Ms Lisa Bond

Profession: Paramedic

Registration Number: PA40923

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 13/09/2021 End: 17:00 20/09/2021

Location: This hearing will be held virtually via video conference

Panel: Conduct and Competence Committee
Outcome: Conditions of Practice

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Whilst registered with the HCPC as a paramedic and employed at East Midlands Ambulance Service, on or around 11 June 2018:

1. You did not convey Patient A to hospital when it was clinically indicated

2. Your actions at 1 put Patient A at risk

3. You did not complete the ePRF to an adequate standard

4. You did not adequately record the care provided to Patient KW

5. The matters set out in paragraphs 1-4 constitute misconduct and/or lack of competence

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


Preliminary matters:

1. This Hearing is being conducted by virtual media in line with the HCPTS protocol adopted in response the COVID-19 pandemic.


2. The Registrant is a Paramedic employed by East Midland Ambulance Service (EMAS) NHS Trust (the Trust) since 23 May 2016 when she was newly qualified. The Registrant had also undertaken her training practice with the Trust.
3. On 11 June 2018, the Registrant and Colleague A, an Emergency Care Assistant, attended Patient A’s home following a request from a Community First Responder for back up.
4. On 20 July 2018, Person E (YL) submitted a complaint regarding the Registrant and Colleague A to the Trust’s Patient Advice Liaison Service in which she questioned why her father had not been conveyed to hospital on 11 June 2018. Amanda Davidson (AD) was appointed as the Incident Investigator.
5. On 27 February 2019, Person B (JW) submitted a Fitness to Practise referral to the HCPC.

6. The Panel received live evidence from four HCPC witnesses, one Expert Witness and the Registrant.
7. Two of the HCPC’s witnesses (JW and HW) provided live evidence to the Panel. They had both been present during the time that the Registrant and Colleague A (a Technician) had been attending Patient A in his home on 11 June 2018. A third HCPC witness (YL), who was noted as the next of kin of Patient A, provided live evidence relating to her telephone conversation from Spain with the Registrant on 11 June 2018. These three witnesses were daughters of Patient A who had eight children, four daughters and four sons. The fourth daughter, who had been at Patient A’s home on 11 June 2018, had chosen not to participate in these proceedings.
8. JW (Person B) gave evidence that was broadly consistent with her sworn statement. She presented as a credible and honest witness who had endeavoured to assist the Panel in understanding why she remained concerned that her father had not been taken to hospital. She told the Panel that she had been the one to ring 999. During the period that a Community First Responder (CFR) and the Registrant were at Patient A’s house she was the one who had undertaken to communicate with Patient A through either writing on a white board or spelling out letters on the palm of Patient A’s hand.
9. HW gave evidence which was again broadly consistent with her sworn statement and previous recorded concerns. She was again considered a credible and honest witness who was keen to emphasise to the Panel that she was unable to understand why the whole process had taken three hours and resulted in her father staying at home rather than being taken to hospital. From her evidence it appeared that she had been less involved in discussions with the Registrant and spent some time in conversation with Colleague A.
10. YL’s evidence was consistent with her previous statements to the Trust and the HCPC. She told the Panel that she had emphasised in her telephone conversation with the Registrant that if Patient A needed to go to hospital, the Registrant should take him.
11. Amanda Davidson had been appointed as Incident Investigator. AD was unable to attend this Hearing due to ill-health. The HCPC called Peter Bainbridge to exhibit the documents exhibited by AD and to answer questions. Mr Bainbridge was unable to provide any detail of matters relating to the report as he had not had any involvement in its production. Mr Bainbridge was however able to provide the Panel with details relating to the Trust’s Policies and particularly in relation to the EMAS Paramedic Pathfinder tool, a flow chart driven framework which supports the clinical decision making for EMAS clinicians in determining outcomes for patients.
12. The Paramedic expert, Mr James Brogan, had been appointed by the HCPC to provide expert clinical evidence. His role was to provide the Panel with an independent, dispassionate and balanced view of the clinical evidence. His duty of care was to the Tribunal and not to either party. The Panel considered that his evidence was balanced and credible. He assisted the Panel in identifying the clinical issues which were relevant to the Panel’s consideration of

Particulars 1 and 2.
13. The Registrant gave evidence. She was considered by the Panel to have also attempted to assist the Panel. The Panel considered her to be an honest witness but like others involved in this case her recollections of events had become coloured by the revisiting of the events. The Panel accepted her evidence on some key issues but at other times had difficulty in reconciling it with other evidence it had heard or documentation it had before it.
14. The Registrant’s evidence was consistent with that of the three daughters in relation to some key clinical treatment points, such as removal of the oxygen mask placed on the face of Patient A by the CFR and administration of Lactulose. In other areas there was a divergence on clinical points. The three daughters were adamant that paracetamol had not been administered and that only one observation had been taken. The Electronic Patient Report Form (ePRF), which is a document that has legal status, shows that there were six sets of observations taken at intervals, with results noted and two medications given. It was asserted by Person B that the Registrant had not been able to take any observations of Patient A whilst he was standing, as he was not able to stand. However, two of the Registrant’s observations recorded on the ePRF at 20.45 and 21.11 state that they have been taken whilst Patient A was standing.
15. In relation to the issue of whether Patient A had refused to go to hospital or not, this was a matter on which there was disagreement and differing interpretations of what was said by Patient A. The CFR, Colleague A and the Registrant all provided evidence at an early stage in the investigation process that Patient A had responded verbally to either lettering being spelt out on his hand or by the use of writing on a white board, his resistance to go to hospital. The three daughters had considered his wording to be more appropriately interpreted as resignation that he would have to go to hospital rather than reluctance or resistance.
Trust’s documentation
16. The Panel had before it documents that were produced by the Trust following receipt of the complaint from Person E on 20 July 2018. These were:
a. Transcript of a recorded interview with the Registrant conducted by AD on the 24 September 2018 and entitled ‘Incident Reference Number: SI/2018/18765 – Incident relating to Patient A complaining of laboured breathing – 11.06.2018’.
b. The Trust’s Serious Incident Investigation Report dated 22 October 2018.
c. Call logs for 11June and 12 June 2018
d. Patient Report Form for Patient A dated 11 June 2018
e. Electronic Patient Report Form regarding incident 11 June 2018
f. Electronic Patient Report Form regarding Incident 12 June 2018
g. Supporting interview notes of interviews undertaken as part of investigation of the incidents with those at the scene on 11 June 2018.
h. Clinical review undertaken with the Registrant following incident on 11 June 2018 and dated 7 November 2018
i. Serious Incident Summary (undated).
j. Capacity and Consent Policy for EMAS (December 2016).
k. On Scene Conveyance and Referral Procedure (November 2017).
Events of 11 June 2018
17. From the documentation and the oral evidence before it the Panel has been able to establish a rough timeline of the events on 11 June 2018 and has collated the following information.

