William Munro

Preliminary Matters

Service

1. A Notice of Hearing dated 8 November 2022 sent to the Registrant’s e-mail address on the HCPC register, informed him of the date and time of the hearing and that it would be conducted by video conference.

2. The Panel found that there had been good service of the Notice of Hearing in accordance with the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003.

Proceeding in the absence of the Registrant

3. Ms Khorassani made an application for the hearing to proceed in the Registrant’s absence in terms of Rule 11 of the Conduct and Competency Rules.

4. She referred the Panel to emails from the Registrant to the HCPC dated 2 December 2022 in which he stated ‘I am presently travelling in South East Asia. I have very limited technical skills and as I also mentioned find the process of Group video conferencing very intimidating and alien. I will therefore not be attending the meeting.’

5. Ms Khorassani submitted that the Registrant had voluntarily absented himself, that there was no evidence that not to proceed today would result in his attending on another occasion and any disadvantage to him was outweighed by the public interest in proceeding.

6. The Panel accepted the advice of the Legal Assessor and took into account the guidance as set out in the HCPC Practice Note “Proceeding in Absence”.

7. The Panel determined that it was reasonable and in the public interest to proceed with the hearing for the following reasons:

i. The Panel found good service in terms of the Notice of Hearing;

ii. the Registrant had stated in his emails that he would not be attending the hearing;

iii. The Panel therefore formed the view that the Registrant had voluntarily absented himself from the hearing and was unlikely to attend at a future date even if the Panel adjourned today;

iv. There has been no application to adjourn and no indication from the Registrant that he would be willing or able to attend on an alternative date and therefore re-listing the hearing would serve no useful purpose;

v. The Panel noted its duty to act in a manner which was in the public interest and in order to achieve that aim should act in a fair, economical and expeditious manner. Therefore, taking all of the aforementioned points into account and noting that this was a mandatory review of an order due to expire on, 6 January 2023. The Panel determined that it should proceed in the absence of the Registrant because the public interest in proceeding with the case outweighed any detriment to the Registrant in not being present.

Background

8. The Registrant was a Paramedic at the time of the alleged incident and had been employed by the Welsh Ambulance Services NHS Trust (WAST) since January 2014.

9. On 28 January 2019, the HCPC received a fitness to practise referral from WAST in respect of the Registrant’s conduct during his attendance to an emergency call on 6 January 2019. On 6 January 2019, two emergency medical technicians, Colleagues A and B (the “first crew”), were attending to Patient A, who was reported to have attempted to end her life by consuming alcohol and medication. When the first crew arrived at the scene Patient A was intoxicated and verbally abusive. Colleagues A and B were unable to persuade Patient A to go to hospital and they contacted ambulance control to request assistance.

10. In response to this request, ambulance control sent a second crew, the Registrant and Colleague C. Colleague C was a Newly Qualified Paramedic undertaking her fourth shift since qualifying. Patient A was transferred from the property to the first crew’s ambulance and taken to hospital.

11. After Patient A had been handed over to hospital staff, Colleagues A and B discussed the events and decided to report the incident to their Clinical Team Leaders. They each completed a DATIX report, a written record of the events. A locality manager, SS was instructed to carry out an investigation into the events reported on the DATIX forms. In SS’s investigation he identified a further concern that the Registrant had not completed a PCR in relation to the incident, but had relied on the PCR completed by Colleague B.

12. On 9 December 2021, a panel of the Conduct and Competence Committee found Paragraphs 1(i) – (iii) and 2 of the Allegation proved. That panel further found that the Registrant’s Fitness to Practise was impaired by reason of his misconduct.

13. That panel found as follows:

‘The Panel notes that although the Registrant made no admissions to the HCPC Allegation other than he accepted that he was “out of order”’. He stated:
• “I reacted badly and allowed my feelings to get the better of me. I was in the wrong. My language was improper, my manner brusque at best, and I was over assertive with the patient and in my use of equipment. I was also clearly unhappy at the conduct of the crew that my colleague and I were sent to assist”.

