Mrs Kielye L Mitchell

Preliminary Matters

Service

1. The Registrant did not attend the hearing. The Panel was satisfied that notice of the hearing was sent to the Registrant at her registered email address on 17 May 2022. A confirmation of delivery was available to the Panel. The email sent to the Registrant contained the date and time of today’s hearing. The Registrant responded to an email from the Hearings Officer on 25 May 2022, stating that she would not be attending the hearing. She asked that a letter/reflective piece and a certificate for a Sepsis course be placed before the Panel.

Proceeding in the absence of the Registrant

2. On behalf of the HCPC, Ms Khorassani invited the Panel to proceed in the absence of the Registrant. She submitted that the Registrant was clearly aware of the hearing and had decided not to attend. No useful purpose would be served by an adjournment. Moreover, this is a mandatory review, and it is in both the Registrant’s interest, and the wider public interest, for the review hearing to take place before the order expires.

3. The Legal Assessor drew the Panel’s attention to the guidance provided in the HCPTS Practice Note ‘Proceeding in the Absence of the Registrant’.

4. The Panel considered the advice of the Legal Assessor and the guidance provided in the Practice Note.

5. The Panel is aware that its discretion to proceed in the absence of a Registrant is one that should be exercised with care and caution. The Panel was satisfied that there had been good service and that the Registrant had decided not to attend today’s hearing. There was no application for an adjournment. The Panel concluded that the Registrant had voluntarily absented herself. This is a mandatory review and the Panel has a duty to review the current Suspension Order. The Panel has concluded that it is appropriate to proceed in the absence of the Registrant.

Background

6. The Registrant is a Paramedic registered with the HCPC. She is employed by the East of England Ambulance Service NHS Trust. At the time of the events set out in the Allegation, the Registrant had worked as a Paramedic for around 16 years.

7. The Registrant was stationed at Colchester Ambulance Station. On the morning of 8 March 2016, Person B (Patient A’s husband) contacted 111 to report that his wife, an otherwise healthy 60-year-old, was unwell. An ambulance was dispatched to her home address. The Registrant attended with her colleague (SH) and transferred Patient A to hospital. Patient A died in the early hours of 9 March 2016. Following a complaint by Person B, the hospital and the Ambulance Service conducted internal investigations. Person B also referred the matter to the HCPC in December 2016. In summary, the case against the Registrant was that she had failed to adequately record or monitor Patient A’s deteriorating condition, which was a form of sepsis, and that she failed to take certain actions.

Substantive Hearing 30 January – 6 February, 13-14 June 2019

8. The Registrant attended the Substantive Hearing and gave evidence. All factual particulars (1-9) of the allegation were found to be proved.

9. The Registrant’s actions or omissions for all but the first two particulars were found to amount to misconduct in that the original panel held that they fell far below the standards expected of a registered Paramedic. Whilst acknowledging that there were extenuating circumstances outside the Registrant’s control, in that there were unusual delays in admitting Patient A to the hospital on the day, the original panel was troubled by the Registrant’s lack of understanding and awareness regarding her own failure to see that Patient A was demonstrating obvious and worsening signs of cyanosis, which was a red flag indicative of circulatory compromise. The panel found that the Registrant’s failings contributed to denying Patient A timely care.

10. The original panel expressed concern about the Registrant’s lack of initiative in documenting Patient A’s deterioration and her lack of insight into her own conduct and the effect this had had on Patient A and her family. The original panel also had concerns about her apparent lack of regard for the impact on others and her lack of remorse. She blamed other staff and minimised her own responsibility. She had not undertaken any reflection apart from one occasion in 2016. There was therefore a risk of repetition. The panel thus found impairment on both personal and public interest grounds.

