Mr Rafal Piotrak

SUMMARY

Decision of the Health and Care Professions Tribunal, sitting as the Conduct and Competence Committee of the Health and Care Professions Council.

This is a review of a Suspension Order imposed on 16 June 2021 for a period of 12 months.

This order is due to expire on 14 July 2022.

Allegation

The following Allegation was considered by a Panel of the Conduct and Competence Committee at a Substantive Hearing on 7-16 June 2021:

1. During the course of your employment as a Paramedic with the East Midlands Ambulance Service NHS Trust, you:
2. On 14 August 2018, attended an emergency call to Patient 1 and you did not:
3. Reassess the patient’s symptoms during the secondary survey until prompted to do so;
4. […]

iii. Offer pain relief until the patient was in the Ambulance;

1. Take Entonox to the scene;
2. Flush the cannula after removing the infusion set.

1. On 14 August 2018, attended an emergency call to Patient 2 and

you did not:

1. Take an adequate history from Patient 2;
2. Assess the patient’s
3. a) Chest; and/or
4. b) abdomen; and/or
5. c) Genitourinary system;

iii. Identify and/or explore a potential differential diagnosis;

1. […..]
2. On 14 August 2018, attended an emergency call to Patient 3 and you did not:
3. Check the Patient’s radial pulses;
4. Check the patient’s temperature; and/or

iii. Undertake an initial blood pressure check without prompting prior to carrying out a BEFAST assessment;

1. [……]
2. Identify and or explore a potential differential diagnosis without prompting;
3. Conduct an abdominal assessment until prompted to do so;

vii. Carry out a bilateral blood pressure assessment until prompted to do so;

viii. Carry out a standing blood pressure check until prompted to do so.

1. [……].
2. [……]
3. […….]
4. Did not consistently provide adequate patient handovers to hospital staff.
5. On 13 August 2018, did not complete a Paramedic Clinical Assessment to an adequate standard.
6. Did not consistently demonstrate effective language and communication skills when communicating with patients.
7. The matters set out in paragraphs 1 – 2 constitute a lack of competence.
8. By reason of your lack of competence your fitness to practice as a Paramedic is impaired.

The Panel at the substantive hearing found the following:

Facts proved:  1a(i), 1a(iii), 1a(iv), 1a(v), 1b(i), 1b(ii), 1b(iii), 1c(i), 1c(ii), 1c(iii), 1c(v), 1c(vi), 1c(vii), 1c(viii), 1g, 1h, 2.

Facts not proved: 1a(ii), 1b(iv), 1c(iv), 1d, 1e, 1f.

Ground: Lack of competence proved

The Panel found the Registrant’s fitness to practise to be impaired and a Suspension Order for a period of 12 months was imposed as a sanction.

Preliminary Matters

Documents

1. The Panel had received electronic versions of a service bundle (12 pages); a hearing bundle (45 pages) which included the determination of the Conduct and Competence Committee following the hearing on 7-16 June 2021.

Service

2. The Panel was satisfied that notice of the review hearing was sent to the Registrant by an emailed letter dated 18 May 2022. The HCPC Certificate of Registration confirmed the Registrant’s email address registered with the HCPC to which the notice was sent. The Panel had sight of confirmation of email delivery dated 18 May 2022.

3. The notice of hearing specified the hearing date. It advised that the hearing would be held remotely and offered assistance in arranging a remote connection.

4. The Panel was satisfied that there had been proper service in compliance with Rule 13 of the (Conduct and Competence Committee) (Procedure) Rules 2003 (“the Rules”) and the (Coronavirus) (Amendment) Rules 2021.

          Application to proceed in the absence of the Registrant

5. Ms Welsh for the HCPC explained that following the sending of the hearing notice, a further email was sent to the Registrant on 31 May 2022 regarding this hearing.

6. Ms Welsh referred the Panel to a recent email from the Registrant to the HCPC dated 13 June 2022 in which the Registrant said:

“Hi I’m sorry I cannot attend meeting I’m working. English health system cross me already, not give me chance”

7. Ms Welsh submitted that it was clear in the light of this email that the Registrant did not intend to be present at this hearing. She submitted that it was therefore in the public interest and the interests of the Registrant for this mandatory review hearing to proceed today. 

