Miss Debbie Porter

Preliminary Matters
Service
1. There were two Notices of Hearing in this case. The first, dated 19 May 2022, was defective in that it stated that the Panel would be meeting on the 10 June 2022 to review an Interim Conditions of Practice Order under Article 31 of the Health Professions Order 2001. An amended Notice of Hearing was emailed to the Registrant on 23 May 2022, informing the Registrant that a panel would be convening for a Substantive Review hearing under Article 30 of the Health Professions Order 2001.

2. The Panel accepted the advice of the Legal Assessor.

3. The Panel was satisfied that the correct Notice of Hearing dated 23 May 2022 was delivered to the Registrant’s registered email address. It contained the date and time of the hearing.

4. The Panel considered whether the first defective Notice of Hearing had had the potential to cause ambiguity. Whilst it noted that it was unsatisfactory to send out inaccurate information, this was clearly a human error which had been rectified in the Notice of Hearing dated 23 May 2022.

5. Further, it noted that the Presenting Officer, Ms Khorassani, sent the Registrant a separate letter on the 23 May 2022, explaining the nature of today’s hearing and the steps that the Registrant should take. This letter made it abundantly clear that this was a review following a substantive hearing.

6. The Panel has therefore determined that any residual ambiguity arising from the first email will have been clarified by the letter sent by Ms Khorassani and finds that there has been good service of the Notice of Hearing.

Proceeding in the Absence of the Registrant
7. Ms Khorassani made an application to proceed in the Registrant’s absence. She invited the Panel to proceed with today’s hearing on the basis that reasonable steps had been taken to secure the Registrant’s attendance. There had been good service and the Registrant had not asked for an adjournment or provided an explanation as to why she would not be attending. She voluntarily absented herself. She submitted that the Panel should consider the public interest in proceeding.

8. The Panel accepted the advice of the Legal Assessor and had regard to the HCPTS’ Practice Note on ‘Proceeding in the Absence of a Registrant’.

9. Under Rule 11 of HCPC (Conduct and Competence Committee) Procedure Rules 2003, a panel has a discretion to proceed in the absence of the Registrant. In reaching a decision on proceeding in the absence of the Registrant the Panel has had regard to all of the circumstances. The Registrant has been served with the Notice of Hearing and is fully aware of her right to attend today’s hearing. She has not applied for an adjournment. The Panel has concluded that the Registrant has chosen has therefore voluntarily absented herself. The Panel is mindful that public protection through the effective regulation of registrants is an overriding objective and that this is a mandatory review. For these reasons, the Panel has determined that it is in the interests of justice to proceed in the Registrant’s absence.

Background
10. The Registrant is a Paramedic who was employed by South Western Ambulance Services NHS Foundation Trust (the Trust) covering Bristol, North Somerset and South Gloucestershire at the time of the incident.

11. She was a Band 6 Paramedic at the time of the events, with approximately 7 blemish-free years’ experience as a Paramedic at the Trust.

12. The Registrant had registered as a Paramedic on 28 September 2011. The Registrant’s role, as a Band 6 Paramedic included responding to all types of emergencies and providing urgent care to patients. She had also been responsible for the supervision of junior members of staff such as Emergency Care Assistants (ECAs) and Student Paramedics when they would be assigned to work with the Registrant as part of an ambulance crew. The Registrant’s Line Manager was GH, the Trust’s Operations Officer.

13. On 20 August 2018, at 14.19 hours the Registrant attended a 999 call with Colleague 1, an ECA. The Registrant was the lead clinician on the scene. They attended to Patient A, a 31 year old male, who had a history of diarrhoea and vomiting for twelve hours. The call log stated that the crew had been informed that Patient A had been ‘shaking since 2am’, ’was dizzy and faint’, had presented with a twelve hour history of diarrhoea and vomiting, was not completely alert and had ‘messed himself’. The Registrant assessed Patient A and deemed it appropriate to leave him at home and advised the patient to self-administer Immodium, to maintain fluid intake and to call the GPs the following day if symptoms persisted. In any case Patient A and Person B were advised to call 999 if the symptoms worsened. Therefore, having given this advice and the advice having been understood by the family, the Registrant discharged Patient A.