The panel considered that this statement demonstrated some insight, but the Registrant then continued in his statement of his position to minimise the seriousness of his conduct. He stated:
• “I mean no defiance or denial however, when I state that I also do, and always have done, dispute the extent of my wrongdoing…. I believe that my actions at the event were wrong but not as blameworthy as has been proposed…Overall, I do not believe that any further sanction is either required or necessary. I present no danger to the public and I do cherish my professional registration”.

The panel noted that in all statements the Registrant is critical of Colleague A and Colleague B and their management of Patient A. In his initial interview with SS, the Registrant placed significant emphasis on the fact that he had not received conflict resolution training. The absence of such training has no relevance to the Registrant’s use of unnecessary force or to threat and unacceptable language he used to Patient A. In the panel’s view, the Registrant deflects responsibility from himself and criticises others. The panel also considered that the Registrant demonstrated little understanding of the role of the regulator and the purpose of professional regulation. He referred to his employer’s disciplinary proceedings and the penalties imposed and submitted that no further sanction is required. There was no evidence before the panel that the Registrant has reflected on the potential impact of his behaviour on the reputation of the profession.

In the panel’s judgment the Registrant has demonstrated limited insight.

The panel considered that the Registrant’s conduct in particular 1 is behavioural and attitudinal in nature, and the panel recognised that such matters are more difficult to remedy. However, the panel considered that the misconduct in this case may be remediable, but that there would only be a prospect of the Registrant demonstrating remediation if he demonstrated a sufficient level of insight and a commitment to engage with the HCPC regulatory process.

In his written submissions, the Registrant chose to provide the panel with information about matters at WAST which did not relate to the HCPC Allegation. It appeared from his submissions that the Registrant is not currently practising as a Paramedic. The Registrant referred in his submissions to a WAST corrective action plan, but he provided no evidence about the content of this plan, or any steps that he had taken as part of that plan.

In his lengthy submissions, the Registrant did not provide the panel with information about what he has learned from the incident, how he might act differently in future, or what he has done to address his past behaviour. The panel concluded that the Registrant has not demonstrated that he has remedied the misconduct.

Having considered the level of the Registrant’s insight and the absence of evidence of remediation the panel decided that there is a real risk that the Registrant would repeat similar behaviour and put patients at risk of harm.

The panel therefore decided that a finding that the Registrant’s fitness to practise is impaired is required to protect service users from the risk of harm.

The panel also considered the wider public interest including the need to uphold the required standards of conduct for Paramedics and to uphold public trust and confidence in the profession. Although the Registrant’s misconduct was a single incident which occurred in a very short space of time, it involved multiple breaches of the Standards of Proficiency for Paramedics and the HCPC Standards of Conduct, Performance, and Ethics. The Registrant failed to treat Patient A with dignity and respect, and put Patient A at serious risk of harm, which is entirely unacceptable. The gravity of the incident is indicated by the impact that it had on Colleagues A and B, both of whom were shocked by the Registrant’s behaviour. Informed members of the public would be particularly concerned by the Registrant’s use of unnecessary physical force and by his language. The panel decided that a finding of current impairment is therefore required in relation to the “public” component of impairment.

The panel therefore concluded that the Registrant’s fitness to practise is currently impaired. He has in the past put a patient at unwarranted risk of harm and is liable to do so in the future, and he has in the past and is liable in the future to bring the profession into disrepute.’

In relation to sanction the substantive panel found the following aggravating features:

• Multiple instances of misconduct in one call out;
• No evidence of remediation;
• Limited insight (as described in the panel’s decision on impairment);
• Real risk of repetition;
• The Registrant was the most senior clinician.
• The panel identified the following mitigating features:
• No evidence that the Registrant’s conduct was premeditated;
• Not a pattern of unacceptable behaviour over a stretch of time.

The panel considered the sanctions in ascending order of severity. The panel decided the Registrant’s misconduct is of a nature and gravity that the option of taking no action would be entirely insufficient to protect the public and to maintain public confidence in the profession. The Registrant’s use of unnecessary force might be described as a form of violent behaviour, where a more serious sanction is likely to be appropriate because such behaviour is likely to affect the public’s confidence in the profession (paragraph 93 of the SP).

