John W Williams

Profession: Paramedic

Registration Number: PA39245

Hearing Type: Review Hearing

Date and Time of hearing: 10:00 28/09/2021 End: 17:00 28/09/2021

Location: Virtual Hearing

Panel: Conduct and Competence Committee
Outcome: Conditions of Practice

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Allegation

During the course of your employment as a Paramedic with South Central Ambulance Service between March 2016 and July 2016 you;

1)       On or around 26 March 2016, attended patient 1 and;

a.    did not complete a primary survey;

b.    did not immediately provide them with oxygen following a below normal oxygen saturation reading.

2)       On or around 31 May 2016, attended patient 2 and;

a.    did not assess the patient’s injury at all, or until prompted to do so, in that you did not:

i.     expose their foot and ankle;

ii.    assess the colour of their foot;

iii.   assess the temperature of their foot;

iv.  assess their pedal pulse;

b.    did not recognise it was a potentially ‘time critical’ incident.

3)       On or around 31 May 2016, attended patient 3 and;

a.    discharged the patient on scene without understanding the nature of their condition;

b.    did not request any assistance in regards to understanding the patient’s condition.

4)       On or around 31 May 2016, attended patient 4 and were unaware of the possible consequences of an Amitriptyline overdose.

5)       On or around 31 May 2016, when questioned by a clinical mentor, were unable to confirm the signs and/or symptoms of a Diazepam overdose.

6)       On or around 30 May 2016, attended patient 5 and did not question the patient regarding sporadic incontinence at all, or until prompted to do so.

7)       On or around 30 May 2016, attended patient 6 and;

a.    did not feel for a radial pulse;

b.    did not understand the patient’s ECG readings, in that you were unable to confirm if the patient was in normal sinus rhythm or not.

8)       On or around 1 July 2016, attended patient 8 and;

a.    did not carry out a visual inspection of their airway;

b.    did not position the patient correctly in order to undertake an abdominal assessment;

c.    did not offer the patient pain relief until prompted to do so;

d.    were unable to identify a potential differential diagnosis.

e.    did not assess Patient 8’s respiratory rate.

9)       On or around 1 July 2016 attended patient 9 and;

a.    did not undertake an ECG during the secondary survey;

b.    did not offer the patient pain relief until prompted to do so;

c.    did not identify an appropriate disposition plan.

10)   On or around 2 July 2016, attended patient 10 and;

a.    Did not carry out a visual inspection of their airway;

b.    did not obtain a respiratory rate;

c.    did not question the patient in order to identify red flags relating to back pain, until prompted to do so;

d.    did   not    communicate   the    side    effects    of    Morphine    before administration to the patient;

e.    before administering a second dose of Morphine failed to check the following until prompted to do so:

a)     Pulse;

b)     Respiratory rate;

c)      Blood pressure;

f.     did not identify air in the syringe which you were about to use to administer Morphine.

11)   On or around 2 July 2016, attended patient 11 and;

a.    did not complete a primary survey;

b.    proposed a plan which would have delayed conveying the patient to hospital had a colleague not intervened;

c.    did not provide them with oxygen therapy.

12)   On or around 4 July 2016, attended patient 12 and did not take the lead in completing the primary survey.

13)   Did not consistently demonstrated effective communication skills when:

a.    Communicating your decisions to patients;

b.    Delegating tasks to other crew members.

14)   The matters as set out in paragraphs 1-13 constitute a lack of competence.

15)   By reason of this lack of competence your fitness to practise as a Paramedic is impaired.

Finding

Background

1. The Registrant is a registered paramedic who commenced employment as a Band 5 Paramedic at South Central Ambulance Service (SCAS) in January 2016.

2. The Registrant self-referred to the HCPC by email on 5 August 2016.

3. As a Newly Qualified Paramedic (NQP), the Registrant was required to participate in the “Preceptorship Programme”, which required a number of shifts to be worked with a clinical mentor. In March 2016, the Registrant's mentor attended a selection of call-outs with the Registrant. Concerns were raised which resulted firstly in the implementation of a formal action plan before a formal capability progress was commenced. During this time, further concerns were reported regarding the Registrant’s performance.

4. The totality of the existing concerns are now reflected in the Particulars of the Allegation set out above. These primarily relate to clinical assessment skills.