8. The Panel considered the submissions on behalf of the HCPC and accepted the advice of the Legal Assessor. The Panel was referred to the HCPTS Practice Note of September 2018, Proceeding in Absence, which sets out relevant guidance from the cases of R v Jones (Anthony) [2004] 1 AC 1HL and GMC v Adeogba and GMC v Visvardis [2016] EWCA Civ 162. The Panel was careful to remember that its discretion to proceed in absence is not unfettered and must be exercised with the utmost caution and with the fairness of the hearing at the forefront of its mind.

9. The Panel noted that the Registrant was given the required notice of today’s hearing date. He was informed of the powers available to the Panel at this hearing. He was informed of his right to attend the hearing and be represented. He was given information and offered assistance to join the virtual hearing. In the circumstances, the Panel was satisfied that all reasonable efforts have been made by the HCPC to inform the Registrant of this hearing.

10. The Panel noted that the Registrant’s in email of 13 June 2022 indicates that he is aware that the hearing is taking place today. He has not sought an adjournment of this hearing on any ground.

11. The Panel concluded that there would be some disadvantage to the Registrant if the matter proceeds in his absence, but was satisfied this could be mitigated within the process and would ensure that the hearing is as fair as possible in his absence. The Panel was also mindful that this was a consequence of the Registrant’s own failure to engage.

12. The Panel concluded that the Registrant has voluntarily absented himself from this hearing and has waived his right to attend or be represented. He has not sought an adjournment for any reason. There is no indication that the Registrant would attend on a future date if today’s hearing were adjourned. The current Suspension Order must be reviewed before it expires on 14 July 2022. The Panel was satisfied that it is in the public interest and in the interest of the Registrant that the review hearing should proceed today.

Background

13. The Registrant had been a Paramedic in Poland and had moved to the UK to take up employment with East Midlands Ambulance Service NHS Foundation Trust (EMAS) at the time of the allegation.

14. Upon starting his employment with EMAS the Registrant completed his 6-week development course and progressed to mentored shifts on the road. The Registrant had three mentors during his transition period, all of whom reported concerns regarding his performance. The Registrant’s probation period was extended and an Action Plan was implemented in February 2018.

15. In May 2018, the Registrant was placed under an 8-week formal capability plan and was provided with additional support. On 16 July 2018 the Registrant became registered as a Paramedic with the HCPC.

16. A capability meeting took place on 25 July 2018, following which the Registrant continued to receive support, but concerns were still raised in respect of his performance.

17. On 10 September 2018, the HCPC received a referral from EMAS regarding the Registrant’s fitness to practise.

18. The Registrant’s case was the subject of a hearing before a panel of the Conduct and Competence Committee (“the original Panel”) on 7-16 June 2021. Allegations of impairment of fitness to practise by reason of lack of competence were considered. The Registrant did not attend the hearing and was not represented. The only information from the Registrant was a communication to the HCPC in which he stated:

“Hello, my Name is Rafal, I Just to work as a student paramedic in Scunthorpe, I like to tell I cannot come to hearing about my pin Number cos I have no money to travel to London, At the moment I working as a Ambulance Care Assistant with Amvale Lt, Medical private company. EMAS not give me a chance to be paramedic I needed more Time to improve my English and clinical skills its difficult to me to do that on short term. I cannot protect myself, emas leave me without any support, even working as a emergency care assistant I did suggest that but they dont, I like to be paramedic in future in UK but if I Will be well prepared for that. Im not agree for example my canniulation skills was poor, and couple diffrent skills, I expect EMAS send me to education Centre to improve my skills, I ask you to keep my pin Number please, At the moment I study Medical books in my spare Time, I give myself couple of years to improving and come back as a paramedic in UK, give me a chance I can prof my skills by anybody,

                 RAFAL PIOTRAK”

19. At the hearing, the HCPC called evidence from a number of staff from EMAS who had had interaction with the Registrant and/or observed his practice, including:

• LB, Paramedic, EMAS,
• GO, Duty Operations Manager, EMAS
• MJ, Paramedic, EMAS,
• AD, Clinical Practice Tutor, EMAS.

20. The factual allegations with the exception of certain particulars (as set out above), were found proved.

21. The original Panel concluded that the statutory ground of lack of competence was proved. In giving its decision, it stated:

“The Panel considered that in this case it has heard from a number of different witnesses about the Registrant’s performance. The context of this case is important background. The Panel has heard that a number of people who qualified in Poland as paramedics were recruited to EMAS. However, there was no understanding by EMAS of the role of a paramedic in Poland. Information subsequently obtained, after the paramedics had been provided with supernumerary posts, has revealed this role to be very different to its English equivalent. Concerns regarding the Registrant’s competence to act as an autonomous paramedic in England do not single the Registrant out as AD explained that the Registrant was far from being the worst of this intake, and that for the majority of the recruits’ equivalence was not found.