• Patient A was an 87-year-old Jamaican man who was profoundly deaf and was blind in his right eye and had only 5% sight in his left eye. He had glaucoma, diverticulitis, stage 3 kidney disease, chronic obstructive pulmonary disease (COPD) and Hepatitis C. He had no medical history of suffering from seizures.
• Around 15.45 Person B who had spent the afternoon in her father’s (Patient A) garden weeding with Patient A, had left to go to the council refuse site whilst Patient A had been left undertaking some work with his arm down a drain and his cap and jacket by his side on the ground. Patient A’s inhaler which he used when he suffered an angina attack was in his jacket pocket. It was a hot day, and it was thought that Patient A had taken in little fluids.
• Around 5.30 Patient A rang Person B saying that he thought he was having a heart attack.
• After arranging childcare Person B had returned to her father’s home to find her father’s cap and jacket were still on the ground by the drain and her father was inside on the sofa rubbing his shoulder and leaning to one side.
• Person B tapped Patient A’s arm to let him know she was there. Person B had written on the white board that she considered that her father had strained his arm when he had put it down the drain and Patient A had responded in terms similar to, ‘yes that would be it.’
• Person B had then contacted her sister (Person E) who was on holiday in Spain. Person B after describing what had happened was instructed by Person E to get their father’s inhaler spray.
• Patient A had then taken two sprays from his inhaler, GTN (Glyceryl Trinitrate).
• Person B then went into the kitchen and when she returned to the living room her father was ‘fitting’ and she therefore called 999. This call was logged as starting at 19.02. At this time Patient A was slumped on the sofa and whilst calling 999 Person B had with one hand attempted to pull her father up. Person B then observed her father’s eyes had gone red, he was shaking, his false teeth had come out and flown across the room and his glasses had come off. She told the call handler that Patient A was having a seizure.
• At 19.06 The Community First Response (CFR) is recorded as arriving at Patient A’s home and at this time Person B was still on the telephone to the call handler.
• At 19.12 the CFR had contact with control to request a Red (priority 2) backup.
• Person B had called her sisters Person D and another, and they had arrived at Patient A’s home.
• Patient A’s breathing was laboured, and the CFR had given Patient A oxygen via a nasal cannula.
• 19.33 A double crew ambulance arrived at the scene and the Registrant and Colleague A took a handover from the CRF.
• The Registrant removed the nasal cannula from Patient A as his saturations were adequate. As he suffered from COPD a prolonged period on oxygen was not appropriate, as it could result in retention of carbon dioxide within the body.
• The Registrant had applied the arm cuff of the blood pressure monitor on Patient A’s arm and this cuff remained there whilst observations were conducted. The Registrant had either left the machine on automatic or had indicated to Patient A when it was to be manually operated by a stroke of Patient A’s arm to alert him to what was to happen.
• 19.36 The first set of observations were taken. These record respiratory rate of 16 breaths per minute (BPM), heart rate (HR) of 113 and blood pressure (BP) of 79/53. This reading was taken whilst Patient A was seated.
• 19.44 a second set of observations were taken which recorded respiration of 24 BPM, BP 89/52 and 113 BPM.
• At some point around then there was a telephone call between the Registrant and Person E in which it is recorded by both parties involved in the call that the Registrant intended taking Patient A to hospital.
• At about this time Patient A either through signing of letters on his hand or through the use of the white board indicated verbally in response something like ‘I’ve got no choice’ or ‘I suppose I have to’.
• At 20.17 a third set of observations were taken.
• At or around 20.18 the CFR left the scene.
• At 20.35 the Registrant undertook an abdominal assessment of Patient A.
• Further sets of observations were recorded as being undertaken at 20.45, 20.54 and at 21.11 hours.
• Two of Patient A’s daughters signed the ‘Discharge at home’ form.
• The Registrant had made the decision not to contact the GP out of hours service in relation to her final findings of abdominal pain and primary and secondary impressions of faint/dizziness and constipation. The Registrant had also made the decision not to contact the Trust Clinical Assessment Team (CAT) to discuss Patient A’s presentation or his decision to refuse conveyance and further treatment.
• At or around 21.46, the ambulance cleared the scene and Patient A remained at home with a daughter or daughters staying with him overnight. Prior to leaving, advice was provided by the Registrant to the daughters to ring the GP in the morning.

Decision on Facts
18. The Panel appreciated that the burden of proof at this stage of the proceedings rested with the HCPC. That burden is to the civil standard on the balance of probabilities. Whilst the Panel has considered admissions made during the Hearing, those admissions do not displace the burden of proof which remains with the HCPC. Those admissions made during evidence have been taken as supportive of any findings on fact by the Panel.
19. The Panel has, as advised, taken into account all information before it and considered its appropriate weight whilst reaching its decision.

