Trevor M Walsh

Profession: Paramedic

Registration Number: PA00065

Hearing Type: Final Hearing

Date and Time of hearing: 10:00 06/06/2022 End: 17:00 10/06/2022

Location: This hearing will be held virtually

Panel: Conduct and Competence Committee
Outcome: Conditions of Practice

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Allegation

As a registered Paramedic (PA00065) your fitness to practise is impaired by reason of misconduct and/or lack of competence. In that:  

1. On 05 July 2018, you attended to Patient X and you did not provide Patient X with adequate care and treatment, in that you: 

a) did not immobilise Patient X prior to moving him;

b) did not give Patient X pain relief prior to moving him;

c) did not place an oxygen mask on Patient X and/or administer a higher amount of oxygen to address his low oxygen saturations;

d) did not convey Patient X to the nearest Major Trauma Centre;

e) did not conduct a full assessment of Patient X;

f ) did not carry out further investigation to rule out tension pneumothorax when you observed diminished chest sounds on Patient X’s right side;

g) did not conduct a full assessment of Patient X’s injuries before moving him;

h) did not consider that Patient X’s reduced alertness level could have impacted his ability to recount accurately what had happened.

 

2. On 05 July 2018, you used the scoop stretcher to move Patient X in an incorrect manner.

 

3. On 05 July 2018, you did not maintain adequate records, in that you did not complete the electronic Patient Report Form for Patient X in an adequate manner, specifically you did not:

a) record your decision making and why immobilisation was not used;

b) record that you gave Patient X fluids;

c) record that you had considered Patient X’s low saturations and/or tachycardia and/or low blood pressure and/or the fact that Patient X was cold on a hot day;

d) document that you completed a further top to toe survey with equal air entry evident on Patient X;

e) document the possibility that Patient X had fallen from a height;

f) record the potential for a significant chest injury based on the observations;

g) record consideration that Patient X’s low blood pressure was an indication of a spinal injury and/or other injuries;

h) record consideration of transport to a Major Trauma Centre and/or the use of a helicopter;

i)  record an assessment of Patient X’s pelvis and/or abdomen and/or chest;

 

4. On 05 July 2018, you did not provide sufficient information during the pre-alert call and/or handover to the hospital in order to ensure a timely treatment for Patient X, specifically you did not:

a) include the possibility that Patient X had fallen from a height;

b) request for a trauma call.

 

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

 

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

  

Finding

SUMMARY

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

Allegation

On 05 July 2018, you attended to Patient X and you did not provide Patient X with adequate care and treatment, in that you:

 

(a) did not immobilise Patient X prior to moving him;

(b) did not give Patient X pain relief prior to moving him;

(c) did not place an oxygen mask on Patient X and/or administer a higher amount of oxygen to address his low oxygen saturations;

(d) -

(e) -

(f) did not convey Patient X to the nearest Major Trauma Centre;

(g) did not conduct a full assessment of Patient X;

(h) did not carry out further investigation to rule out tension pneumothorax when you observed diminished chest sounds on Patient X’s right side;

(i) -

(j) did not conduct a full assessment of Patient X’s injuries before moving him;

(k) did not consider that Patient X’s reduced alertness level could have impacted his ability to recount accurately what had happened.

 

On 05 July 2018, you used the scoop stretcher to move Patient X in an incorrect manner.

 

On 05 July 2018, you did not maintain adequate records, in that you did not complete the electronic Patient Report Form for Patient X in an adequate manner, specifically you did not:

 

(a) record your decision making and why immobilisation was not used;

(b) record that you gave Patient X fluids;

(c) record that you had considered Patient X’s low saturations and/or tachycardia and/or low blood pressure and/or the fact that Patient X was cold on a hot day;

(d) document that you completed a further top to toe survey with equal air entry evident on Patient X;

(e) document the possibility that Patient X had fallen from a height;

(f) record the potential for a significant chest injury based on the observations;

(g) record consideration that Patient X’s low blood pressure was an indication of a spinal injury and/or other injuries;

(h) record consideration of transport to a Major Trauma Centre and/or the use of a helicopter;

(i) record an assessment of Patient X’s pelvis and/or abdomen and/or chest;

(j) -

 

On 05 July 2018, you did not provide sufficient information during the pre-alert call and/or handover to the hospital in order to ensure a timely treatment for Patient X, specifically you did not:

 

(a) include the possibility that Patient X had fallen from a height;

(b) request for a trauma call.