Evidence has been heard that the Registrant was provided with an extended training programme, which lasted well in excess of three months that would normally be offered to new recruits to EMAS. He was provided a number of mentors, each of whom, although adopting different approaches, made clear that they expended effort in trying to help the Registrant reach the required standards of a HCPC registered paramedic. The Registrant also received clinical management support from LB and KT.

The measures described indicate that EMAS provided substantial support to the Registrant, and that any shortcomings in his practise cannot be said to have arisen as a result of a lack of support or supervision. Rather it appears that the expected knowledge and skills, of both a language and clinical nature were not demonstrated. More than one witness has described how they found the Registrant’s professional performance to be unacceptably low in respect of a number of his patients.”

22. The original Panel found that the Registrant’s fitness to practise was currently impaired by his lack of competence in respect of both the personal and public components of impairment. In giving its decision, the original Panel stated:

“In terms of determining the personal element, the level of insight shown by the Registrant is central to a proper determination of this issue, along with his current competence and whether deficiencies have been remedied. The Panel in exercising its professional judgment to assess the Registrant’s insight have considered his correspondence with the HCPC in 2019. However, it notes that there has not been any meaningful update to that, given that the Registrant has not attended, nor provided any updated information or submitted any statements regarding his current professional practice.

The Panel has not been provided with any evidence of attempts to remediate the deficiencies in his practice. Time has elapsed since the Registrant was referred to HCPC but there has been no corresponding communication in terms of what improvements, if any, have been made in his practise during this intervening period. Accordingly, all the Panel has before it, is the assertion by the Registrant that some of his clinical skills, such as cannulisation, are not sub-standard and the more nuanced position set out by multiple witnesses to the Registrant’s deficiencies concerning how to communicate his ability to act autonomously and take the lead, despite intensive supervision and oversight.

The Registrant indicated in his e-mail on 30 July 2019, that he may need a ‘couple of years’ before reaching the required standard for a paramedic in this country. However, the panel are without any indication as to what stage the Registrant has now reached, or if any progress has been made at all. The role of a paramedic in this country is one where a Registrant would be required to take the lead in respect of communicating, assessing and treating patients. A paramedic may visit a person when they are at their most vulnerable and the potential consequences of his failings, on his patients, the reputation of the profession and the confidence that the public have in its regulator are all considerations that the Panel takes into account in making its decision as to current impairment.

In terms of the likelihood of a repetition of the Registrant’s behaviours, the Panel without evidence of improvement concerning his confidence, ability to act autonomously, and remedy the lack of competence in communicating with patients and making complete and appropriate handovers to hospital staff, cannot assess if these deficiencies have been remedied.

The Panel find both the personal and the public component to be engaged in this case. The Registrant, perhaps through no fault of his own, was unfamiliar with the expectations of the role that EMAS had in mind for him, but has conceded in effect that the standards were not one that he was able to meet in 2018. Further, that without evidence that there has been improvement and that progress has been made in meeting those standards, that the public’s confidence in the profession would be undermined if a finding of impairment were not made.

The Registrant did not have skill-based competencies that were required, such that this affected his ability to communicate effectively with patients in the course of his work as a registered paramedic or make safe handovers of patients to hospital. While some of his failures may have been exacerbated by his natural shyness, the inability to undertake assessment and communicate with patients or professional colleagues in hospital in effecting a handover are deficiencies which do not allow safe practice. Without knowing that these deficiencies have been remedied the Panel has little choice but to find current impairment.”

23. Having found that the Registrant’s fitness to practise was currently impaired, the original Panel considered the issue of sanction.

24. The Panel set out the aggravating and mitigating factors it identified as follows:

“The Panel noted that had the Registrant worked without supervision, there was a risk to patient safety on the basis that a complete patient assessment and patient handover would not have been communicated to the hospital staff. Further, this is a case in which the Registrant did not ask for help, or admit where he was struggling in relation to clinical findings, until expressly asked.