11. The original panel reconvened to consider sanction on 13-14 June 2019 and took account of the Registrant’s apology to the family of Patient A in a reflective piece, together with evidence of courses she had undertaken and positive testimonials from senior colleagues. A Suspension Order of 12 months duration was determined to be the appropriate and proportionate sanction. The panel indicated that a period of suspension would enable the Registrant to provide the following evidence that would assist a reviewing panel:

i. Reflections on patient advocacy

ii. A report from a paramedic mentor, concerning the failings in this case;

iii. A Personal Development Plan (PDP) on the failings identified.

First Substantive Review

12. A substantive review was conducted on 1 June 2020. That panel concluded that the Registrant’s fitness to practise was impaired on both the personal component and the public component.

13. The reviewing panel noted that the Registrant still did not accept all the findings of the panel at the substantive hearing but reminded itself of the principle confirmed in Yussuf v GMC [2018] EWHC 13 (Admin) that a Registrant is entitled not to accept the findings of a panel or tribunal and that their lack of acceptance does not prevent a review panel from determining that their fitness to practise is no longer impaired. It accepted that the Registrant was entitled to contest the Allegation in this case and raise points of mitigation. The reviewing panel acknowledged that the Registrant had an otherwise unblemished career, that there were significant extenuating circumstances and that the original incident was more than four years ago.

14. The Registrant had continued to be employed as a Senior Emergency Medical Technician (EMT).

15. The panel found that the Registrant remained preoccupied with her own strong sense of injustice at the outcome of the hearing and that she continued to focus on her own predicament rather than developing her insight and demonstrating how she had remedied her original misconduct. In particular, she had not provided a reflective piece on patient advocacy as expected by the original panel. The panel determined that the Registrant’s failings were capable of remedy, especially in view of her long experience and her positive testimonials, but it was not satisfied that she had provided sufficient evidence of insight into her own failings and remediation so as to allay the original concerns. In the absence of such evidence, there remained a risk of repetition.

16. The Registrant’s fitness to practise therefore remained impaired on personal grounds. The panel determined that a finding of impairment was necessary in the wider public interest to protect the public and to maintain public confidence in the profession. A reasonable and informed member of the public would expect such a finding in the absence of greater evidence of remediation and/or insight. That panel extended the Suspension Order for a further 12 months.

Second Substantive Review

17. The second substantive Review took place on 1 June 2021. The Registrant provided the documentation requested by the previous reviewing panel. It included details of courses undertaken by the Registrant and a reflective piece on patient advocacy (the “Patient Advocacy Statement”). The Registrant also provided an email that responded to material lodged by the HCPC which had been provided to the HCPC by Person B (widower of Patient A).

18. The Panel accepted that the Registrant had had an otherwise unblemished career as a paramedic. The events set out in the Allegation appeared to be a one-off event, albeit an extremely serious one. The panel found that the Registrant had clearly reflected on the incident. She had apologised to Patient A’s family and had provided reflective statements, including a letter and the Patient Advocacy Statement.

19. The panel found that the reflections showed a degree of insight on the part of the Registrant. However, having considered all of the available material, the reviewing panel was not satisfied that the Registrant had developed sufficient insight into the events underlying the Allegation. Moreover, the panel was not satisfied that the Registrant had adequately addressed the concerns raised by the previous panel. It found that the Registrant still held a strong sense of injustice in relation to the underlying events and the regulatory proceedings. The Registrant had stated that: “I feel I was left to take the failings of the NHS as a whole on my shoulders, I should have been supported in getting my patient seen. Unfortunately, it is in the news all the time regarding long delays at hospitals and very sick patients waiting in the backs of ambulances with Paramedics”. She had stated: “Myself and my colleague were the only ones within the hearing who experienced what happened that day from start to finish. In the HCPC hearing it is very easy to look at things black and white, unfortunately in emergency care, nothing is ever black and white, nothing is ever textbook. I did what I thought was my best that day in the circumstances presented to me and have continually reflected over how we could have improved the situation right from the patient’s home address through to the final handover at hospital. By going through this process, I have become a much stronger person, more confident and knowledgeable in my profession”.