14. The Trust received a further 999 call at 16.01 hours from Patient A’s wife, Person B. Person B stated that Patient A had started to feel worse at 15.35 hours and had collapsed to the floor at 15.40 hours. When the second ambulance crew arrived, they found that Patient A was unconscious and apnoeic and they diagnosed that he was in cardiac arrest. Emergency resuscitation measures were performed but, sadly, Patient A died, confirmed at 16.21 hours. The Police and the Coroner were informed as this was an unexpected, but not suspicious, death. A Coroner’s Inquest was held into the death of Patient A from 2 to 5 December 2019.

15. MH, Paramedic Operations Officer for the Trust and RG, Quality Lead at the time and now Clinical Lead for the Trust both conducted separate and parallel internal investigations into the concerns around the initial call out to Patient A by the Registrant. MH’s investigation was a disciplinary investigation to determine whether the readings relating to Patient A’s oxygen saturation levels had been amended. RG’s investigation focused on the clinical care that the Registrant provided to Patient A and was part of the Trust’s Root Cause Analysis.

16. On 3 October 2018 the Trust advised that a serious Incident investigation would take place. The Registrant was interviewed on 5 October 2018 to clarify the contents of her original statement dated 21 August 2018. She was asked to comment on the change of oxygen saturations. She amended her statement, signed and dated it on the same date.

17. The Registrant was placed on restricted practice on 21 August 2018 but this was lifted on 22 August 2018 after statements had been taken and after the Trust had made a decision about the Registrant’s ongoing practice. However, after the Coroner’s involvement into the death of Patient A, the Trust decided to place the Registrant back on restricted practice and change her status to that of an Emergency Clinical Assistant on 21 September 2018. After the investigation meeting of 5 October 2018, the Trust decided to suspend the Registrant from all duties until the outcome of the disciplinary process.

18. The Registrant’s disciplinary hearing took place on 7 January 2019. The allegation was of gross misconduct, in that the Registrant had failed to deliver appropriate patient care and had falsified readings in respect of a patient that she had discharged on scene. The decision letter of the disciplinary hearing was sent to the Registrant on 16 January 2019.

19. On 14 May 2019, the Registrant self-referred to the HCPC. She stated that she had undergone a phased return to work from 17 January 2019 when her suspension was lifted by the Trust, and, by 14 May 2019, had resumed all her Paramedic duties.

The Coroner’s written documentation
20. The Coroner, PH asked WM, Consultant Cardiologist at the Liverpool Heart and Chest Hospital NHS Foundation Trust, to write a report for him on the care and treatment that Patient A received from the Paramedics on the first occasion, referring to the involvement of the Registrant and Colleague 1 in Patient A’s care on 20 August 2018. In his first report dated 2 October 2019, WM addressed Patient A’s past medical history and eleven categories of comments in answer to questions from the Coroner. WM ’s conclusion was as follows:

“Conclusion and Issues…

This is a sad and very unfortunate case. I appreciate my comments are with the benefit of hindsight. I have a high regard for the ambulance service. They have to make decisions on scene. I work in a heart attack centre in Liverpool and as a consequence have close contact with Paramedics and Ambulance Teams. However, there appeared to have been several serious errors in Patient A's management.

• Patient A's symptoms do not appear to have been taken seriously, and there was an alleged comment that he may have been exaggerating his symptoms.

• There is variance and some disagreement in the accounts given by Person B and the Paramedic.

• There was lack of appreciation as to how ill Patient A was.

• Signs were missed or ignored.

• The initial observations were overwritten in order to put the observations in a better light. In addition there was failure to document the clinical rationale for such a significant alteration in the observations.

• ECG - was deemed to be unnecessary.

• Hospitalisation was also deemed to be unnecessary in spite of grave warning signs.

• Patient A received no real treatment. He was advised to take Paracetamol, sips of water and lmodium. What he required was administration of oxygen and hospitalisation.