 

The matters set out in paragraphs 1a to 4b constitute misconduct and/or lack of

 

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

 

 

Facts Proved: 1(c), 1(h) & 3 (in its entirety)

Facts Not Proved: 1(a), 1(b), 1(f), 1(g), 1(j), 1(k), 2, 4(a) & 4(b)

Grounds: Misconduct

Fitness to Practise Impaired: Yes

Sanction: Conditions of Practice Order for 12 months

Preliminary Matters

Admissions

1.             At the outset of the hearing Mr Padley, on behalf of the Registrant, indicated that Particular 2 and Particular 3 (in its entirety) were admitted by the Registrant. The Panel would take these admissions into account when deciding whether the facts were proved.

Background

2.             The Registrant is a Paramedic registered with the HCPC.

3.             At the relevant time the Registrant was employed by East Midland Ambulance Service (“the Trust”). He began working for Lincolnshire Ambulance Service in 1986, which later merged with the Trust. He initially worked as an Ambulance Technician and qualified as a Paramedic in 1992.

4.             On 5 July 2018, at 14:43, a 999 call was received in relation to Patient X. He was an 84 year old patient who was reported to have fallen off a ladder in his garden. The Registrant and his crewmate, Colleague A, an Emergency Care Assistant (ECA), were working on a Double Crewed Ambulance and attended the scene at 14:55. The Registrant assessed Patient X before transporting him to Boston Pilgrim Hospital Emergency Department. Further tests at the hospital determined that Patient X had a flail chest (an acute chest injury in which two or more ribs become detached from the rest of the ribcage) and a suspected haemo-pneumothorax (blood in the chest). Patient X passed away at the hospital.

5.             This incident was raised to the Patient Advice and Liaison Service. Staff at the hospital had concerns around why Patient X had been transported to Boston Pilgrim hospital rather than a Major Trauma Centre (MTC).

6.             The Trust commenced a Serious Incident investigation into the care of the patient and concerns were raised in relation to the treatment the Registrant provided to the patient. Amanda Davidson, a Serious Incident Investigator, conducted the investigation on behalf of the Trust.

7.             As part of the investigation Ms Davidson interviewed the Registrant. In her statement she records his responses as follows:

“I asked Trevor Walsh to give an account of what happened on 5 July 2018. Trevor Walsh told me that the crew received the call in the usual way and he thought it said the patient had fallen from a ladder. However, the patient denied that this is what had occurred. Trevor Walsh described how he and Colleague A considered contacting control about requesting a helicopter but they decided to wait until they got there to assess the situation. He said that he considered the potential mechanisms of injury and the worst case scenario.

 

Trevor Walsh said he did a top to toe” of Patient X and found that he had no neck or back pain. He said Patient X was uncomfortable when they moved his arms and legs and it seemed the discomfort was located in his right shoulder. They took Patient Xs pulse which was tachycardic, and he was a little bit clammy. Trevor Walsh said they were in a hot environment so they decided to move him to the ambulance. Trevor Walsh said he remained mindful that the patient could have fallen so they wanted to limit his movement.

 

When they were in the ambulance Trevor Walsh said that he listened to the right side of Patient Xs chest. He thought there could be diminished sounds however it was a noisy environment because the air-conditioning was on. Trevor Walsh said that Patient Xs oxygen saturation was reduced. Patient X had a score of around 14-15 on the Glasgow coma scale which indicates reduced consciousness. He told me Patient X said he had a history of high blood pressure. Trevor Walsh said that the patients blood pressure was low which may not have been normal for him; however this could have been impacted by working in the bright sunshine.

 

I asked Trevor Walsh what he would have done if he knew that Patient X had definitely fallen from the tree. He said that he would have formally immobilised the patient, and split the scoop stretcher rather than ease him onto it. He also said he would have called control to see if a helicopter was available and probably taken the patient to a MTC. Trevor Walsh identified in interview that he used to be a helicopter paramedic so he should have been well versed in how to deal with traumatic injuries.”

 

8.             A referral was made to the HCPC. As part of its investigation Kingsley Napley Solicitors, on behalf of the HCPC, instructed Mr David Lee, a Paramedic, to provide expert evidence.

9.             The witness statement of Amanda Davidson was not challenged and was admitted as hearsay evidence.

10.          Mr Lee attended the hearing and provided oral evidence based on his report dated 10 August 2021.

 

Half-time submission

11.          At the conclusion of the HCPC’s case, Mr Padley made a submission that there was insufficient evidence to find the facts proved in relation to the entirety of Particular 1, Particular 2 and the entirety of Particular 4.

