered that on the latter ground, evidence relating to the Registrant’s private life should be given in private session. The remainder of the mitigation stage of the hearing would be held in public.

The Registrant’s evidence

IN PRIVATE

83. [REDACTED]
84. [REDACTED]

IN PUBLIC

85. The Registrant said she was 17 when she joined the RAF. She had no skills beyond those she had gained as a Paramedic and not being able to practise was therefore significant.
Submissions on sanction

86. Ms Lykourgou addressed the Panel in relation to sanction and provided written submissions. She referred to the devastating impact of these events on Person B and family members of Patient A and she read paragraphs from Person B’s witness statement in which she explained the lasting impact.

87. Ms Lykourgou said that the HCPC still had concerns as to the Registrant’s insight and remorse in relation to impact on Patient A’s family and on the Paramedic profession and public confidence.

88. Ms Lykourgou proposed the Panel should consider sanctions at the higher level in this case and referred to conditions, a suspension or striking off. She referred to the guidance in the HCPTS Sanctions Policy on those sanctions. She submitted that the HCPC’s position is that this matter is so serious that all options should be considered to ensure public confidence in the profession is maintained.

89. Mr Attenborough submitted that the Sanctions Policy required the Panel to strike a balance between the competing interests of the Registrant and the HCPC’s overriding objective to protect the public. The decision must deal with the concerns raised but be fair, just and reasonable.

90. Mr Attenborough reminded the Panel of the mitigating factors in the Registrant’s case. He addressed the Panel on the sanction options and submitted that striking off was disproportionate and proposed that the Panel could consider lesser sanction options.

Panel decision on sanction

91. The Panel received and accepted the advice of the Legal Assessor. The Panel referred to the HCPC’s Sanctions Policy (March 2019) (“the Sanctions Policy”) and applied it to the Registrant’s case on its own facts and circumstances.

92. In considering the question of sanction in this case, the Panel was mindful that as stated in the Sanction Guidance (paragraph 10), the primary purpose of a sanction is to protect the public and the considerations in reaching this judgment are:

- Any risk the Registrant might pose to those who use or need their services;
- The deterrent effect on other registrants
- Public confidence in the profession concerned
- Public confidence in the regulatory process.

93. The purpose of a sanction is not to be punitive, though a sanction may have a punitive effect.

94. The Panel understood that it was required to take a proportionate approach in considering sanction. It referred to the guidance in the Sanctions Policy which indicates that a panel is required to strike a balance between the competing interests of the Registrant and the HCPC’s overriding objective to protect the public. The decision must deal with the concerns raised but be fair just and reasonable (paragraph 20).

95. The starting point for the Panel was that its finding against the Registrant in this case arose from a very serious incident on 5 March 2014. The Panel has recognised throughout its consideration of the case the continuing impact of these events on Person B and Patient A’s family.

96. The Panel has found that the remedial action the Registrant has taken in the last seven years during which she has continued to practise as a Paramedic safely, without further adverse incident and with the support of her employer, has been sufficient to address the personal component of current impairment and the Panel was satisfied there is not a risk of repetition of the past misconduct. The Panel’s finding of current impairment is in relation to the public component of impairment, that is the impact of the Registrant’s past conduct on the maintenance of professional standards and of public confidence in the Paramedic profession.

97. The Panel proceeded to identify the mitigating and aggravating factors present in the case. The Panel identified the following mitigating factors:

  • The Registrant has engaged in the HCPC regulatory process;
  • The Registrant has not been the subject of any HCPC regulatory findings prior to these events or since;
  • The matters found proved related to a single episode of care on one day;
  • Admissions were made to the majority of the factual allegations for the purposes of this hearing and misconduct was not contested;
  • The Panel had heard mitigation evidence relating to the Registrant’s personal circumstances. The Panel gave limited weight to this, bearing in mind the guidance in the Sanctions Policy that matters of mitigation are likely to be of considerably less significance in regulatory proceedings where the overarching concerns is the protection of the public (paragraph 25).
  • The Registrant has demonstrated that she has insight, has undertaken remediation of the concerns and has shown remorse.

The Panel identified the following aggravating factors:

  • The harm caused by the events relating to Patient A, the impact on Person B and Patient A’s family and the impact on public confidence in the Paramedic profession (paragraph 54 of the Sanctions Policy).

98. The Panel considered the issue of sanction referring to Sanctions Policy. The Panel took a proportionate approach and considered the available sanctions in ascending order of seriousness:

Mediation
This was not appropriate, as the matter was too serious to be addressed by means of mediation.

No Further Action
Given the risk to the public interest, public confidence in the profession and in the HCPC’s regulatory process, and the need to recognise the impact of these matters upon public confidence, the Panel concluded the matter was too serious for no further action to be appropriate.

Caution
The Panel considered the factors indicating that a Caution Order may be appropriate. In the circumstances of this case the Panel considered this may be the appropriate sanction but it proceeded to consider the further options.

Conditions of Practice Order
The Panel did not consider this was a case in which conditions of practice were appropriate. Given the Registrant’s satisfactory practice since the events and remedial steps taken with the support of her employer during that period, the Panel did not see conditions of practice as appropriate or workable. The Panel did not consider that conditions could be formulated which could address the public interest issues.

Suspension
The Panel carefully considered whether a period of suspension would be an appropriate response in this case. In so doing, the Panel referred to the HCPC Sanctions Policy as to when a suspension order is appropriate, at paragraph 121. The Panel concluded that whilst the factors identified there are present in this case, the Panel was of the view that to impose a period of suspension would be disproportionate in this case. It would in the Panel’s view not serve the public interest to suspend a useful Paramedic given that the Registrant has practised safely with the full support of her employer since 2014. The Panel concluded that a Suspension Order would not be appropriate and would be disproportionate.

The Panel went on to consider whether the ultimate sanction, a striking off order, was required in this case. It was mindful that this is the sanction of last resort. For the avoidance of doubt, the Panel also concluded that a striking off order would be disproportionate in this case.

99. In reaching its decision on sanction in the light of the above, the Panel noted the guidance at paragraph 102 of the Sanctions Policy that a Caution Order should be considered in cases where the nature of the allegations means that meaningful practice restrictions cannot be imposed, but a Suspension Order would be disproportionate. The Panel has concluded that this is such a case.

100. The Panel bore in mind that a Caution Order will appear on the HCPC Register but will not restrict the Registrant’s ability to practise. The Caution Order may be taken into account if a further allegation is made against the Registrant.

101. The Panel considered the appropriate duration for the Caution Order. It concluded that a period of two years would address public confidence in the circumstances of this case, would protect the public interest and demonstrate the seriousness of the matter to the profession and the public.

102. The Panel’s decision therefore was to impose a Caution Order for a period of two years.

 

Order

ORDER: That the Registrar is directed to annotate the register entry of Mrs Emma Stevens with a caution which is to remain on the register for a period of 2 year(s) 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.

Hearing History

History of Hearings for Mrs Emma Stevens

Date Panel Hearing type Outcomes / Status
08/03/2021 Conduct and Competence Committee Final Hearing Caution