Particular 1
You did not convey Patient A to hospital when it was clinically indicated.
20. Patient A had not been conveyed to hospital and this was not disputed.
21. It appeared from her evidence that the Registrant had accepted that this was a case which warranted conveyance to hospital for further assessment and treatment. The reason provided by the Registrant for her decision not to convey Patient A to hospital was that she did not consider that she had his consent to go to hospital and that his reluctance to go was such that she considered it inappropriate to exert any coercion.
22. The two daughters who gave evidence had been present on 11 June 2018 had insisted that Patient A should have gone to hospital and that he never said anything which indicated resistance to going to hospital.
23. As to whether it was clinically indicated that Patient A, subject to his consent, ought to be conveyed to hospital, was an issue on which Mr Brogan supplied evidence. His overall view was that all the evidence indicated that hospital was the best place for Patient A.
24. Mr Brogan identified key indicators which had presented themselves at the outset of the assessment and analysis process. These he called ‘red flags’: clinical markers which should have directed the Registrant’s mind toward a differential diagnosis and alternative course of action and treatment. Some of those markers had been noted by the Registrant, however she had not identified correctly the relevance of or the relationship between those markers.
25. The Registrant had indicated that the taking of the GTN provided a causal link with the reduction in the blood pressure. Mr Brogan informed the Panel that this medication was a short term relief medication, and its effects would have worn off after a relatively short period of time. An extended period of hypertension, low blood pressure, beyond a period of 30 minutes, and certainly beyond an hour, should be treated with extreme caution and other sources sought for the continued low blood pressure readings.
26. Mr Brogan told the Panel that abdominal pain may be an indicator of referred pain from another point in the chest cavity. This could be an indicator of cardio-vascular issues which should not be ruled out given that Patient A’s medical history was one of cardiovascular disease. From the documentation Mr Brogan had not seen any evidence that this abdominal pain had been considered by the Registrant within a wider context than constipation.
27. Mr Brogan informed the Panel that where there is no recorded history of a seizure for this Patient and so this should have been considered as an abnormal activity. The fact that Patient A was suspected of having experienced a seizure was potentially related to low levels of oxygen in the brain. This could be a life-threatening condition which should have been a ‘red flag’ indicator to the Registrant that there was something very serious happening. There was in fact no mention of the patient suffering a seizure in the ePRF prepared by the Registrant although it had been recorded within the initial 999 call and also within the PRF completed by the CFR.
28. In relation to the issue of the ECG recording, Mr Brogan informed the Panel that there were several changes to the ECG, which were suggestive of a cardiac event. Against this, the Registrant had recorded “chest clear, ECG – NSR – tachy – no change in rhythm”. Mr Brogan also explained to the Panel that a finding of NSR, or Normal Sinus Rhythm is at odds with both the heart rate evident, and also with the ‘ST Segment’ changes he had noted on the ECG.
29. Mr Brogan observed that there was such little narrative in relation to the thought process and so little to evidence a full assessment that it is reasonable to draw the conclusion that the Registrant had at the time failed to appreciate the significance of the clinical presentation.
30. Given this evidence before the Panel, it accepted that there were sufficient clinical markers to indicate that Patient A’s clinical presentation warranted hospital admission. The Panel finds this particular proven to the relevant standard of the balance of probability.

Particular 2
Your actions at 1 put Patient A at risk in that the potential life-threating conditions could not be rules out outside a hospital setting.
31. The Registrant’s position on this appears to be the same as for Particular 1, in that she appreciated the clinical position and the need for conveyance to hospital for further assessment and treatment however she considered that she did not have Patient A’s consent to take him to hospital.
32. The Panel has accepted the evidence of Mr Brogan that the indicators he identified above in relation to Particular 1, were life threatening conditions and could not be ruled out without further analysis within a hospital setting.
33. The Panel accepts that this is the case, and so makes a finding on this particular.

Particular 3
You did not complete the Electronic Patient Report Form (ePRF) to an adequate standard in that:
a) you did not ensure it recorded:

(i) an accurate summary of the history provided and/or the patient’s presentation;

(ii) Any differential diagnoses and/or working diagnosis;

(iii) Any information given to Patient A and/or his family about why he should be conveyed to hospital and/or your concerns about his presentation;

(iv) Any advice to Patient A that he should be conveyed to hospital.

(v) That Patient A’s refusal to be conveyed to hospital was against your advice; and/or

(vi) If you had assessed Patient A’s capacity and/or how his capacity had been assessed.

34. These limbs of the particular include many permutations and alternatives, of which each individual element has been thoroughly considered by the Panel. The factual finding here is crucially that there are no entries relating to any of these matters within the documentation prepared by the Registrant.
35. Mr Brogan commented that it was essential to have a full report and a continuing narrative that evidenced the thought process of the clinician as well as the assessment and treatment processes. In regard to recording advice given or decisions made, it was crucial that the documentation was as full and accurate as possible as other clinicians would rely upon a registrant’s observations and notes.
36. The Registrant in her evidence admitted deficiencies in her record-keeping and observed that if it had been better at the time, she would not be before her Regulator now. As she acknowledged, ‘if it is not written down then it did not happen’.
37. The evidence before this Panel is that in addition to there being no recording within the ePRF of these issues as particularised within Particular 3(a), there is no evidence from sources other than the Registrant’s verbal evidence that these issues were considered.
38. The Particular is however limited to making a recording of those issues and this Panel accordingly finds on a factual basis that it is proven to the requisite standard.
(b) it recorded “No Chest Pain” and also that Patient A had developed chest/angina pain;