5. The matter was first referred to the Investigating Committee Panel ("ICP") on 17 February 2017, who determined that there was a case to answer. Following this decision, the investigation continued and the matter was returned to the ICP on 22 September 2017, which determined that there was a case to answer in relation to further particulars which had been put forward. On 17 July 2018, a preliminary hearing was held in which a panel of the Conduct and Competence Committee allowed proposed amendments to the Allegation.

6. On 29 June 2018, the Registrant's representative wrote to the HCPC suggesting that the matter could be resolved by means of a Consent Order. The letter set out the case that the Registrant did not deny the HCPC allegations and accepted that he was not practising at the level required of a NQP when initially employed by SCAS. The letter also indicated that the Registrant had voluntarily stepped down from his role as a paramedic to work as an Emergency Care Assistant (ECA) with SCAS. He had been in this role for 20 months and had gained sufficient patient exposure and practical experience to commence independent practice as a NQP. Conditions of Practice involving supervision were suggested as the appropriate outcome. This was confirmed by the Registrant’s representative in an email dated 18 July 2018. The HCPC decided that disposal by consent by way of Conditions of Practice was suitable.

The Decision of the First Panel

7. On 5 February 2019, a panel of the Conduct and Competence Committee considered a joint application by the HCPC and the Registrant that the case be disposed of by consent by a Conditions of Practice Order on agreed terms.

8. In its determination on 5 February 2019, the first panel stated as follows:

“… The Panel took account of the content of the e-mails sent by the Registrant’s legal representative, including an email dated 29 June 2018 which confirmed that the Registrant had voluntarily stepped down from his role as a Paramedic to work as an Emergency Care Assistant and had been successfully working in that role for the past 20 months. The email confirmed that his work had gone very well and he had now gained the correct level of patient exposure and practical experience required to commence independent practice as a NQP. His supervisors in the Ambulance Trust now considered that he is fit to recommence work as a paramedic.


...The Panel also took into account an undated letter from the South Central Ambulance Service NHS Foundation Trust which confirmed that the Registrant’s job offer was subject to normal standard conditions and that all NQPs would be given front loaded shifts with more senior clinically trained staff along with advice lines in accordance with the national NQP standards. The letter confirmed that the concerns which had been raised with the HCPC had been addressed to their satisfaction and that the Registrant now meets the standard that is required to work as a NQP.


... The Panel was satisfied that there was potential for a finding of impairment in this case on both public protection and public interest grounds as a result of the Registrant’s lack of competence.


... Nevertheless, the Panel was satisfied that the Registrant had demonstrated insight into the matters which led to the making of allegations, and had engaged in the fitness to practise process. The Panel was satisfied that the public would be adequately protected by such an order and that such an order was proportionate in the circumstances. The Panel was also satisfied that public confidence in the profession and the regulator would be maintained by the making of such an order. The order was proportionate in the circumstances, and the conditions of practice were workable, as confirmed by correspondence with the Registrant's employer, South Central Ambulance Service NHS Foundation Trust.


... Accordingly, the Panel approves a Consent Order imposing a Conditions of Practice Order of one year’s duration in the terms set out below.

Order:

That the Registrar be directed to annotate the Register to show that for a period of 1 year from the date that this Order comes into effect (the Operative Date), you, John W Williams, must comply with the following conditions of practice:

1. You must place yourself and remain under the supervision of a workplace supervisor, registered by the HCPC or other appropriate statutory regulator and supply details of your supervisor to the HCPC within one month of recommencing work as a Paramedic. You must attend upon that supervisor as required and follow their advice and recommendations.

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

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

4. You must inform the following parties that your registration is subject to these conditions:

A. any organisation or person employing or contracting with you to undertake professional work;

B. any agency you are registered with or apply to be registered with (at the time of application); and

C. any prospective employer (at the time of your application).

5. You must work with your supervisor to formulate a Personal Development Plan designed to monitor and address any deficiencies in the following areas of your practice:
a) Undertaking assessments
b) Communicating effectively with colleagues and patients

6. Within three months of starting work as a Paramedic you must forward 16 a copy of your Personal Development Plan to the HCPC.

7. You must meet with your supervisor on a monthly basis to consider your progress towards achieving the aims set out in your Personal Development Plan.

8. You must allow your supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan.”

The Two Subsequent Reviews

9. The Conditions of Practice Order was first reviewed on 7 January 2020 at a hearing at which the Registrant was represented by Counsel. In the period since the Order had been made, the Registrant had been unable to find employment as a Paramedic and hence had been unable to make progress in remedying his professional shortcomings. The second panel decided that the Registrant’s fitness to practise remained impaired and directed that the Conditions of Practice Order remain in place for a further 12 months.