20. The panel found that Registrant had continued to focus on the impact that the underlying events had had on her. The Registrant had not addressed the impact that the facts found proved would have had on Patient A or on Patient A’s family. She did not address the impact the events found proved would have had on public confidence in the profession.

21. The second reviewing panel therefore found that the Registrant continued to be impaired on the personal and public components and imposed a further 12 month Suspension Order.

Today’s Hearing

The Registrant’s letter/reflective piece

22. The Registrant provided a letter/reflective piece which was undated which stated that since the last review hearing she had continued to work as a Senior Emergency Medical Technician. She stated that since the original incident she had not received a single complaint.

23. Addressing her insight into the impact of her failings on Patient A’s family and Person B, she stated that she thinks about the pain that Person B and his family feel everyday at the loss of a wife and mother, missing her voice and her presence. She wrote:
“I understand that there are no words that I could offer the family to make the loss of their mother and wife any more bearable,…”

24. In terms of her personal development and insight, she stated that she had continued to update her knowledge. She has now attended three Sepsis courses and spent time with the Sepsis Lead in A&E at Colchester Hospital. She stated that her ability to recognise potential transitional reverse/ cold sepsis is now up to date. In addition, she recently attended a Sepsis Awareness Course which she had funded herself. The course is CPD accredited and CQC compliant. The course included:-

• Understanding and identifying sepsis

• Risk factors from Sepsis

• Treatment options in Sepsis

• Finding the source of infection in Sepsis.

25. The Registrant stated that she had become an advocate on Sepsis and had worked to help improve her colleagues understanding of Sepsis, stressing the importance of watching for signs and understanding the potential speed of a patient’s decline. She stated that knowledge of Sepsis in the East of England Ambulance Service had improved. She also stated that she and her colleagues had worked through the Covid 19 pandemic. The Registrant referred to failings outside her control.

26. The Registrant stated that she had thought about that day when Patient A died “many many times for the last 6 years, its all I have thought about on most days. My biggest change would be pushing to off load and make the hospital responsible for supporting me in my concerns for her decline in observations especially during the last few years, where it has been published on an almost daily basis about the pressures of ambulances being made to wait with incredibly unwell and time critical patients on board for hours and hours outside of A&E departments. I am aware that the investigations such as blood tests, treatment and advanced drug therapy that a Sepsis patient needs apart from the basic treatment that we as ambulance clinicians are able to give, are not available on the back of an ambulance.”

27. At the end of her letter/ reflective piece, she stated that she had made the difficult decision to give up her job “that I had always loved”. She stated that she did not intend to practice as a Paramedic in the future.

28. She went on to state that the last 6 years had been a stressful time for her and her whole family and that she had received “some negative responses” following articles in the press.

29. Appended to the letter was the Sepsis Awareness Certificate dated 7 February 2022.

The HCPC submissions

30. Ms Khorassani made oral submissions to the Panel. She invited the Panel to extend the Suspension Order for a further 12 months. She acknowledged that the Registrant had provided a further reflective piece and evidence of attending a self-funded Sepsis course. She stated that the Registrant was developing insight but that it wasn’t yet there.

31. She submitted that the Registrant remains impaired in that she has not provided sufficient up to date evidence to show that there are no longer any risks to the public.

32. She went on to state that it is unclear whether the Registrant is still working as a Senior Emergency Medical Technician. She invited the Panel to impose a further period of suspension to give the Registrant one last chance to show that that she had developed sufficient insight. She argued that there was insufficient assurance for a Conditions of Practice Order to be appropriate.

Decision

33. 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.

34. 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.

35. 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.

36. 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,

37. 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.

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

39. 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. The Panel has had regard to the HCPTS Sanctions Policy.

Impairment

40. 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.

41. The Panel remains satisfied that the conduct is remediable. The Panel notes that the Registrant has had an otherwise unblemished career. The incident appears to be a one-off.

42. In terms of the personal component the Registrant’s reflective piece/ letter shows an increased awareness of Patient A’s family. It shows that the Registrant has continued to develop her knowledge on Sepsis and that she has recognised her duty to ensure that any patient with signs of Sepsis is prioritised.