39. The Panel noted that both these entries were accurate in that they were recordings of a situation at a point in time, a snapshot of Patient A’s condition. One was made as part of a tick box process and the other as a freehand recording. Both were appropriate within their two different contexts within the form.
40. The Panel therefore makes no finding in relation to particular 3(b).
Decision on Grounds
41. The Panel appreciated at this stage in the proceedings there is no burden on the HCPC and that the issues of lack of competence and/or misconduct are matters for the Panel’s judgment.
42. The Panel must consider whether, individually or collectively, the matters on which it has made findings amount to misconduct or derive from a lack of competence. For this purpose, the Panel has discounted from its consideration Particular 3(b), on which it has made no finding. The Panel has ignored any outcomes of which it has been made aware and which do not form part of the issues alleged.
43. The Panel has received representations from the HCPC that the matters on which the Panel has made findings should be considered as misconduct. In support, it was advanced that this is an isolated incident in which the Registrant’s standards have been found wanting. There are no previous regulatory proceedings and according to the Registrant’s Representative there have been no subsequent complaints or cause for concern arising from the Registrant’s practice. Further, the Panel does not have before it the customary sample of cases which evidence that the Registrant’s practice has been found consistently wanting, as would be the case in a lack of competence matter. The Panel was provided with further advice from the Legal Assessor on the case of Calheam where a single incident had been considered to be due to a lack of competence.
44. The Panel noted that the Registrant has described herself as a competent practitioner. The references provided to the Panel by the Registrant are recent and all indicate that she is practising at present and that those supplying the references have not identified any cause for concern. However, the Panel noted that only one of the references was from a fellow paramedic colleague, the others being references from three EMT colleagues. The Panel notes that there is a limited amount of information from the Registrant’s employer relating to her current practice. That which is before the Panel relates to the assessment and correction of the Registrant’s practice as required by her employer, following the receipt of the complaint in July 2018. The Panel has accepted that there have been no previous nor subsequent fitness to practise issues.
45. The Panel has accepted that the Registrant’s actions in this instance did arise from her acts and omissions rather than her lack of knowledge, competence or matters outside of her scope of practice. As stated in the Panel’s decision on findings of fact, this is a complex case and one that was likely to have been more challenging for the Registrant particularly at an early stage in her career.
46. In relation to particulars 1 and 2, the Panel considers that these are serious matters. Whilst the issue of consent may have been the reason for a total breakdown of understanding and communication between the Registrant, Patient A and the three daughters, an assessment of the whole evidence discloses a sequence of acts and omissions which have contributed to Patient A being exposed to risk.
47. There had been insufficient recognition of the seriousness of the situation on arrival at Patient A’s home. The Panel noted from the bundle that whilst there had been a miscoding of the call, as a category 6 (breathing difficulty) rather than a 10 (chest pain), identified as part of the subsequent investigation, this did not impact on the Registrant’s response, as she had been informed that Patient A had difficulty breathing, had experienced a seizure and had chest pain. Person B (who is a retired Operating Department Practitioner) had identified that Patient A had suffered a seizure. There is no note anywhere in the ePRF of a seizure.
48. The Registrant had ascribed Patient A’s lack of responsiveness to the fact that he had been in the sun, was possibly dehydrated, and after experiencing chest pain, he had taken two sprays of his GTN. Use of this medication would have contributed to a lowering of his blood pressure which had been identified by the CFR. However, as this Panel heard from Mr Brogan, the effects of the GTN would have worn off after a relatively short period of time, in the region of 30 minutes. The 999 call was at 19.02 hours, after the two sprays of GTN had been administered. The first set of observations taken by the Registrant are timed at 19.36 when a blood pressure of 79/53 and a heart rate of 113 were recorded. The blood pressure remained low for an extended period of around 75 minutes. Mr Brogan described abnormal changes to the ECG and these were in the context of a patient with a complex medical history. These ‘red flags’ as defined by Mr Brogan were all indicators that there is something serious to be investigated.
49. As identified in the finding of fact in relation to Particular 1, several ‘red flags’ had been overlooked by the Registrant when undertaking her assessment and analysis of Patient A. The ePRF records that the Registrant had applied Paramedic Pathfinder (Medical) to her management of the case. Mr Bainbridge of the Trust had explained that Paramedic Pathfinder was a decision-making support tool, designed to assist crew in determining the most appropriate outcome for patients. However, there were exclusions to its use and the Panel noted that ‘non traumatic chest pain’ was one such exclusion.
50. The Registrant has recorded on the ePRF that the ‘presenting complaint’ was a symptom of abdominal pain. Ultimately, the ‘primary impression’ was recorded as ‘faint/dizziness’ with the ‘secondary impression’ being recorded as ‘constipation’. It is appreciated that these entries may have been made at the time of making the discharge at home decision.
51. The Registrant had considered the administration of the GTN and the low blood pressure reading to have a causal link. She had noted the chest pain and the history of cardiovascular disease and relevant history of medication. She had however failed to give weight to the fact that the Patient had been observed having a seizure and the significance of changes apparent on the ECG. Further, she had overlooked the fact that the administration of GTN would have naturally worn off and that any delayed recovery thereafter should have been considered as a cause for concern. Instead, the Registrant has narrated her interpretation of the ECG as “ECG NSR – tachy – no changes to rhythm”. The Registrant’s identification of abdominal pain together with a history of heart failure as noted on the ePRF should have alerted her to the possibility of referred pain with a cardiac cause.. These were all clear clinical indicators of the need to take Patient A to hospital immediately and this view was endorsed by the Trust Medical Director in the Investigation report.
52. The evidence of the daughters was that when not well, Patient A lost the residual sight that he had in his left eye. Further, he was aged 87, was deaf, blind in one eye, with less than 5% sight in the other eye and was entirely dependent on those around him to either sign on his hand or write on a whiteboard in order to communicate with him. He had a history of angina, heart failure, kidney disease, COPD and had initially complained of heart chest pain. Communication would have to be explicit and considered in order that Patient A would be fully informed prior to determining his decision over care and treatment.
53. It was this lack of understanding that there were more serious issues to be investigated at the outset, which had led the Registrant to ultimately pursue the wrong course of action. It appears that although those ‘red flags’ had been overlooked in her assessment, the Registrant had, based on Patient A’s presentation, initially decided to take him to hospital. This is what the Registrant indicated to Person E when she spoke to her in Spain. It was after this, that the Registrant identified that there was a reluctance on the part of Patient A to go to hospital. It appears to the Panel that it was at this time that the Registrant’s concerns about her having a lack of consent to convey Patient A to hospital, had begun to influence and guide the Registrant’s decision making.
54. Having identified that there was resistance and reluctance by Patient A to go to hospital, the Registrant recognised that she had to obtain ‘informed consent’ for a discharge at home, in circumstances which indicated a conveyance to hospital. It is appreciated by the Panel that this was a complex situation and that communication directly with Patient A had been challenging. The evidence from the Registrant is that Patient A continued in his resistance to go to hospital. There is little evidence to inform the Panel as to whether Patient A had fully understood what the risks were to him, arising from his decision to stay at home. In not recognising the clinical red flags apparent to Mr Brogan, the Panel felt that Patient A would not have been properly informed by the Registrant as she herself had not recognised those same red flags.
55. From the evidence before the Panel, the core issue of the Registrant not being able to override Patient A’s resistance to go to hospital, had not been fully understood or appreciated by the 3 daughters who were present. It appears from the evidence that various conversations had taken place over a considerable period during which the Patient’s Observations were improving. There is also evidence that some of the responsibility of discussing the issue of whether to take Patient A to hospital and the issue of informed consent had been left with Colleague A. The responsibility for this communication lies professionally with the Registrant and whilst delegation is appropriate in some instances, the Registrant must continue to provide appropriate supervision and support to those they delegate work to. There is no evidence of clear and understandable communication to the three daughters on this issue of consent by the Registrant. The Registrant has relied on the fact that two of the daughters had signed for ‘discharge at home’ as proof that they had appreciated that she could not force their father to go to hospital.
56. The daughter’s initial complaint to the Trust and their testimony to this Panel identified their continued confusion as to why the Registrant had not taken Patient A to hospital. Their concern that the Registrant had not, during the period of nearly 3 hours, conveyed their father to hospital indicate that there had not been a full and comprehensible discussion about the issue of informed consent and Patient A’s refusal to receive continued care and conveyance against advice.
57. From the evidence it appears that the daughters’ wish for the father to go to hospital had waned as their father’s condition improved and his blood pressure stabilised. The passage of time, and the improvements in the observations supported the Registrant’s position that it was safe to leave Patient A at home following his refusal and that the daughters relied on the Registrant’s professional opinion on this. As the Registrant said to the Panel, she didn’t think Patient A was going to die that night and thought that she was leaving him in a situation which was appropriate in those difficult circumstances.
58. The issues of consent and the appropriateness of discharge at home could have been resolved if the Registrant had taken the decision to involve outside agencies in the thought, analysis and clinical decision-making processes. Whilst the Panel appreciates that other agencies would not have been able to communicate directly with Patient A, they may have been able to identify correctly all or any elements of the red flags. This further information may have persuaded Patient A to change his position on whether to go to hospital as he would have been better if not fully informed. The Panel considered that in any case, discussion with more senior clinicians would have enabled further patient safety netting to be put in place.
59. The Trust policy regarding on scene referral and conveyance provided direction in cases where patients were not conveyed. Within the Policy, it directed the Registrant to document:

• That a mental capacity assessment had taken place
• Robust safety netting was in place
• Details of any referral made to an alternative care provider
• Instructions for the patient’s continued care, including associated red flags.

60. The Panel has heard the reasons given by the Registrant for the decision to leave the Patient at home, namely that one of the daughters would be in attendance overnight and that advice was given to contact the GP in the morning. The Registrant’s conscious decision not to seek outside assistance from the wider multi-disciplinary team within the Trust or within primary care resulted in the decision-making and responsibility remaining with her.
61. The Registrant’s acknowledged poor record keeping has further exacerbated the situation. Her completion of the form does not provide an accurate description of the presentation of Patient A. Nor does it give a flowing narrative which identifies and tracks the clinician’s thought process. The risk of being perceived as sitting at a laptop at the expense of delivering patient care is appreciated by the Panel. However the scant and incorrect information recorded on the ePRF, the lack of narrative about the conflict of his being conveyed to hospital, together with his vulnerability in terms of truly understanding the risks of his decision, are not of the standard or quantity expected. A fellow practitioner would not be able to fully appreciate the full situation which presented itself to the Registrant nor the information provided to her and be able to rely upon it.
62. The Panel has therefore concluded that there are multiple clinical and professional reasons why the Registrant’s treatment of Patient A resulted in an inappropriate working diagnosis and the subsequent incorrect treatment and management of his case.
63. The Panel appreciates that whilst a registrant’s actions may be in breach of the standards expected of a practitioner, such breach would not in itself be the sole basis on which to make a finding of misconduct. The Panel’s assessment of the Registrant’s acts and omissions is that her conduct has breached the following provisions of the HCPC’s Standards of Proficiency for Paramedics and Standards of Performance Conduct and Ethics for all registrants.
64. In relation to the Standards of Proficiency for Paramedics (2014 Edition) the Panel has found the Registrant’s action in breach of the following standards:
1.1 know the limits of their practice and when to seek advice or refer to another professional
1.4 be able to work safely in challenging and unpredictable environments, including being able to take appropriate action to assess and manage risk
4.1 be able to assess a professional situation, determine the nature and severity of the problem and call upon the required knowledge and experience to deal with the problem
4.2 be able to make reasoned decisions to initiate, continue, modify or cease treatment or the use of techniques or procedures, and record the decisions and reasoning appropriately
4.6 be able to make and receive appropriate referrals
4.8 be able to make a decision about the most appropriate care pathway for a patient and refer patients appropriately

8.1 be able to demonstrate effective and appropriate verbal and non-verbal skills in communicating information, advice, instruction and professional opinion to service users, colleagues and others

8.7 understand the need to provide service users or people acting on their behalf with the information necessary to enable them to make informed decisions

9.1 be able to work, where appropriate, in partnership with service users, other professionals, support staff and others.

9.6 be able to contribute effectively to work undertaken as part of a multi-disciplinary team

10.1 be able to keep accurate, comprehensive and comprehensible records in accordance with applicable legislation, protocols and guidelines
65. In relation to the Standards of Conduct Performance and Ethics the Panel considers that there has been breach of the following:
1.1 You must treat service users and carers as individuals, respecting their privacy and dignity.
1.2 You must work in partnership with service users and carers, involving them, where appropriate, in decisions about the care, treatment or other services to be provided.
1.3 You must encourage and help service users, where appropriate, to maintain their own health and well-being, and support them so they can make informed decisions.
1.4 You must make sure that you have consent from service users or other appropriate authority before you provide care, treatment or other services.
2.2 You must listen to service users and carers and take account of their needs and wishes.
2.3 You must give service users and carers the information they want or need, in a way they can understand.
2.6 You must share relevant information, where appropriate, with colleagues involved in the care, treatment or other services provided to a service user.
3.1 You must keep within your scope of practice by only practising in the areas you have appropriate knowledge, skills and experience for.
3.2 You must refer a service user to another practitioner if the care, treatment or other services they need are beyond your scope of practice.
6.1 You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.
8.1 You must be open and honest when something has gone wrong with the care, treatment or other services that you provide by:

• informing service users or, where appropriate, their carers, that something has gone wrong;
• apologising;
• taking action to put matters right if possible; and
• making sure that service users or, where appropriate, their carers, receive a full and prompt explanation of what has happened and any likely effects.

66. Taking all these matters into consideration, the Panel has concluded that the Registrant’s conduct had fallen far short of that required of a registered Paramedic. Whilst the Panel appreciates that this was an extremely challenging and complex situation with difficult communication issues, there remained some key elements of the Registrant’s practice which on this day fall far short of what is expected. Further, the poor record keeping has resulted in there being no clear and understandable narrative of what was happening, the thought processes involved, the communication with Patient A and his daughters and the resolution of the issues involved. Three crucial elements have not been addressed.

• Correct identification and assessment of the clinical issues which would have resulted in a different treatment plan.
• Poor verbal communication with all parties of the Registrant’s reasoning and logic in her decision-making process.
• A wilful resistance by the Registrant to obtain assistance and independent support at the scene from a GP or remotely from the Trust’s Clinical Assessment team (CAT).