10. The Order was next reviewed on 8 January 2021 at a hearing attended by the Registrant and Counsel acting on his behalf. The Registrant gave oral evidence and produced documents relevant to his fitness to practise. He informed that panel that he had recommenced work as a Paramedic with SCAS on 21 September 2020 and had complied with the Conditions of Practice, having provided the HCPC with the name and details of his supervisor at SCAS, namely KH, working under her supervision. He had also formulated the Personal Development Plan (PDP) required. In its determination, the second reviewing panel stated as follows:


“… The Panel found the Registrant to be candid and genuine when giving his evidence and found the Registrant’s responses to questions were honest. The Panel noted that the Registrant had complied with the conditions imposed on his registration and was also of the view that the Registrant demonstrated further insight into his failings. The Panel was encouraged that the Registrant had successfully gained employment as a Paramedic with SCAS in September 2020, and commended the Registrant for engaging with the regulatory proceedings, attending the hearing and providing the documents contained with his bundle, to it.


… However, whilst the Panel recognised that the regulatory process had been a salutary one for the Registrant and he had demonstrated some improvements, the Panel remained concerned by the evidence before it, which clearly demonstrated that the Registrant was unable to show a sustained and continued improvement in his practice, notwithstanding the supervision in place to support him. In particular, the Panel noted that the Registrant accepted a drop in his performance in December 2020, only two months into his new role. Further, the Panel had regard to the testimonial letter provided by his colleague Ms C, in which she noted a significant improvement in the Registrant’s practice further to concerns raised in 2016. However, she qualified this by stating ‘I feel that if John is supported well and continues to develop his knowledge and assessment skills that he will be a safe clinician’.


…. The Panel noted that whilst the Registrant had complied with the conditions of practice and had provided a PDP, which he had formulated with his supervisor, the PDP provided contained no evidence relating to outcomes or his progress. Consequently, the Panel remained concerned regarding the lack of evidence relating to the Registrant undertaking assessments and communicating effectively with colleagues and patients, areas of concern raised in respect of the Registrant’s competence to practice as a Paramedic. Further, whilst the Panel noted the Registrant’s evidence regarding his omissions on the ePRF [electronic Patient Report Form], the documents were not before the Panel for it to consider.”

11. That panel decided that the Registrant’s fitness to practise remained impaired. It decided that a further period of conditional registration was appropriate for a further nine months and added that:


“… a review panel may be assisted by the following:


i. his attendance at any future review hearing;


ii. references from his supervisors addressing his progress against his PDP;


iii. references from colleagues regarding his communication;

and

evidence of any further steps to maintain his skills, including evidence of training and Continuing Professional Development…”

The Panel varied the Conditions of Practice as follows:

“ORDER:

The Panel directs the Registrar to vary and extend the current Conditions of Practice Order against the registration of Mr John W Williams for a further period of 9 months from the date of expiry of the current order. The Conditions are as follows:

1. You must place yourself and remain under the supervision of a workplace supervisor, registered by the HCPC or other appropriate statutory regulator and supply details of your supervisor to the HCPC within one month of recommencing work as a Paramedic. You must attend upon that supervisor as required and follow their advice and recommendations.

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

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

4. You must inform the following parties that your registration is subject to these conditions:

A. any organisation or person employing or contracting with you to undertake professional work;

B. any agency you are registered with or apply to be registered with (at the time of application); and

C. any prospective employer (at the time of your application).

5. You must work with your supervisor, meet with them on a monthly basis, and document, record and complete your progress in your Personal Development Plan to monitor and address any deficiencies in the following areas of your practice:

A. Undertaking assessments

B. Communicating effectively with colleagues and patients

6. You must forward a copy of your completed, updated and signed Personal Development Plan to the HCPC at least 14 working days before the next review hearing

7. You must allow your supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan.”

This Review Hearing

12. Mr Watkins explained the background to the case by reference to a bundle of documents relied on by the HCPC. The Registrant had provided a bundle of documents and gave oral evidence to explain them. He was cross-examined by Mr Watkins and answered questions from the Panel.

