Ms Margaux Ducker

Preliminary Matters

Service

1.     The Panel finds proper service by notice dated 6 October 2021 sent to the Registrant’s registered address by email. The Panel was satisfied that the Registrant had received the notice of hearing and that the Rules on service were complied with. The notice of hearing informed the Registrant that this review of the current Order would take place today by video conference.

2.     The Registrant has stated by email dated 17 October 2021 that she will not be attending the hearing, she has not practised since 2018 and has no intention of returning to Paramedic practice. This has been confirmed in a telephone call made to her by the HCPC on 4 November 2021.

Proceeding in the absence of the Registrant

3.     On behalf of the HCPC, Mr D’Alton asked the Panel to proceed in the absence of the Registrant under Rule 11 of the Procedure Rules and to take into account the HCPTS Practice Note on Proceeding in the Absence of the Registrant. He submitted that it was in the public interest for this statutory review hearing to proceed. The Panel must balance the overriding interest of public protection with fairness to the Registrant.

4.     The Panel concluded it was in the public interest to proceed in the absence of the Registrant, has considered the HCPC Practice Note, and taken the Legal Assessor’s advice. There is a burden on a registrant to engage with their regulator and the Registrant is aware of the hearing today. There is a statutory requirement for the Order to be reviewed before it expires, on 3 December. The Registrant has voluntarily chosen not to attend today’s hearing and it is not likely that the Registrant would participate in these proceedings on a future date if this hearing is adjourned. There has been no request for an adjournment and it is appropriate to proceed in the absence of the Registrant.

Background

5.     This is a Review Hearing under Article 30 (1) of the Health Professions Order 2001, which requires the review of a substantive order prior to its expiry.

6.     The Registrant was formerly employed as a Clinical Adviser by iHeart, part of the Barnsley Healthcare Federation (the Federation). iHeart is a triage and referral service that provided extended access to General Practitioner (GP) appointments in Barnsley.

7.     On 16 July 2018 LJ, an Advanced Nurse Practitioner, also undertaking the role of a Clinical Adviser for the Federation, overheard the Registrant on a call with a service user. LJ was concerned that the Registrant had allegedly told the service user that no appointments were available, without undertaking an appropriate triage of the presenting complaint.

8.     LJ reported her concerns to the Registrant’s line manager SC as she did not consider that the Registrant had safely dealt with the caller. SC undertook a review of the call, and also reviewed a number of other calls taken by the Registrant on 16 July, and 2 calls that had been handled by the Registrant on 30 May 2018. The Registrant had incorrectly told callers that appointments were not available and she had failed to triage patients appropriately.

9.     The Registrant did not contest the factual allegations at the final hearing but pointed to a number of extenuating circumstances and reasons for her actions. The Panel did not find a lack of competence and noted the Registrant did complete a Triage training course. The Registrant did not lack the necessary skills to appropriately triage patients; but she had not carried out the basics of triage as she had told the callers no appointments were available.

10. The original panel did not consider particular 1(b)ii to amount to misconduct. The Registrant ought to have checked whether the patient was able to attend hospital unassisted, but there was nothing in the call to suggest Patient B was unable to do so, as he had indicated he had attended the hospital and his own doctor that day.

11. The Panel considered that the Registrant’s failure to appropriately triage patients was a serious falling short of the standards expected of a registered Paramedic. It was a basic requirement of the Registrant’s role to assess the needs of callers and ensure they were safe.

12. The failure to triage appropriately meant that the Registrant was unable to determine whether these patients were safe to wait until they could be seen face to face. Advice was given without taking an appropriate history and therefore did not take account of the full medical needs of the patients.

13. The failure of the Registrant to triage the patients placed them at serious risk of harm and amounted to misconduct. The Registrant’s conduct, in dishonestly telling patients that no appointments were available, was serious misconduct and was behaviour which fellow practitioners would find deplorable. The Registrant’s actions had the potential to place those patients at serious risk of harm. The effect of her conduct was that those patients were unnecessarily kept waiting to be triaged. This could have resulted in a deterioration in their condition.

14. The Registrant’s actions had the potential to place pressure on other healthcare professionals to deal with these patients. She had breached Standards 1,2,6,9 and 10 of the HCPC’s Standards of Conduct, Performance and Ethics and Standards 1,2,4,8 and 10 of the HCPC’s Standards of Proficiency for Paramedics. The facts found proved involved serious and wide-ranging failures including dishonestly telling patients that no appointments were available. This was serious misconduct and was behaviour which fellow practitioners would find deplorable.