67. These elements have led to a failure to take the correct immediate action, an absence of an informed decision being discussed, resolved and documented, and resulted in a long period of indecision and anxiety for all those involved, including the Registrant.
68. The Panel has concluded that the Registrant’s conduct on that day amounts to serious misconduct.

Decision on Impairment
69. In reaching its decision on impairment the Panel took into account:
• The advice of the Legal Assessor.
• The parties’ representations.
• That the requirements of impairment are expressed in the present tense, i.e. that fitness to practise ‘is impaired’.
• That the decision regarding impairment of the Registrant’s fitness to practise is a matter of judgment for the Panel.
• Rule 9 of the Health Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 (as amended) provides ‘where the Committee has found that the health professional has failed to comply with the standards of conduct, performance and ethics established by the Council under Article 21(1)(a) of the Order, the Committee may take that failure into account, but such failure will not be taken of itself to establish that the fitness to practise of the health professional is impaired.
• The guidance issued by the HCPTS entitled ‘Finding that fitness to practise is impaired.
• The four references which were produced by the Registrant. Three were from technicians who had worked alongside the Registrant and a fourth from a fellow Paramedic. Two of the technicians had worked with the Registrant since the events in this case took place; one technician and the paramedic had known the Registrant for seven years, from the start of her training to become a paramedic. These references did not state that they were made in anticipation of being used in these proceedings, nor that the referees had full knowledge of the allegations laid against the Registrant. The Panel noted however that one was from VS, who had been with the Registrant during her interview with the Investigating Officer, and another was from a technician ES, who had been supporting crew when the Registrant had been observed on 7 November 2018. Both would therefore be aware of the issues. A third spoke directly to the issues which formed the substance of the allegation. These references all focus on the Registrant’s character strengths rather than her clinical abilities.
70. The Panel is required to consider two components in reaching its decision on current impairment. The personal and the public.
71. In relation to the personal component the Panel considered whether the matters found as constituting misconduct were:
• capable of remedy; and
• whether they have been remedied; and,
• whether there is any likelihood of a repetition of the that conduct.
72. The Panel considered whether the elements the Panel has identified as practice failings when making its decision on misconduct were capable of remedy. Those practice issues were:
• Lack of sound clinical assessment and analysis – her failure to correctly identify indicators which would have led her to a different outcome on a Patient Pathway analysis.
• Poor communication skills – her failure to explain fully and to communicate effectively with those around her.
• An inability to identify when it is appropriate to escalate a situation and engage with the multidisciplinary team. Her attitudinal approach was one of complete autonomy and disregarded the need to work in a collegiate way in the best interests of a patient.
• Poor record keeping which meant that a fellow practitioner would be unable to establish the thought process taken by her to reach her decision.
73. The Panel considered that these four elements were capable of remedy. The Panel therefore considered what evidence it had, that these practice issues had been fully addressed.
74. The evidence that is before the Panel of training, learning and reflection is only that which had been mandated by her employers following the receipt of the complaint from Person E. The evidence of this was derived from:
• Verbal confirmation from the Registrant that she had been on a Pre-Hospital Assessment and Discharge course (PHAD).
• A review of her practice undertaken on a 12-hour shift on 7 November 2018. It identified four incidents at which the Registrant attended. In the record of the observations of that shift it is noted:
‘Lisa has now completed a period of mentorship and can reflect on the ePRF that instigated this SI, she realises that it was not to a standard that is required by the trust and it could and should have been better. She has improved her report writing and has a better understanding of the differences between a refusal to travel and a recommendation that a patient need not travel. Her ePRF includes a good standard of safety netting, including mental capacity assessment. She is using pathfinder to make clinical judgments. She is completing her Enhanced Clinical Assessment in December as part of her TNA and hopes this will improve her medical writing further.
In my opinion Lisa’s report writing is to a good standard, this should improve further if she completes the Enhanced Patient Assessment Course. I therefore feel at this time that, no further input is required.’
75. This evidence of improvement in her report writing was supported by the verbal testimony of the Registrant when she stated on several occasions that she would now always make sure that her notes were thorough.
76. The Panel noted the limitations of this information, in that it did not have before it any of the following, which would have provided evidence that the Registrant had fully and effectively addressed her practice failings.
• A copy of Training Needs Analysis which had been undertaken by the Trust in 2018. This would have been evidence of what had informed the Trust’s steps of providing mentorship for a four-week period and one review of practice.
• A statement or reference from the Paramedic who had undertaken her mentoring for four weeks.
• A statement or reference from a Senior Clinician concerning her clinical practice and/ or knowledge.
• Evidence of undertaking a report writing course or samples of her improved record keeping skills.
• Details of the reflective practice which was recommended by the Trust.
• Evidence of mediation being undertaken.
• Evidence of any further learning, training and reflection undertaken in the past three years. Particularly training in relation to communication skills in difficult and challenging situations.
• A piece of reflective writing prepared for this hearing in which she identified the basis of her failings and how they had been remedied. Such reflection could have addressed the issues of remorse, insight, and regret for the events of June 2018 and the lesson learnt from those events in 2018.
77. The Panel has therefore concluded that whilst the Registrant has complied with the requirements of her employer, those requirements were not, in the Panel’s view, sufficiently robust in evidencing how they had addressed the failings identified by this Panel. The measures undertaken had not encouraged the Registrant to consider and reflect on her practice. Further there is no evidence that the Registrant has unilaterally and proactively taken any personal responsibility for the remediation of her practice failings. This being the case, there remain areas in her practice which have not been addressed and remedied through training, learning or developed insight.
78. The Panel then considered whether there was a likelihood of a repetition of the conduct found proved and took into account the verbal evidence of the Registrant. It noted that there had been a denial of the matters alleged. Limited admissions had been made in evidence relating to poor record keeping but this was at a late stage in this hearing.
79. In relation to particulars 1 and 2, the Registrant was recorded as saying in this hearing that if her record keeping had been better, she would not be before this Panel. This demonstrates that there has been no acknowledgement by her that there were other facets of her practice that had fallen short of the required standards, and that it was not a simple record keeping failure. The Registrant has stated that her position is now to use recording of actions as a defence and a means to avoid further complaint.
80. The Registrant’s reliance on the fact that Patient A did not wish to go to hospital, ignores the ways in which she could have dealt better with that complex and developing situation. In her interview with the Investigating Officer the Registrant has given her reasons for not seeking support from third parties such as a GP and the CAT. In essence, the reasons given were that it was a waste of time and effort. The Panel noted that the Registrant’s view of obtaining guidance from a GP was limited to ringing a GP practice during surgery hours.
81. The Registrant has subsequently undertaken a PHAD course in which she would have learnt the steps that are appropriate in the event of a patient refusing to go to hospital. That training may have also identified the procedure to be adopted should there be an expression of a wish to die at home, the sole topic which the Registrant recalled. That course would also have highlighted the need to engage other agencies when a patient had refused to be conveyed to hospital in the presence of red flags and clinician concern and the need to establish that the patient was fully informed prior to providing consent to stay at home. There has been no reference to these aspects of the training in the Registrant’s evidence.
82. In this Hearing the Registrant has restated her reasons for not seeking support from the wider multidisciplinary team in June 2018. It also appears from her evidence that this is still her view on engaging with the wider multidisciplinary team in such a situation. When questioned she had now accepted that she could have left Patient A with a completed RESPECT Form relating to his wish to die at home and taken steps to record that she had obtained fully informed consent to discharge at home. This ignores her responsibility as part of a wider team to obtain further advice from a senior clinician and continue to explore an appropriate forward care plan. This is evidence that the Registrant is still accepting her autonomous practitioner role and ignores the limitations of that role within a wider multidisciplinary team.
83. The Panel considers that whilst the Registrant may have improved her practice in some areas, there are elements of her practice which she still needs to recognise, address and remedy. It is the Panel’s view that until this has happened, there remains the likelihood of a repetition of those failings.
84. The Panel then considered the public interest in the Panel making a finding of current impairment. There are three elements of the Panel’s consideration.
• Protection of service users.
• Upholding professional standards.
• Maintaining confidence in the Profession.
85. The Registrant’s current presentation of her attitude to the events in June 2018 and her failings which have not been fully remediated pose a risk to the Public. Therefore, in such a situation, it is the Panel’s view, that a finding of impairment is warranted for the protection of service users.
86. In relation to maintaining professional standards, members of the public would consider the Registrant’s resistance to seeking additional support from the multidisciplinary team when in such a complex situation as unacceptable. Further the lack of any demonstration of continuing learning and developing insight into her conduct would be of concern to the public and would be considered as to be a failure to uphold professional standards.
87. Further, in relation to upholding the reputation of the profession, members of the public would be appalled that an 87-year-old man, with complex and multiple life-threatening conditions, had not been given fuller information and an overall better standard of service.
88. The Panel further noted that whilst the Registrant’s actions had not been reckless, they were misguided in relation to the issue of consent. Her actions had not caused actual harm but had exposed Patient A to a greater degree of risk. Her clinical failings and poor communication had contributed to that level of risk.
89. The Panel therefore finds that a finding of impairment is warranted on the public component.
90. The Panel having concluded that the Registrant’s fitness to practise is impaired on both the personal and public components moved forward to consider what was an appropriate restriction on the Registrant’s practice.
Decision on Sanction
91. The Panel appreciated that at this stage its consideration of which sanction to impose is a matter of balancing the need for service user protection and, those of the Registrant’s interest. Such a decision is also to be in the wider public interest in maintaining and upholding standards and preserving the reputation of the profession. The imposition of a restriction is not to be seen as a punishment, but as a measure to ensure that the public and service users are not exposed to risk and act as a deterrent to other members of the profession.
92. The Panel further appreciated that sanctions are not intended to be punitive, but they may result in having a punitive impact on a registrant: it should only take the minimum action necessary to ensure the public is protected. This means considering the least restrictive sanction available to the Panel first, and only moving on to a more restrictive sanction if it remains necessary to protect the public.
93. In undertaking this task, the Panel has considered the terms of the HCPTS Sanctions Policy. The Panel has taken and accepted the advice of the Legal Assessor on the matters which are relevant at this stage in the proceedings.
94. The Panel has received representations from both parties on the matters which it should consider when reaching a decision on the appropriate and proportionate restriction to place on the Registrant’s practice.
95. The Panel noted the HCPC was taking a neutral position on sanction and commended the HCPTS Sanction Policy to the Panel.
96. The Registrant choose to give further evidence during which she supplied the Panel with evidence of voluntary study. These were:
• A ‘Top-up’ degree course with Coventry University. She is undertaking this course remotely part-time. She commenced this course in September 2018. Due to the COVID-19 pandemic the date for completion is now April 2022.