As mitigating factors, the Panel took into account that the Registrant was offered a post and recruited for a job by EMAS. They conducted a recruitment exercise where the difference between practise from a paramedic in Poland, and in England was not explained. The Registrant has exhibited some insight in acknowledging that the role and standards are different in England and Poland and that it would take him some time to reach those standards. All the witnesses indicated that the Registrant over the course of the year he worked at EMAS, he exhibited a positive attitude which demonstrated his desire to learn. The Panel also took into account that the Registrant has not had any previous fitness to practise concerns found against him”.

25. In its determination the original Panel stated:

“The Panel considered that as a professional, the Registrant ought to have sought help when it was appropriate to do so. It took into account that his personality may not have assisted him with this, as he was described as “shy”. It took into account that there were no attitudinal failings and that the issues raised as a lack of competence could be remediated with more learning, experience and confidence gained.

Where the Panel is not helped is a lack of up-to-date information from the Registrant. The Registrant did indicate his desire and willingness to learn in order to reach the standards of a HCPC registered Paramedic which he acknowledged he was not at in 2018/9. However, it has no way of knowing whether the learning, experience and confidence that his Paramedic colleagues recommended has been obtained. It cannot assess his clinical English language vocabulary at this moment in time and whether his communication and confidence have improved so as to allow him to practise safely without restriction.”

26. The sanction imposed by the original Panel was a Suspension Order for a period of twelve months.

27. The original Panel made recommendations as to information which it considered would assist a future panel at the review hearing, which were:

• Written confirmation that the Registrant still wishes to pursue a career as a HCPC registered Paramedic;

• Course certificates, showing the completion of training in clinical communication, addressing both patient assessment and effective patient handovers;

• Certificates evidencing any other relevant Continuing Professional Development;

• Any testimonials from those for whom the Registrants works in a clinical setting;

• Reflections in writing, demonstrating his insight into his lack of competence, its potential effect on his patients and his profession.

Submissions

28. Ms Welsh submitted that in the absence of any new information or engagement from the Registrant, other than his email of 13 June 2022, the HCPC’s position was that he continued to present a real risk to patients and to public confidence in the Paramedic profession. The HCPC considered that there remained to be a real risk of repetition of the concerns about the lack of competence found by the original Panel given the length of the period of supervision and support which the Registrant was afforded during his employment with EMAS.

29. Ms Welsh submitted that the Panel should conclude that the Registrant’s fitness to practise remains impaired in respect of both the personal and public components and the appropriate order is a further period of suspension of 12 months.

Decision:

30. The Panel received and accepted the advice of the Legal Assessor. The Panel was mindful of its powers upon a review of a Suspension Order under Article 30(1) of the Health Professions Order 2001 and referred to the HCPTS Practice Note, Review of Article 30 Sanctions Orders. The Panel’s task is to conduct a comprehensive review of the current order. The Panel must not seek to go behind the findings of the Panel which considered the case at the original hearing in June 2021. This Panel must first decide whether it finds the Registrant’s fitness to practise to be currently impaired by reason of lack of competence. In accordance with the guidance in the case of Abrahaem v GMC [2008] EWHC 183 (Admin), the persuasive burden to satisfy the Panel of fitness to practise at a review hearing is upon the Registrant.

31. The Panel was referred to the HCPTS Practice Note, Fitness to Practise Impairment, and to the HCPC Sanctions Policy. The Panel was advised that if it found the Registrant’s fitness to practise to be currently impaired, then it should consider what steps to take in respect of the current order in accordance with its powers under Article 30(1) of the Health Professions Order.

32. The Panel was reminded that this matter concerns a lack of competence allegation and at the date of this hearing on 15 June 2022 the Registrant will not yet have been continuously suspended for a period of two years. Therefore, the power in Article 29(6) to make a striking off order is not available to the Panel at this review hearing.

33. The Panel carefully considered all the documents presented and the submissions on behalf of the HCPC. No submissions or evidence had been provided on behalf of the Registrant. The Panel referred to his email of 13 June 2022.

34. The Panel first considered whether the Registrant’s fitness to practise remains currently impaired. The Panel carefully considered the reasoning set out in the determination of the original Panel following the hearing in June 2021, which it accepted.

35. At the original hearing the Registrant did not participate. The original Panel commented in its determination about the position it faced in the absence of evidence or up to date information from the Registrant. At this review hearing, the Registrant’s non-engagement has continued.  The only change in circumstances is that the Registrant has now been suspended from practice for twelve months and his email dated 13 June 2022, as referred to above.  