12.          Mr Padley highlighted that the nature of the allegations was such that there were two parts, the factual part (did or did not something happen) and the opinion part (did it fall below adequate care and treatment, was it an incorrect manner, was the information sufficient to ensure timely treatment). Mr Padley submitted that there was no evidence to counter the Registrant’s account about what went on at the site with the patient, in the ambulance and at the hospital, because the HCPC had not called any witnesses who were there. The Panel was left, he said, with the accounts given by the Registrant and the electronic Patient Record Form (ePRF), such as it was. He said the Registrant accepted the ePRF was flawed in that he had not maintained an adequate record of what took place. Consequently, said Mr Padley, the ePRF was an unreliable document and could not be relied upon to establish what was or was not done.

13.          Mr Padley dealt with the Particulars in reverse order.

Particular 4

14.          Mr Padley said the evidence from Mr Lee was that the pre-alert call and handover would have been verbal. Mr Padley posed the question, “Is there anything the hospital did which makes the handover incorrect?” He answered his question with a “No.” There was, he said, no evidence from the hospital to suggest Patient X did not receive the timely treatment set out in the allegation. Thus, even the matters alleged in sub-particulars (a) and (b) were true the allegation would still fail since there was nothing from the hospital to say Patient X did not receive timely treatment. Furthermore, in his Trust interview the Registrant said he did let the hospital know that Patient X fell from a height and there was nothing to undermine that evidence.

Particular 2

15.          Mr Padley said that the evidence about how to use a scoop correctly came from the Registrant and Mr Lee. He said that if one were looking at a spinal injury then the scoop should be split and the patient immobilised. However, Mr Lee conceded that if the Registrant was lifting the Patient without any intention to immobilise his spine then the way in which the Registrant used the scoop would be appropriate. Mr Padley said the Registrant was not concerned with spinal immobilisation because he was concerned about the patient’s breathing and this was supported by the recorded observations. Mr Padley submitted that it was a difficult question to whether spinal immobilisation should have been considered and that one had to look at what was done and why it was done. He emphasised that on Mr Lee’s evidence if the patient was being lifted without considering spinal immobilisation then what was done was appropriate. It could not therefore be said that the scoop had been used incorrectly.

Particular 1(a)

16.          With reference to 1(a), Mr Padley said that when providing his evidence in chief Mr Lee had said the Registrant should have fully immobilised a confused patient who had fallen from a height. However, he accepted that a Glasgow Coma Score (GSC) of 14/15 did not necessarily mean Patient X was confused. Mr Lee said it could be one of three things, namely confusion, not having spontaneous reaction with his eyes or not having full moment of his limbs. Mr Lee also accepted that if there were potential respiratory issues then you would not immobilise the patient flat. The mechanism of injury in this case was, Mr Padley submitted, wholly uncertain. There was a complete absence of evidence from anyone on the ground. The evidence of a ladder against a tree did not tell us anything, he said, and this complete lack of certainty about the mechanism of injury caused difficulties for the Paramedic.

17.          Mr Padley said that Mr Lee had said it would make the patient worse if he was lying flat and had respiratory issues. Mr Lee could not say whether the decision not to immobilise was appropriate or not without being there and that the reason given by the Registrant for not wanting to immobilise was appropriate because respiration takes priority. Mr Padley submitted that bearing in mind the potential respiratory issues there is evidence of, the decision not to immobilise cannot be said to be inadequate care and treatment of Patient X.

Particular 1(b)

18.          Mr Padley said that Mr Lee agreed that intravenous paracetamol was the only appropriate pain relief in the circumstances (morphine being contra-indicted by the low blood pressure and entonox not possible because of the respiratory issues) and that the Registrant made a judgement call about when to provide it. Mr Lee said it was “difficult to make a call and one could argue it both ways”, in other words it was not wrong to decide to move him out of the sun prior to providing pain relief. Mr Padley highlighted that the allegation was about not giving pain relief prior to moving the patient and not about how long it actually took to provide pain relief. In his Trust interview the Registrant said it was a very hot day and he decided to move Patient X into the cooler environment of the ambulance. Mr Padley said there was no evidence to refute this decision and that one had to take into account environmental factors. Mr Padley submitted that if the HCPC’s expert said it was a difficult call that could be argued both ways it could not then be said that the Registrant’s decision to move Patient X before giving pain relief amounted to inadequate care and treatment.