• The golden hour was lost. In my opinion Patient A was let down by the initial Ambulance Team which led to his death.”

21. The Coroner held an Inquest that took place from 2 – 5 December 2019. He found that on 20 August 2018 ‘the Deceased, who was suffering with serious undiagnosed ischaemic heart disease, developed gastroenteritis’. ‘The medical cause of death was given as 1(a) Cardiac failure; 1(b) Ischaemic heart disease; 1(c) Coronary artery atheroma; II Gastroenteritis’. At the conclusion of the Inquest, the Coroner recorded that Patient A’s death was one of ‘natural causes contributed to by neglect’.

22. On 13 December 2019, the Coroner wrote to the HCPC raising serious concerns with regard to the Registrant’s fitness to practise.

The Substantive Hearing
23. The Registrant did not attend the Substantive Hearing nor was she represented. The panel had before it the Registrant’s self- referral dated 14 May 2019 and a response to the Allegation, dated 31 March 2021. She accepted most of the Allegation. The Panel noted in its decision that the Registrant had an unblemished record before this incident. She worked as a Paramedic after the incident. It referenced reflections in August 2018, Continued Professional Development (CPD) training in 2019 and January 2020. In addition, the substantive panel had a number of references and testimonials. It appears that the Registrant worked under an Interim Conditions of Practice Order until December 2020. At this point the Registrant informed the HCPC that she had decided to leave the profession of Paramedic.

24. This Panel notes that the determination of the substantive panel did not include the findings in relation to Particular 4 in its summary of “facts not proved”. For the avoidance of doubt, this Panel observes that no finding of dishonesty was made by the previous panel.

Summary of decision of the panel at the Substantive Hearing on Grounds an Impairment and Sanction.
Misconduct
25. The panel concluded that the facts found proved amounted to misconduct and that the Registrant’s actions and omissions surrounding the events of 20 August 2018 were serious. In the panel’s judgement, the Registrant’s identified failings both in relation to her clinical performance and in her record keeping fell seriously below the standards expected of a registered Paramedic. The panel found that the Registrant had failed to uphold her professional standards in several fundamental areas and had breached fundamental tenets of the profession. It found that the Registrant, by her actions and omissions, put the health, safety and wellbeing of a vulnerable patient at risk of harm and in so doing she had undermined the trust and confidence that the public was entitled to have in her as a registered Paramedic at the front-line of patient care. In so doing she had brought her profession into disrepute. The panel considered that the Registrant’s acts and omissions also betrayed the trust and confidence of her Paramedic colleagues.

Impairment
26. For these reasons, the panel had no doubt that the Registrant’s fitness to practise was impaired at the time of the events.

27. The panel concluded that the Registrant’s failings identified were remediable, as they occurred around a single callout to a patient and concerned sub-standard clinical practice and record keeping that, in principle, could be addressed so as to prevent recurrence in the future.

28. The panel found that the Registrant had no known matters against her before these events, and none since 2018. It noted that she was allowed to return to practice as a Paramedic by her then employer, the Trust, in 2019 after training, reflection and supervision.

29. The panel however found that the Registrant had not remediated her failings. The panel concluded that the Registrant’s remediation would have to be “full and robust to prevent the accumulation of errors that had taken place at her hands on 20 August 2018 ever taking place again in the future. The outcome for Patient A and his family was tragic and serious and the Registrant’s role in that was significant. Whilst there has been no determinative conclusion as to whether her acts and omissions that day directly caused Patient A’s demise, nevertheless the Panel was conscious that her catalogue of errors and her failure to adapt to the situation she found herself in and to have the required professional curiosity to change her overview of Patient A was a contributory factor in Patient A not being transported to hospital in a timely manner”.

30. The panel noted the Registrant’s reflective pieces dated August 2018 and January 2020 and the written evidence she produced of her CPD training at that time in 2019. The panel also took into account that the Registrant had undergone the Trust’s training and supervision in 2018/2019 and that she had been returned to unrestricted practice for a period of time in 2019, with no further failings or issues identified in that limited time. However, the panel was also aware that the Registrant’s employment at the Trust had been curtailed after the Coroner’s Inquest, that although she was returned to unrestricted practice by the Trust in 2019, the Registrant stated in her 31 March 2021 response document that she had left the profession in October 2020.