• A confirmation that she had engaged in an online webinar on the subject of clinical examination completed in October 2020.
• Poster advert for a multi-agency fire and ambulance CPD event in August 2020, which the Registrant stated that she attended.
97. The Registrant gave further clarification on the training she has undertaken and gave some limited reflection on how traumatic giving evidence in this hearing must have been for the family when reliving that day.
98. In undertaking its task, the Panel made an assessment of the aggravating and mitigating factors identified in this case.
In relation to the mitigating factors the Panel identified the following:
• The Registrant had been a direct entry student, qualifying in April 2016 and at the time of the incident may not have had the benefit of the two-year formal post qualification mentoring to transition from student to registrant.
• At the time of the events on 11 June 2018 she had two years’ experience.
• This is the first time that the Registrant has been before her regulator.
• There have been no subsequent concerns raised about her practice.
• The Registrant has been working for EMAS without restriction for the 3 years since the events that led to this Hearing.
• The Registrant has engaged in the investigation undertaken by her employer, EMAS.
• The Registrant was the subject of an extended period of mentorship in the months following this incident.
• The Registrant has fully engaged in this Hearing and with the HCPC process.
• The Registrant is well regarded by her colleagues.
• The Registrant in her role of mentor to student paramedics had independently identified a wish and need to further her training and has enrolled on a suitable degree course which has increased her knowledge and skills.
• This was a complex and difficult multifaceted situation which occurred early in her career when she was dealing with a patient with a complex history.
In relation to the aggravating factors the Panel has identified the following:
• The Registrant made denials at the outset of this hearing.
• When informed on 12 June 2018 that Patient A had died, she had not taken it upon herself to contact a senior manager to provide any relevant information nor to identify any personal involvement. She had waited till a letter of complaint arrived before providing information that may have been helpful to the wider organisation.
• The Registrant has not shown any remorse, apology, or regret beyond a factual acceptance
• The Registrant has not made any admissions as to where she could have improved her practice other than in relation to her record keeping.
• The Registrant has not shown sufficient insight into this incident, and this is reflected by her lack of understanding of what she did not know and should have done in this difficult and complex situation. There is still very limited insight and reflection into the boundaries of her own knowledge which led to her working independently without support.
• Further she has not reflected upon the overall impact of her actions on the family, not just in attending this hearing and having to revisit those events but the events of the day and for the intervening period of three years.
99. In deciding what is the appropriate and proportionate restriction the Panel started its deliberations at the bottom of the scale and worked its way up till it found one which balanced the interests of the Registrant, service users and the wider public.
100. The Panel considered that the option of taking no further action was inappropriate in this case where there has been limited remediation of the Registrant’s clinical and professional failings. The option of mediation was inappropriate in those circumstances.
101. The imposition of a Caution Order would not, in the Panel’s view, provide any degree of service user protection and further would not address the failings which this Panel has now identified. The Panel’s decision not to impose a Caution Order is supported by the terms of the Sanctions Policy which states that a Caution Order is appropriate where there has been appropriate remediation, there is a low risk of repetition, and the Registrant has shown good insight. Those elements are not present in this instance.
102. The Panel then considered whether it was appropriate and proportionate to impose a Conditions of Practice Order. In considering this the Panel considered the following terms of the HCPTS Sanctions Policy which states that a Conditions of Practice Order may be appropriate where:
• The registrant has insight;
• The failure or deficiency is capable of being remedied;
• There are no persistent or general failure which would prevent the registrant from remediating;
• Appropriate, proportionate and realistic and verifiable conditions can be formulated;
• The panel is confident the registrant will comply with the conditions;
• A reviewing panel will be able to determine whether or not those conditions have or are being met; and
• The registrant does not pose a risk of harm by being in restricted practice.
103.The Panel further noted that that the HCPTS guidance states that ‘conditions will only be effective in cases where the registrant is genuinely committed to resolving the concerns raised’.
104.The Panel has again considered the evidence of the Registrant. It has noted that she is willing and committed to complying with any conditions this Panel imposes. It has been implicitly indicated that her employer is willing to support the Registrant and has provided her with further mentoring and training since the event to help her learn and remediate her practice.
105.Although the Panel has found that the Registrant had not gained sufficient insight into all the events that led to the complaint and to this hearing, it noted that the deficiencies are remediable and that the Registrant had started to address the record-keeping element of her poor practice. The Panel considers that with the correct supervision and support of her employers, together with ongoing training, the remaining deficiencies in her practice could be addressed. Further, she could be assisted in developing insight and more meaningful reflective practice beyond that which she has already received in the last three years.
106.The Panel also considered that there was a public policy need to retain a paramedic who is held in regard by her Trust and colleagues, and where the events leading to this hearing involved an isolated incident and where no further concerns have been raised subsequently. The Panel has noted that she is a registrant committed to improving her clinical knowledge and practice.
107.The Panel has concluded that it is possible in this instance to formulate conditions of practice. When formulating the conditions set out below, the Panel had focused upon the matters it identified which require remediation. These are clinical assessment and differential diagnosis, communication, issues of informed consent, escalation of concerns, and record-keeping.
108.The Panel in considering whether those conditions are proportionate and provide the relevant level of service user protection looked at whether a period of suspension was necessary for such service user protection. In this regard the Panel took into consideration the fact that the Registrant had worked to date without any cause for concern. She has undertaken further training and whilst only having limited insight has developed some insight. The Panel has, as stated above, considered the public interest in the retention of the Registrant’s skills for the benefit of the service users. The Panel considers that the conditions it has drafted are robust enough to ensure such service users’ protection and that in all the circumstances a period of suspension would be disproportionate.
109.The Panel in accepting that conditions are appropriate in this instance is satisfied that they will provide sufficient protection to the public by ensuring that the Registrant’s practice is supervised, monitored and remediated to the standard expected.
110.The Panel determined that a period of twelve months with production of information as identified in the Order, should be sufficient for the Registrant to demonstrate the level of learning and insight required. The Panel has chosen not to exercise its discretion to limit the Registrant’s ability to call for an early review