13. The Registrant referred to a PDP that he prepared in January 2021, following the previous review hearing. He explained that he had attended bi-monthly review meetings with his manager, JH, and pointed to the feedback that he had received from three colleagues who attended on patient visits with him in July and August 2021. He stated that when he started at SCAS he had self-referred to the HCPC and decided to take a step down to work as an ECA, which had given him the confidence to perform now to the standard of a NQP. He told the Panel that JH had nominated him for a role as a sole driver and responder and referred to the form signed by her dated 2 September 2021. It was JH, said the Registrant, who ‘gave evidence’ against him in 2016 with respect to the concerns about his clinical competence. He also referred to her recommendation that he be given the role of a Placement Practice Educator. Had she had any doubts about his competence, said the Registrant, JH would not have put him forward for these two roles.

14. When cross-examined by Mr Watkins, the Registrant explained that he did take steps that were set out in his new PDP. He accepted that not all the columns in the PDP had been completed but pointed to steps he had taken and work that he had done which formed part of that plan. He referred to the difficulty of obtaining feedback from colleagues, who were very busy in view of the current pressures on the ambulance service. He referred to difficulties in having further meetings beyond those that he did attend. He explained that the concerns expressed in the reports in relation to documents concerned some drop-down boxes (“tabs”) that he had not filled in on the ePRF, but the content for which he had put elsewhere in the free text box. He accepted that he had fallen behind in the written work he was supposed to have completed for his NQP training but explained that this was because of ill health and the major problems caused by the demands of his work for the ambulance service.

15. He said that he would like to work as a Paramedic without restrictions on his registration. He would be having monthly meetings with his ‘supervisor’ as part of his NQP training. He considered that he was now able to practise in a safe and competent manner. He also mentioned the considerable self-reflection he had undergone to make sure that other medical professionals would understand his notes, and to write them up as fully as possible.

16. In answer to Panel questions, the Registrant explained that the Capability framework referred to in the reports of the meetings in his bundle of documents had been set up by SCAS as a way of managing the Conditions of Practice imposed by the HCPC. There was not a formal Capability Assessment. He accepted that the new PDP did not contain within it any evidence of the outcomes from the objectives set out in the PDP. However, he said that JH’s letter of 31 August 2021 showed that the steps were complete. He did accept that he had not met his supervisor every month as required by the Conditions of Practice, and that four meetings had taken place and no more (during one month he had been on paternity leave). He accepted that he had taken on board the criticisms of his record-keeping, but not before 7 September 2021, as set out in KH’s letter of that date.

17. Mr Watkins submitted that the Registrant’s fitness to practise remained impaired. In particular, he referred to the Registrant’s failure to attend monthly reviews and produce the required documentary evidence of progress in his PDP. It was only shortly before the hearing that he had satisfactorily addressed the shortcomings in his approach to documenting his work. The Panel could not be confident that he would continue to keep his performance to the required standard. Mr Watkins submitted that a further period of conditional registration was appropriate, for a period of 6 months.

18. The Registrant submitted that he was now practising to the required standard of a NQP at his stage of the development framework. He would be attending monthly meetings with his supervisor, where he could seek out any further assistance required. He referred to his insight and reflections on his shortcomings and on the steps he had taken to remedy them.

19. The Panel received advice from the Legal Assessor, which it accepted.
Decision

20. The Panel considered that the Registrant has shown evidence of some further insight and has clearly made progress towards an unrestricted return to practice. However, he has not met with his workplace supervisor, KH, on a monthly basis, as required by Condition 5. Leaving aside the meeting in June 2021 when he was on paternity leave, the Registrant attended only four monthly meetings of those required since 8 January 2021. He has not recorded his progress towards the aims in his PDP. In breach of Condition 6, the PDP forwarded to the HCPC was not completed, updated, and signed. The importance of a completed PDP had been stressed by the previous reviewing panel in its determination. This Panel was concerned that the Registrant’s failure to produce the completed PDP on this occasion showed a lack of insight into an important matter that had been required by a panel of his regulator. The Panel did not accept his explanation that the difficulties he referred to in his evidence would have prevented him from undertaking all the required monthly meetings and keeping his PDP updated. It was not satisfied that he had achieved all the outcomes set out in the PDP.