31. The panel considered that the Registrant’s second reflective piece, although revealing an improved breadth of insight into the events was incomplete. The panel concluded that the January 2020 reflective piece was lacking in relation to the Registrant fully recognising her part in the seriousness of the errors she made on 20 August 2018, their consequences and how she would address those now to prevent recurrence in the future.

32. The substantive panel concluded that it had not received any recent update on the Registrant’s reflection, nor was there any evidence that she had undertaken any recent and relevant courses to fully address her shortfalls in clinical practice and record keeping.

33. As the Registrant did not attend the hearing, she had not provided the panel with an updated account of any additional remediation she may have completed. The panel concluded that the Registrant’s insight into these events was not complete and lacked specific reference as to how she would prevent a recurrence of these events in the future. Without a complete picture of the level of the Registrant’s recent remediation, the panel was unable to conclude that she would be a safe and effective practitioner. Thus, in the panel’s judgement, the risk of repetition of these events remained.

34. The panel determined that an informed member of the public including fellow Paramedic professionals, would be dismayed to find that the Registrant was deemed to be fit to practise now. They would consider that the public would remain at risk of harm in the absence of any reassurance by the Registrant that she had addressed all the issues raised by this case with full insight into her actions and omissions.

35. The panel concluded that the trust and confidence that the public was entitled to have in the Paramedic profession, its standards and its regulatory process would be undermined if the Registrant was permitted to return to unrestricted practice.

Sanction
36. The panel noted the mitigating and aggravating factors. It listed these in the following way:-
“Mitigating factors:
• This was a one-off incident in a career lasting seven years;
• The Registrant consistently acknowledged most of her failings from an early stage;
• The Registrant expressed remorse, regret and an apology to Patient A’s family in her reflective pieces;
• The Registrant demonstrated some insight into her failings from an early time;
• The Registrant had undergone remediation by way of training and supervision organised by the Trust and had returned to unrestricted practice at the Trust by 2019;
• In her short time at the Trust in unrestricted practice during 2019, the Registrant had no further issues raised about her practice; and
• The Registrant produced positive references and testimonials reflecting that she was a trusted and valued professional

Aggravating factors
• The case was extremely serious, as it involved the Registrant’s failure to professionally adapt her practice to a patient, who was presenting with symptoms consistent with a serious underlying condition;
• By intransigently setting herself on a track that prevented her from undertaking a greater amount of routine and basic clinical tests on the patient, such as seeking further clarification from the patient’s wife and lacking sufficient professional curiosity with regard to the patient’s condition, the Registrant failed to capture a more informed overview.

37. The panel began by considering the sanction in ascending order of gravity. The panel noted that the Registrant had complied with a Conditions of Practice Order for almost 18 months but as she was no longer working and had left her Paramedic position in December 2020 no workable conditions could be formulated. It observed that the Registrant had made important decisions since the Interim Conditions of Practice Order was imposed and was therefore unable to continue her remediation journey whilst in practice.

38. In the panel’s judgement, by leaving the profession and by expressing an intention not to return to it, the panel could not be confident that the Registrant was genuinely committed to resolving the concerns raised by this case. The panel considered that there might be a situation in the future when the Registrant might change her mind and be willing to undertake what would be required of her by way of remediation. The Panel found that the proportionate order was a Suspension Order. It noted that: - “Paramedics are at the forefront of the healthcare panorama and are in the frontline of healthcare provision in a variety of scenarios when they arrive on any scene”.

39. The substantive hearing panel determined that a Suspension Order would provide the necessary protection for the health, safety and wellbeing of the public and it also would uphold public confidence in the profession and its regulatory process. It stated that a reviewing panel would be assisted by the following: -

• That the Registrant might wish to consider appearing in person before the review panel;

• That the Registrant might wish to send an updated and relevant reflective piece;

• That the Registrant might wish to provide updated and relevant CPD documentation;

• That the Registrant might wish to provide any updated references and testimonials from any employer, or others, all of whom should know the details of this case.