15. The Panel went on to find the Registrant’s fitness to practise was currently impaired by reason of that misconduct. The Registrant had dishonestly told patients that no appointments were available and had failed to triage them appropriately, which placed them at risk of harm and the Registrant’s misconduct had breached key HCPC Standards. She had brought the profession into disrepute and had undermined confidence in the profession.

16. The Registrant had been working in an environment that had been subject to significant change. Her dishonesty, in telling patients there were no appointments on one shift during a short period had to be viewed in the context of her unusually stressful working environment.

17. The Registrant was developing insight into the seriousness of her misconduct, the impact on patients and the profession. She accepted that her handling of the calls fell below the standard expected and apologised for her misconduct. The Registrant was a good clinical practitioner and with the development of meaningful insight, the Registrant’s misconduct was remediable. The Registrant was unlikely to repeat her dishonest conduct but there remained a risk that the Registrant would repeat other matters of the kind found proved. The finding of impairment on public protection grounds was required.

18. In addition, there was a finding of impairment on public interest grounds. The public expects professionals to be honest and truthful when giving information and would be concerned by the Registrant’s misconduct. Furthermore, the need to maintain public confidence in the profession, and to declare and uphold proper standards, would be undermined, if a finding of impairment of fitness to practise was not made on public interest grounds.

19. The Panel identified the following aggravating factors: The Registrant's conduct put patients at risk of harm. The Registrant’s conduct involved multiple patients on two separate occasions. The Registrant has not demonstrated remediation.

20. The following mitigating factors were identified, by the original panel: The Registrant admitted her conduct fell below the standard required. The Registrant was working in a particularly difficult environment at the time of the misconduct. The Registrant had apologised and expressed genuine remorse. The Registrant had developing insight, had engaged, and cooperated fully with the HCPC throughout this process.

21. The options of taking no further action, or mediation, were not appropriate or proportionate. In view of the findings made in relation to impairment and the need to uphold proper professional standards, the Panel concluded that a Caution Order would not be appropriate to address the misconduct and would not provide sufficient public protection.

22. The Panel considered a Conditions of Practice Order was appropriate, based on the factors in paragraph 106 of the Sanctions Policy, because the Registrant had sufficient insight, the conduct was capable of remedy and it was possible to formulate appropriate and workable conditions.

23. The dishonesty found in this case was closely linked to the clinical working environment. The dishonesty occurred during one shift, over a short period, was isolated and out of character. A suspension would be disproportionate. A Conditions of Practice Order would allow the Registrant to return to practice with conditions. The reviewing Panel would be assisted by the Registrant attending the review hearing, providing details of the steps she has taken to comply with the Conditions of Practice, and a reflective statement that addresses the concerns found.

Submissions by the HCPC

24. Mr D’Alton summarised the background of the case as recorded in the decision of the previous panel. The HCPC position was that the Registrant’s fitness to practise was still impaired on the public and personal components. There was insufficient evidence of insight and the Registrant’s misconduct including dishonesty posed a serious risk to patients. There were mitigating factors such as her stressful workplace but the risk of repetition remains.

25. The previous panel gave guidance on steps the Registrant could take to assist this Panel, including a need for future engagement. However, she states she does not intend to return, in the future, to Paramedic practice, as explained in her written statement read to the Panel by Mr D’Alton.

26. There is an obligation upon the Registrant to address the concerns raised but she has failed to do so, suggesting her fitness to practise is still impaired. As is noted in the relevant Practice Note the reviewing Panel’s task: “is to consider whether all the concerns raised in the original finding of impairment...[have] been sufficiently addressed.

27. The decision in Abrahaem v GMC [2008] EWHC 183 (Admin) states there is a “persuasive burden” on the Registrant to demonstrate at a review hearing that he or she has fully acknowledged the deficiencies which led to the original finding and has addressed that impairment sufficiently “through insight, application, education, supervision or other achievement...”

28. All sanction options are open to the Panel including a Striking-Off Order. However, any sanction should not be disproportionate or overly punitive. In the HCPC’s telephone conversation with the Registrant on 4 November 2021, she stated that she accepts the allegation and wishes to be removed from the HCPC Register. There is according to the HCPC the possibility of a Voluntary Removal in this case but that requires further investigation. Therefore the most appropriate disposal today would be a Suspension Order.

Legal Assessor’s advice

29. The Legal Assessor advised that the Panel is dealing with a Review under Article 30(1) of the Health Professions Order 2001 and should take into account the HCPTS Practice Note: Review of Article 30 Sanction Orders.