36. The Panel regretted that the Registrant has not attended the hearing today or provided up to date information to this Panel. He has not engaged substantively with the HCPC in the period since the substantive hearing in June 2021. This Panel has no new or up to date information from the Registrant, for example about his current circumstances or any action he may have taken towards remedying his lack of competence.

37. The Panel considered that the information which the original Panel recommended the Registrant should provide to assist this Panel was comprehensive and detailed. However, the Registrant has not provided any of the suggested information, including not providing confirmation that he still wishes to pursue a career as an HCPC registered Paramedic.  

38. The Panel is not able to assess whether the deficiencies in the Registrant’s clinical competencies which were identified by the original Panel, such as the inability to undertake assessment and communicate with patients or professional colleagues in hospital in effecting a handover, have been addressed, but has no evidence to confirm that they have. As the original Panel stated, such deficiencies do not allow safe practice and the Panel agrees that the Registrant would present a risk if permitted to practise without restriction.

39. This Panel is not able to assess whether there has been any change or development in the Registrant’s level of insight, but concluded that the terms of the Registrant’s recent email of 13 June 2022 suggest that there has not.

40. The Panel noted in particular the following findings of the original Panel with which it agrees:

“The Registrant indicated in his e-mail on 30 July 2019 that he may need a ‘couple of years’ before reaching the required standard for a paramedic in this country. However, the panel are without any indication as to what stage the Registrant has now reached, or if any progress has been made at all. The role of a paramedic in this country is one where a Registrant would be required to take the lead in respect of communicating, assessing and treating patients. A paramedic may visit a person when they are at their most vulnerable and the potential consequences of his failings, on his patients, the reputation of the profession and the confidence that the public have in its regulator are all considerations that the Panel takes into account in making its decision as to current impairment”.

41. Given these circumstances, this Panel agrees with the findings of the original Panel in concluding that there remains a risk to service users and that the Registrant’s fitness to practise is currently impaired in respect of the personal component of impairment.

42. The Panel is further satisfied that to permit a Paramedic with the level of deficiencies in competence identified in the findings of the original Panel would undermine public confidence in the Paramedic profession and its regulation.

The Panel therefore also finds impairment of fitness to practise in respect of the public component of impairment.

43. Having concluded that the Registrant’s fitness to practise is impaired, the Panel next considered its powers at this review hearing. The Panel considered the available sanctions in ascending order of seriousness. Its starting point was that the issues found proved at the original hearing put patients at risk. The risk of repetition identified by the original Panel remains unaddressed. 

44. The Panel was satisfied that, given the Registrant’s lack of engagement in this review process, that to take no action, to mediate or to issue a caution to the Registrant would not provide the necessary public protection or address the public interest. The Panel concluded that a conditional order would not be appropriate in circumstances where there has been no contact from the Registrant and where there is no evidence before this Panel that the Registrant’s lack of competence has been addressed. Further, given the lack of engagement from the Registrant, the Panel could not have confidence that the Registrant would engage or comply with conditions of practice.

45. The Panel considered carefully whether a further period of suspension would be appropriate. The Panel was mindful that it is not able at this review hearing to consider making a striking off order under Article 29(5) of the Health Professions Order because the Registrant has not been continuously suspended for a period of two years.

46. The Panel determined that the appropriate order is that a further period of suspension be imposed from the date when the current order expires. The Panel concluded that 12 months is the appropriate period. This will allow the Registrant a further opportunity to address the issues relating to his professional competence and to re-engage with the HCPC process. The Panel strongly urges the Registrant to do so.

47. This Panel considered the information which is likely to assist a future review Panel remains the same as recommended by the original Panel, namely:

• Written confirmation that the Registrant still wishes to pursue a career as a HCPC registered Paramedic;

• Course certificates, showing the completion of training in clinical communication, addressing both patient assessment and effective patient handovers;

• Certificates evidencing any other relevant Continuing Professional Development;

• Any testimonials from those for whom the Registrants works in a clinical setting;

• Reflections in writing, demonstrating his insight into his lack of competence, its potential effect on his patients and his profession.

ORDER:

The Registrar is directed to suspend the registration of Rafal Piotrak for a period of 12 months. 

The Order imposed today will apply from 14 July 2022.

This Order will be reviewed again before its expiry on 14 July 2023. 

History of Hearings for Mr Rafal Piotrak