Today’s Hearing
40. The Registrant did not attend the hearing nor was she represented.

41. Ms Khorassani invited the Panel to find that the Registrant remained impaired. She submitted that the Registrant had not provided any fresh information to show that she had addressed the concerns raised by the substantive panel. She submitted that for all of the reasons outlined by the substantive panel, the HCPC’s position was that the Registrant remained impaired on both the personal and public component.

42. Ms Khorassani went on to invite the Panel to impose a further 12 month Suspension Order. She submitted that the HCPC’s position was that despite the Registrant’s failure to engage in this hearing or at the final hearing, that the Registrant’s failings were remediable and that she should be given one last chance to engage with her regulator and to remedy her failings.

43. The Panel accepted the advice of the Legal Assessor. She reminded the Panel that it was required to conduct a full assessment of the Registrant’s fitness to return to unrestricted practise.

44. A substantive review is a two-stage process. The first task of the Panel is to decide whether the Registrant’s fitness to practise is currently impaired and if so, to then consider what sanction, if any, to impose.

45. The Legal Assessor reminded the Panel that it must determine whether the Registrant’s fitness to practise is impaired today, taking into account the Registrant’s conduct at the time of the events and any relevant factors since then, such as whether she has developed insight, whether the matters are remediable or have been remedied, and any likelihood of repetition.

46. The Panel’s task is not to punish the Registrant for past acts. However, the Panel is required to take account of past acts and omissions in order to make an informed assessment as to whether the Registrant’s fitness to practise is currently impaired. The persuasive burden rests with the Registrant to show that she is no longer impaired,

47. The Panel was advised to take into account:
• the ‘personal’ component: the current competence, behaviour, etc of the Registrant, including any evidence of insight and efforts towards remediation; and
• the ‘public’ component: the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession.

48. The Panel has considered all the relevant material and has had regard to the HCPTS Practice Notes on ‘Impairment’ and ‘Article 30 Reviews’.

49. The Panel’s role is not to conduct a rehearing of the Allegation nor is it to go behind the previous findings. In carrying out its assessment, the Panel has exercised its own independent judgement. In considering sanction, the Panel has had regard to the HCPTS Sanctions Policy.

Decision
Impairment
50. The Panel considered the two components relating to impairment, the personal and the public component. It considered whether the conduct was remediable, whether it had been remedied and whether it was likely to be repeated. It noted that there was no new evidence of reflection or remediation from the Registrant and that the most recent communication from the Registrant was that she had left the profession of Paramedic.

51. The Panel remains satisfied that the conduct is remediable. The Panel notes that the Registrant worked following this incident, engaged with the Trust and began work to remediate her actions. The Registrant has had an otherwise unblemished career. This appears to have been a one-off incident.

52. On the evidence available, the Panel is not reassured that there would be little or no risk of repetition, if the Registrant were permitted to return to unrestricted practice now. This was an extremely serious incident with tragic consequences. The substantive panel and the Coroner found that the Registrant’s failures were serious. She failed to detect signs of serious illness and her recording was unacceptably poor. The Panel notes that the substantive panel found that although the Registrant had shown improved breadth of knowledge and insight in her reflections into the tragic events in August 2018, she had never fully recognised her part in the serious errors made.

53. The Registrant is not currently working as a Paramedic. She did not attend the Substantive Hearing or this Substantive Review Hearing.

54. There is therefore no evidence before this Panel that the Registrant has continued to develop insight nor is there any evidence of any recent remediation. She appears to have not followed the recommendations of the substantive panel.

55. This Panel echoes the findings of the substantive panel that the Registrant’s decision not to attend to speak to her insight and remediation has created “a lacuna”.

56. The Panel therefore finds that the Registrant continues to pose a risk to the public as she has not demonstrated that the gaps in her knowledge have been filled or that she has developed fuller insight. In the circumstances, her fitness to practise remains impaired on the personal component.