The panel considered the option of a Caution Order but decided that it would be insufficient. The guidance in paragraph 101 of the SP was not applicable because the panel has found that there is a real risk of repetition, the Registrant has demonstrated limited insight, and has not provided evidence of remediation. A Caution Order would not impose a restriction on the Registrant’s practice as a Paramedic and it would not provide a sufficient measure of protection against the risk of repetition of similar misconduct. A Caution Order would also be insufficient to mark the gravity of the Registrant’s breach of multiple professional standards.

The panel next considered the option of a Conditions of Practice Order. The panel decided that conditions of practice would be insufficient to mitigate the risk of repetition the panel has identified. The panel decided that the Registrant has not demonstrated a sufficient level of insight for conditions of practice to be appropriate. The panel was also of the view that conditions of practice would not currently be workable. Although the Registrant has engaged with the HCPC to some extent, he has not attended the hearing and the panel has little information about his current circumstances. The Registrant described himself as an “ex- Paramedic”.

The panel also decided that a Conditions of Practice Order would be insufficient to mark the gravity of the Registrant’s departure from the required standards for Paramedics. A more serious sanction was necessary to send a clear message to members of the public and the profession that the Registrant’s behaviour on 6 January 2019 was entirely unacceptable.

The panel then considered guidance in the SP on a Suspension Order. The panel considered that this case did not involve all the factors highlighted in paragraph 121 of the SP. The panel considered the Registrant’s submissions to the HCPC and was of the view that it was uncertain whether he may be able to resolve or remedy the misconduct. The Registrant’s recognition that his behaviour on 6 January 2019 was wrong was positive, but for the reasons explained in the panel’s decision on impairment he has demonstrated limited insight. In its decision on impairment the panel was of the view that the Registrant’s conduct might be remediable. Therefore, in these circumstances, given the uncertainty described, the panel decided that it would be disproportionate to impose a Striking Off Order.

In reaching its decision that a Striking Off Order would be disproportionate, the panel had regard to the SP. A Striking Off Order is a sanction of last resort. It is the appropriate sanction for serious misconduct where the Registrant lacks insight and is unwilling to resolve matters. The panel considered that at this stage it is uncertain whether or not the Registrant is willing to resolve matters.

Having decided that a Striking Off Order would be disproportionate, the panel decided that a Suspension Order was the appropriate sanction.

Having decided that a Striking Off Order would be disproportionate, the panel decided that a Suspension Order was the appropriate sanction. The panel considered that a Suspension Order was sufficient to protect the public because the Registrant would not be permitted to practise as a Paramedic, and this protects against the risk of repetition. A Suspension Order was sufficient to maintain public confidence in the profession and to uphold the required standards for Paramedics. A Suspension Order is a serious sanction which sends a very clear message to members of the public and the profession that the misconduct in this case is entirely unacceptable.

The panel decided that the Suspension Order should be for the maximum period of twelve months. The panel considered that any lesser period would not be sufficient to mark the gravity of the Registrant’s misconduct. A twelve-month period would also allow sufficient time for the Registrant to read and reflect on the panel’s decision, begin the process of remediation, and prepare evidence for a review panel.

The panel therefore decided that the appropriate and proportionate sanction is a twelve-month Suspension Order. The panel took into account the Registrant’s interests but decided that they were outweighed by the need to protect the public and the wider public interest.

The Suspension Order will be reviewed before it expires. A future review panel may be assisted by the following evidence:

• A written reflective piece including the Registrant’s learning from the incident on 6 January 2019 and consideration of the impact or potential impact of his conduct on the patient, colleagues and the reputation of the profession;

• Evidence of any remediation (e.g. relevant training courses, personal development plan);

• Evidence that the Registrant has kept his knowledge and skills up to date;

• Testimonials/references from employment paid/unpaid.

14. The Registrant emailed the HCPC on 27 November 2022 and 2 December 2022. He advised that he was travelling in South East Asia on ‘a voyage of discovery.’ He expressed regret and apologised for his actions. He further stated that he had sought counselling which ‘had a very positive outcome’ and attended classes and read profusely on behaviour in the workplace.