30. Article 30(1) provides that a Conditions of Practice Order or Suspension Order must be reviewed before it expires and that the reviewing Panel may: extend, or further extend the period for which the order has effect; make an order which could have been made when the order being reviewed was made; or, replace a Suspension Order with a Conditions of Practice Order.

31. Any order made following an Article 30(1) review only takes effect from the date on which the order under review expires, so the Registrant must continue to comply with the expiring order until then.

32. The review process is not a mechanism for appealing against or ‘going behind’ the original finding that the Registrant’s fitness to practise is impaired. The purpose of review is to consider if the Registrant’s fitness to practise remains impaired; and, if so, whether the existing order or another order needs to be in place to protect the public. The key issue which needs to be addressed is what, if anything, has changed since the current order was made.

33. The factors to be taken into account include: the steps which the Registrant has taken to address any specific failings or other issues identified in the previous decision; the degree of insight shown and whether this has changed; the steps which the Registrant has taken to maintain or improve his or her professional knowledge and skills; whether any other fitness to practise issues have arisen; whether the Registrant has complied with the existing Order.

34. The decision reached must be proportionate, striking a fair balance between interfering with the Registrant’s ability to practise and the overarching objective of public protection. Given that part of the Panel’s task is to assess whether the fitness to practise of the Registrant remains impaired, the Panel should also take into account the HCPTS Practice Note on Finding Impairment and the HCPC Sanction Policy.

Decision

35.     The Panel accepted the advice of the Legal Assessor. The Registrant has not complied with the suggestions of the previous panel as to what may be helpful steps to take in respect of the review hearing. The comments made by the original panel make clear that this is not a case in which the Registrant has no insight.

36.     However, there is a persuasive burden on her to demonstrate to a reviewing Panel that she has taken steps to develop her insight, by further reflection and to remediate her misconduct. There is no evidence of any material change in the Registrant’s circumstances and she has requested removal from the HCPC Register.

37.     The Panel has concluded that the Registrant’s fitness to practise still remains impaired on personal component grounds. That is because the Registrant has not taken steps to develop sufficient insight or remedy her conduct to address the previous panel’s finding of impairment. There would be a risk of repetition if the Registrant decided to resume working.

38.     The Panel has also concluded that the Registrant’s fitness to practise still remains impaired on public component grounds. That is because members of the public would not have confidence in the profession or this regulatory process, if the Registrant’s ability to practise was not restricted. The failure to triage patients properly created an obvious risk of harm and no steps to remediate her misconduct, have been taken by the Registrant.

39.     In considering the available sanctions today, the Panel considered the options in ascending order of gravity in accordance with the HCPC Sanctions Policy.

40.     The serious nature of the misconduct means that it is not appropriate or proportionate to take no further action or to impose a Caution Order. The Panel went on to consider a further Conditions of Practice Order. However, the Registrant has not engaged with the current conditions and she is not working as a Paramedic. Therefore it is no longer possible to identify workable and effective conditions. Another Conditions of Practice Order is therefore not appropriate.

41.     The Registrant’s misconduct was a serious breach of the HCPC Standards of Conduct Performance and Ethics. However, the previous panel found that she had demonstrated some insight and that there were significant mitigating circumstances suggesting her misconduct was remediable.

42.     The Panel has decided that a Suspension Order for 12 months is appropriate to enable the Registrant to agree to be voluntarily removed from the HCPC Register and for that process to be completed; or to demonstrate further insight and remediation in respect of her misconduct.

43.     Accordingly, the Panel imposes a Suspension Order for 12 months. This is the least punitive sanction which the Panel could have imposed, in accordance with the HCPC Sanctions Policy. The Panel has also decided that this is the fairest outcome balancing the Registrant’s interests and the public interest.

44. To impose a Striking-off Order today would be unduly punitive and disproportionate, in all the circumstances. A suspension for 12 months will provide sufficient time to complete a Voluntary Removal Agreement or for the Registrant to take steps to remediate her misconduct. Unless in the interim period there has been a Voluntary Removal of the Registrant from the Register, today’s Suspension Order will be reviewed, before it expires, and if no steps have been taken by Registrant to reflect and develop her insight and remediation the next reviewing panel is likely to impose a Striking-off Order.

45. The Registrant will be subject to a Suspension Order for 12 months effective from the expiry of the current Conditions of Practice Order.

Order: The Registrar to directed to suspend the Registration of Ms Margaux Ducker for a period of 12 months, upon the expiry of the existing order. 

The Order imposed today will apply from 3 December 2021.

History of Hearings for Ms Margaux Ducker