43. The Panel finds that the reflective piece/letter prepared for this hearing left questions unanswered. There is an underlying tone to the letter which displays that the Registrant still has a strong sense of injustice, whilst at the same time showing improved insight. On the face of the reflective piece, it appears that the Registrant still places an over reliance on delays in A &E, rather than fully accepting her own failure to identify an emergency.

44. The Panel did not have up to date references from the Registrant’s Line Manager attesting to her current practice nor was there evidence of continued professional development (save the course on Sepsis). The Panel was not sure whether the Registrant is still working as a Senior Emergency Medical Technician. In the circumstances, the Panel shares the concerns of the previous panels that the Registrant has not demonstrated sufficient meaningful remediation or insight for it to confidently conclude that the risk of repetition is low. Due to the serious nature of the misconduct, the Panel has determined that it would have needed to hear oral evidence from the Registrant and from her Line Manager to consider whether the Registrant has developed real and meaningful insight into her failings.

45. On the evidence available, the Panel is not reassured that there would be little or no risk of repetition if the Registrant was permitted to return to practice. The Panel therefore concluded that the Registrant’s fitness to practise remains impaired on the personal component.

46. The Panel next considered the public component of impairment. The Tribunal considered the public interest requirements that arise in this case to be significant. The Registrant’s failures contributed to a fatality. 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

47. 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.

48. 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.

49. 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.

50. A Caution Order is not appropriate because the Registrant has not provided sufficient evidence of remedial action being taken such that the risks identified by the previous panels have been reduced.

51. The Panel next considered a Conditions of Practice Order. The Registrant did not attend the hearing. She did not provide a letter from her Manager proposing Conditions of Practice. There was no evidence that conditions could be formulated which would be workable and realistic. 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.

52. The Panel next considered a Suspension Order. It has noted that the panel at the substantive hearing and the two earlier review panels have found that the Registrant’s failings to be remediable and that a Suspension Order was appropriate.

53. It also notes that the Registrant has engaged since the last review hearing and that she worked as a Senior Emergency Medical Technician throughout the Covid 19 pandemic. It is six years since this incident and there are no further complaints relating to her conduct that the panel is aware of.

54. The Registrant has continued to develop her knowledge around Sepsis and has partially met the suggestions of the last panel.

55. The Panel is concerned that the Registrant chose not to attend the hearing today. The last paragraph of the Registrant’s letter/reflective piece suggests that she has taken a considered decision to leave the profession of Paramedic. The Registrant’s position appears inconsistent because the rest of the letter/reflective piece suggested that the Registrant is still working as an Emergency Medical Technician and is trying to remediate her failings as a Paramedic.

56. The Panel is aware of drift in this case. In this context and in the context of the Registrant’s non-attendance and declaration that she intends to leave the profession, the Panel considered whether a Striking-Off Order was appropriate.

57. It reminded itself that a Striking-Off Order is a sanction of last resort. As the Registrant has continued to develop insight and remediate her failings, it has concluded that such an order would be premature.

58. However, the moment is fast approaching when this will not be the case and the Registrant’s most recent assertion that she intends to give up her profession does not bode well.

59. The Panel has determined that the 12 month Suspension Order requested by Ms Khorassani would serve no useful purpose. The Registrant now needs to seriously consider her position. The Panel has determined that a 6 month Suspension Order is proportionate, so that the Registrant can make an informed decision about her future.

60. The Registrant should be aware that a future panel is likely to impose a Striking -Off Order when this case is next reviewed. In the event that the Registrant is committed to her profession, a future panel is likely to want to hear oral evidence from her and from her Line Manager so that it can determine both insight and the management of risk going forward. A future panel will also be assisted by all of the reflective pieces and references that the Registrant has provided in the past.

Order: The Registrar is directed to suspend the registration of Ms Kielye Mitchell for a further period of 6 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 January 2023.

History of Hearings for Mrs Kielye L Mitchell