Today’s Review Hearing

Submissions

15. Ms Khorassani, on behalf of the HCPC, told the Panel the current Suspension Order was due to expire on 6 January 2023. She set out the background leading up to today’s hearing. She set out the powers available to the Panel and submitted that the role of the Panel was to review the existing order and set out the approach the Panel should take in conducting the review. She submitted that it was for the Registrant to demonstrate that he had acknowledged the deficiencies identified by the substantive panel and had appropriately addressed them.

16. Ms Khorassani submitted the current Suspension Order should be extended.

17. Ms Khorassani accepted that the Registrant in his recent emails to the HCPC had further expressed regret and remorse in relation to what had occurred.

18. Ms Khorassani submitted that whilst the Registrant in his emails had referred to volunteering at St John Ambulance for a short time in the UK and ‘shadowing medics’ whilst abroad he had failed to provide any details of this or documents evidencing it. Ms Khorassani further submitted that whilst the Registrant had also referred in his emails to counselling again, he had failed to provide any details of this counselling or how it has assisted him in relation to the regulatory concerns identified by the substantive panel.

19. Ms Khorassani submitted that the Registrant required to provide more evidence of his remorse and insight including a reflective piece, evidence of work undertaken and a report from his supervisor.

Decision

20. The Panel is mindful that its task today is not to go behind the decision of the previous panel but to determine whether or not the Registrant’s fitness to practise remains impaired and if there is current impairment, what, if any, order should be made when the current order expires. The Panel has considered all the relevant evidence. The Panel took into account the submissions of Ms Khorassani, together with the advice of the Legal Assessor. The Panel also took into account the contents of the emails from the Registrant to the HCPC dated 27 November 2022 and 2 December 2022. In reaching its decision, the Panel has exercised its own independent judgement.

21. The Panel considered the relevant Practice Notes issued by the HCPTS, ‘Review of Article 30 Sanction Orders’ and ‘Finding that Fitness to Practise is Impaired’’, together with the HCPC’s Standards of Conduct, Performance and Ethics and the HCPC Sanctions Policy (SP).

22. The Panel first considered whether the Registrant’s fitness to practise is currently impaired. In reaching this decision, the Panel has considered both the personal component and the public component.

23. In relation to the personal component, the Panel noted that the substantive Panel had concluded that the Registrant had demonstrated limited insight. The substantive panel further concluded that the Registrant’s conduct was in particular 1 was behavioural and attitudinal. That Panel considered that the Registrant’s conduct ‘may be remediable, but that there would only be a prospect of the Registrant demonstrating remediation if he demonstrated a sufficient level of insight and a commitment to engage with the HCPC regulatory process.’

24. The Panel considered that there had been limited engagement by the Registrant since the substantive hearing.

25. The Panel further considered that the Registrant had continued to show some regret and remorse for his actions. However, the Registrant had failed to engage and attend this hearing. The Panel further considered that the Registrant’s overall engagement with the HCPC since the substantive hearing was limited.

26. Having considered the recent emails from the Registrant, the Panel determined that the Registrant had failed to demonstrate any significant development in his insight since the substantive hearing and that the Registrant’s insight therefore remains limited.

27. The Panel also determined that, whilst the Registrant has referred to volunteering for St John Ambulance and ‘shadowing medics’ he had not provided any evidence of the nature and extent or results of his volunteering or shadowing, or any reports or references from those supervising his volunteering or shadowing. The Panel did, however, note that in his email of 2 December 2022 to the HCPC the Registrant had stated that he was trying to “reconnect” with the several companies he had worked with and would “endeavour to write a reflective piece”.

28. Similarly, the Registrant in his emails has referred to seeking counselling but has failed to specify what counselling he may have undertaken and how this may have assisted him in addressing the concerns identified by the substantive panel.

29. The Panel noted that the substantive panel had stated that any reviewing panel might be assisted by the Registrant providing the reviewing panel with a written reflective piece, evidence of remediation, that he had kept his knowledge and skills up to date and testimonials. The Panel determined that the Registrant had failed to provide this information for this hearing.