Order: The Registrar is directed to annotate the Register to show that Lisa Bond is the subject of a Conditions of Practice Order for a period of twelve months.

The Conditions are:

1. You must work with a senior clinician as your personal Supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice:

a. Identification of clinical red flags within patient presentation and the formulation of differential diagnosis.

b. Understanding the application of the mental capacity act including informed consent and the process of obtaining informed consent or the refusal thereof.

c. Your referral of onward care of patients where they are not conveyed to hospital.

d. Your practice in the area of clinical escalation within the Trust where you are faced with clinical concerns which compete with patient autonomy.

e. Ensuring that your record keeping is accurate, comprehensive and comprehensible.

2. You must maintain a record of every case where you have undertaken treatment but where the patient has not been conveyed or not been referred to another health care provider which must be signed by your personal supervisor, and you must:

a. provide a copy of these records to the HCPC on a three-monthly basis, the first report to be provided within three months of the Operative Date, or confirm that there have been no such cases during that period; and

b. make those records available for inspection at all reasonable times by any person authorised to act on behalf of the HCPC.

3. Within 6 months of the operative date satisfactorily complete a period of learning around the Mental Capacity Act and cases where informed consent must be gained prior to conveyance and treatment or refusal of such.

4. You must maintain a reflective practice profile detailing your reflection on patient cases involving:

a. Identification of clinical red flags within patient presentation and the formulation of differential diagnosis.

b. Your referral of onward care of patients where they are not conveyed to hospital.

5. You must provide a copy of that profile to the HCPC on a three-monthly basis or confirm that there have been no such occasions in that period, the first profile or confirmation to be provided within three months of the Operative Date.

6. You must provide a reflective piece of writing in relation to the events on 11 June 2018 and the impact of your actions on Patient A, his family members who were his carers.

This order will be reviewed again before its expiry on 18 October 2022.


A Hearing was held via video-link and Conditions of Practise were imposed.

Hearing History

History of Hearings for Ms Lisa Bond

Date Panel Hearing type Outcomes / Status
31/08/2022 Conduct and Competence Committee Review Hearing Interim Conditions of Practice
13/09/2021 Conduct and Competence Committee Final Hearing Conditions of Practice