21. The Panel was also concerned that it was not until 7 September 2021 that his workplace supervisor had been able to accept the Registrant had taken on board necessary changes to his approach to documentation, despite reminders given to him at a previous meeting with his manager on 8 April 2021 and in a letter to him from KH dated 19 July 2021. The Panel is concerned that those changes may not yet be embedded into his practice. More generally, in the absence of a PDP signed by his supervisor identifying the necessary changes, the Panel is not satisfied that there is sufficient evidence to persuade it that all those changes have been made. The Panel is also concerned that the Registrant had been late in presenting the required 25% of his NQP practice portfolio as required by the training framework. That work should have been available by 17 April 2021 (an extended deadline of 16 August 2021 was met). Although mitigating factors were taken into account by the Registrant’s manager in extending the deadline, the Panel remained concerned about this lateness.

22. Despite the favourable observations given by the three colleagues, there are also reservations expressed in their feedback. For example, the Registrant had not challenged the Nurse in Charge on the occasion of a hospital admission when the patient’s condition appeared to render that necessary.

23. The Panel has taken into account all the positive matters urged on it by the Registrant, but is still concerned that there remains a risk of repetition of shortcomings in his ability to practise safely as a Paramedic. Although he has demonstrated some further insight, as shown by his evidence of self-reflection in particular, there is still a worrying lack of insight into the importance of the requirements of this regulatory process. Further, informed members of the public would be concerned to learn that the Registrant had not complied with the requirements of the Conditions of Practice and that there is a risk of repetition of the shortcomings in his professional practice. Therefore, the Registrant’s fitness to practise remains impaired by reason of lack of competence with reference to both the personal and public component of impairment.

24. The Panel bore in mind that sanction is a matter for its own independent judgement and that the purpose of a sanction is not to punish the Registrant but to protect the public. Further, that any sanction must be proportionate, so that any order must be the least restrictive order that would protect the public interest, including public protection.

25. The Panel considered the option of a Caution Order. However, it decided that this would not provide adequate protection for the public.

26. The Panel next considered a Conditions of Practice Order. It considered that the appropriate response at this review would direct a further period of conditional registration. The Registrant has made significant progress towards a return to unrestricted practice. However, it considers a further period of six months of conditional registration to be necessary, subject to the same Conditions of Practice as are presently in place (save for a minor clarification to Condition 6 requiring that the updated PDP be signed by both the Registrant and his supervisor). The further monthly meetings and completion of the objectives in the PDP should enable the Registrant to demonstrate that he will be fit to practise without restriction.

27. The Panel considered a Suspension Order, but decided that this would be disproportionate at this time given the continuing development of the Registrant’s insight and remediation, and his engagement with his regulatory body.

28. The Panel also considered that a reviewing panel may be assisted by the following:

• The Registrant’s attendance at the next review hearing;
• Signed and dated references from his supervisor(s) and colleagues addressing his progress.

Order

Order

The Panel directs the Registrar to extend the varied Conditions of Practice Order against the registration of Mr John W Williams for a further period of 6 months from the date of expiry of the current order.

The Conditions are as follows:

1. You must place yourself and remain under the supervision of a workplace supervisor, registered by the HCPC or other appropriate statutory regulator and supply details of your supervisor to the HCPC within one month of recommencing work as a Paramedic. You must attend upon that supervisor as required and follow their advice and recommendations.

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

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

4. You must inform the following parties that your registration is subject to these conditions:


a. any organisation or person employing or contracting with you to undertake professional work;


b. any agency you are registered with or apply to be registered with (at the time of application);

and

c. any prospective employer (at the time of your application).

5. You must work with your supervisor, meet with them on a monthly basis, and document, record and complete your progress in your Personal Development Plan to monitor and address any deficiencies in the following areas of your practice:

a. Undertaking assessments
b Communicating effectively with colleagues and patients

6. You must forward a copy of your completed Personal Development Plan, updated and signed (by yourself and your supervisor), to the HCPC at least 14 working days before the next review hearing.

7. You must allow your supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan.

 

Notes

No notes available

Hearing History

History of Hearings for John W Williams

Date Panel Hearing type Outcomes / Status
28/09/2021 Conduct and Competence Committee Review Hearing Conditions of Practice
08/01/2021 Conduct and Competence Committee Review Hearing Conditions of Practice
07/01/2020 Conduct and Competence Committee Review Hearing Conditions of Practice
05/02/2019 Conduct and Competence Committee Consent Order Hearing Conditions of Practice
21/12/2018 Conduct and Competence Committee Final Hearing Adjourned
16/07/2018 Conduct and Competence Committee Final Hearing Adjourned