30. The Panel determined that the Registrant has currently failed to demonstrate appropriate insight into the full nature and extent of his misconduct on patients, colleagues – particularly the example set to junior colleagues and the public confidence in the profession and the HCPC as a Regulator. The Panel further determined that the Registrant had currently failed to demonstrate any remediation.

31. The Panel therefore concluded that the Registrant remained impaired in respect of the personal component.

32. The Panel then went on to consider the public component of impairment. The Panel reminded itself that part of its role was to maintain professional standards and uphold confidence in the Paramedic profession. The Panel considered that there remained a risk of potential harm due to the Registrant’s misconduct. The Panel was satisfied that a member of the public, appraised of all of the circumstances of this case, would have their confidence in the profession, and the regulator, undermined if a finding of current impairment was not made on public interest grounds. The Panel therefore determined that the Registrant is impaired on the public interest component also.

33. Accordingly, the Panel concluded that the Registrant’s fitness to practise remains impaired on both the personal and public components.

34. Having determined that the Registrant’s fitness to practise remained impaired the Panel went on to consider sanction.

35. The Panel bore in mind that sanction is a matter for its own independent judgment 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. The Panel had regard to the HCPC guidance titled ‘Sanctions Policy’.

36. The Panel considered the option of a caution order. The Panel determined that a caution order would not provide adequate protection given the wide-ranging failings and ongoing risk to the public identified by the substantive hearing panel.

37. The Panel next considered the option of replacing the existing Suspension Order with a conditions of practice order. The Panel took into account that the Registrant had not attended this review hearing and had failed to provide any of the materials that the substantive panel had suggested could assist any review panel. The Panel determined that the Registrant had failed to demonstrate appropriate insight or remediation. The Panel therefore considered that due to the Registrant’s ongoing failure to demonstrate insight and remediation that conditions of practice would not be proportionate appropriate or workable.

38. The Panel next considered extending the current Suspension Order. The Panel took into account the SP and particularly the factors set out in paragraph 121 in relation to when a suspension order might be appropriate. The Panel considered that the concerns identified by the substantive panel represented a serious breach of the HCPC’s Standards of Conduct, Performance and Ethics. The Panel considered that the Registrant has demonstrated regret and remorse for his actions. The Panel further considered that, although it has determined that the Registrant has still not demonstrated an appropriate level of insight and remediation, that his most recent communications demonstrate that he continues to take steps in this process. As such the Panel considered that, at the current time, there is evidence to suggest that the Registrant may be able to resolve or remedy his failings.

39. The Panel did consider a Striking Off Order, but considered that, at the current time, this would be disproportionate. However, the Panel considered that any further reviewing panel might give serious consideration to imposing a Striking Off Order if the Registrant does not fully engage and demonstrate insight and remediation in the future.

40. The Panel determined to extend the current Suspension Order for the maximum period of 12 months. The Panel considered that this would allow the Registrant sufficient time to return to the United Kingdom and undertake further reflection and remediation prior to the next review hearing.

41. The Panel therefore decided that the appropriate and proportionate sanction is a twelve-month Suspension Order. The Panel took into account the Registrant’s interests but decided that they were outweighed by the need to protect the public and the wider public interest.

42. This extended Suspension Order will be reviewed before it expires. A future review panel may be assisted by the following evidence:

• A written reflective piece including the Registrant’s learning from the incident on 6 January 2019 and consideration of the impact or potential impact of his conduct on the patient, colleagues and the reputation of the profession. The reflective piece should also include any learning that the Registrant has taken from counselling in relation to his actions and reference any learning that he has taken from his travels and ‘voyage of discovery’.

• Details of the Registrant’s intentions with regard to returning to work as a Paramedic and how he considers this would occur.

• Evidence of any remediation (e.g. relevant training courses, personal development plan);

• Evidence that the Registrant has kept his knowledge and skills up to date;

• Testimonials/references from employment paid/unpaid.

ORDER: The Registrar is directed to extend the current Suspension Order for a period of 12 months.

The Order imposed today will apply from 6 January 2023

This Order will be reviewed again before it's expiry on 6 January 2024

History of Hearings for William Munro