57. The Panel next considered the public component of impairment. The Panel considered the public interest requirements that arise in this case to be significant. In the Panel’s judgement, an informed member of the public and the Registrant’s fellow professionals would consider that the public would remain at risk of harm in absence of any reassurance that the Registrant had addressed all the gaps in her knowledge and had insight into her actions and omissions. Paramedics occupy a position of trust and vulnerable members of the community depend on them in times of crisis. The Panel considers that a reasonable member of the public would be concerned at the prospect of the Registrant returning to work wholly unrestricted. This is because she still has not shown that the public can be reassured that she would always offer an adequate level of care to patients.

Sanction
58. The Panel considered the HCPC’s Sanctions Policy and accepted the advice of the Legal Assessor that a sanction should be the least that is necessary to ensure public protection.

59. The Panel reminded itself that the purpose of a sanction is not to punish the Registrant and that a sanction must be reasonable and proportionate.

60. In this case it is not appropriate to make no order because of the serious nature of the failings identified by the original panel and the risk of repetition identified above.

61. A Caution Order is not appropriate because this was a serious incident and the Registrant has not provided sufficient evidence of remedial action being taken such that the risks identified by the previous panels have been reduced.

62. The Panel next considered a Conditions of Practice Order. The Registrant did not attend the hearing. From the information that she has provided it appears that she has not been working in the profession as a Paramedic for around 18 months. In the circumstances, the Panel could not formulate Conditions of Practice that would provide sufficient public protection, maintain confidence in the profession and which would be workable and enforceable. Accordingly, the Panel concluded that such an order would not be appropriate or proportionate.

63. The Panel next considered a Suspension Order. It has noted that the panel at the substantive hearing found the Registrant’s failings to be remediable and that a Suspension Order was appropriate and proportionate.

64. The Registrant worked after this incident both in unrestricted practice and latterly under an Interim Conditions of Practice Order. There were no further incidents. The Registrant also worked during the early part of the Covid 19 pandemic.

65. The Registrant did not attend the substantive hearing or this hearing and the Panel therefore considered whether there was merit in a further 12 Month Suspension Order as submitted by Ms Khorassani on behalf of the HCPC.

66. As the Registrant has stated that she has left the profession of Paramedic the Panel considered whether a Striking Off Order was appropriate.

67. It reminded itself that a Striking Off Order is a sanction of last resort, for persistent deliberate and reckless acts. This was an extremely serious incident, involving a sequence of serious mistakes and omissions but it was not deliberate.

68. This was a finely balanced decision because the Registrant is not engaging and has said she has left the profession of Paramedic. However, the Panel is mindful that it must impose the least restrictive option. The Panel has therefore determined that in the circumstances the Registrant should be allowed a further period of 12 months to re-engage in what will be a difficult journey to remediate her failings in the event that she wishes to resume her career as a Paramedic. It has made this decision knowing that the current Suspension Order will protect the public.

69. The Registrant should be aware that if she fails to engage the next panel is likely to consider a Striking Off Order. Any future reviewing panel is likely to be assisted by the following:
• evidence of ongoing reflection and relevant learning following the incident;
• evidence of current and relevant Continuous Professional Development;
• updated references and testimonials from any employer, or others, all of whom should know the details of this case.
Further, the Panel wishes to emphasise that attendance by the Registrant at any review is likely to be pivotal if the Registrant wishes to return to Paramedic practice.

The Registrar is directed to suspend the registration of Miss Debbie Porter for a further period of 12 months on the expiry of the existing Order.

The Order imposed today will apply from 12 July 2022.
This Order will be reviewed again before its expiry on 12 July 2023.

Right of Appeal
You may appeal to the High Court in England and Wales against the Panel’s decision and the order it has made against you.

Under Articles 30(10) and 38 of the Health Professions Order 2001, any appeal must be made to the court not more than 28 days after the date when this notice is served on you.

History of Hearings for Miss Debbie Porter