Particular 1(c)

19.          Mr Padley submitted that if a patient refuses to allow a mask to be applied the Paramedic cannot force the patient to take it. He said the fact of the refusal should have been recorded on the ePRF and the Registrant accepted that his record was inadequate. However, Mr Padley submitted, there was no evidence of what went on in the ambulance to undermine what the Registrant said in his statement about the patient’s refusal to put on the mask. Mr Padley said the HCPC could not rely on the ePRF to prove something did not happen when its own case was that the ePRF was an incomplete document. He added that the HCPC could have taken a statement from Colleague A, the ECA, but they did not do so. He said that in the ambulance it was recorded that Patient X had a GCS of 15/15, so there was no element of confusion present at the time he refused to wear the mask.

Particular 1(f)

20.          Mr Padley said that the position was established that if the journey time goes beyond 45 minutes then it was not necessarily appropriate to go to an MTC. He said there was no evidence to suggest that Pilgrim Hospital was somewhere inappropriate to go. Mr Padley said that Mr Lee had agreed that the timing to get to an MTC was a valid issue to consider. He added that he could not comment on the geography, but if it was more than 45 mins then it is “black and white”. The nearest MTC was an hour’s journey, said Mr Padley, and there was no evidence to undermine that assertion. Accordingly, he submitted, there was no evidence to show that taking Patient X to the Pilgrim Hospital amounted to the provision of inadequate care and treatment and in fact it was the better option given the distance to the MTC.

Particulars 1(g), (h) & (j)

21.          Mr Padley dealt with these Particulars together since they related to a similar issue. He said that Mr Lee went through, in his evidence in chief, the assessment that should have been undertaken. However, he could not conclude what was or was not done in light of the questionable ePRF. Mr Padley took the Panel to the part of his Trust interview where the Registrant set out what was done. He said he did a primary survey and started a secondary ‘top to toe’ survey. He repeatedly asked Patient X if he had fallen from a tree and Patient X each time said he had not. He listened to Patient X’s chest. He placed him on a scoop to make him as comfortable as possible and there was a record of the observations taken.

22.          With reference to 1(h) Mr Padley said Mr Lee was asked to comment on what the Registrant said he had done in his statement. Mr Lee’s response was that he agreed with the approach taken and what was looked for and that if the examination was performed as the Registrant said it had been then it was a valid examination. Mr Padley said there was no evidence to gainsay the Registrant’s account and that on Mr Lee’s evidence the assessments were performed adequately.

Particular (k)

23.          Mr Padley said that, when asked, Mr Lee had said the Registrant did consider Patient X’s reduced alertness level as this was something that was recorded in the ePRF.

HCPC’s response

24.          In responding to the half-time submissions made by Mr Padley, Ms Collins, on behalf of the HCPC, argued that there was evidence to support the entirety of Particular 1 and also Particular 2. She conceded however that there was no evidence to support Particular 4.

Particular 4

25.          Ms Collins said that she accepted that both the alert call and the handover to the hospital were verbal and that the HCPC did not have evidence of what was said in those calls. She accepted that no staff had been spoken to by the HCPC and that there was, therefore, no realistic prospect of a positive finding in relation to Particular 4.

Particular 1(a)

26.          Ms Collins said Patient X was not strapped down, no head guards were used and he was not immobilised. She submitted that was not adequate. She said that Mr Lee had said it was a judgement call made in relation to what was seen at the time and what the Paramedic decided to do.

Particular 1(b)

27.          Ms Collins submitted that 53 minutes passed before pain relief was given. Whether this was adequate was, she said, a matter for the Panel. She reminded the Panel that Mr Lee said pain relief should be given at the earliest opportunity and that, with a pain score of ten out of ten (the highest possible) 53 minutes was a long time to wait. She asked was it appropriate to not give the intravenous paracetamol at the scene, since it would only take five to ten minutes and was it adequate not to give it to Patient X before moving him.

Particular 1(c)

28.          Ms Collins reminded the Panel that in his Trust interview the Registrant had said he did not put a face mask on the patient as he felt it would agitate him. There was therefore, she submitted, evidence that no oxygen mask had been used when it should have been.

Particular 1(f)

29.          Ms Collins submitted that it was a question of fact that Patient X was not transported to an MTC. She said no phone call was made to the MTC to see if they would accept the patient or whether the Air Ambulance could get Patient X to the MTC any more quickly. She added that it was more than 45 minutes to drive to the MTC and that Mr Lee had accepted it was a judgement call. Ms Collins said it was for the Panel to decide whether the Registrant had “made the right judgement call.”

Particulars 1(g)(h) & (j)

30.          Ms Collins approached these sub-particulars jointly in a similar way to Mr Padley. She submitted that Mr Lee’s evidence had been that further tests could have been done and that if a full assessment had been done the life threatening injuries could have been identified. She said Mr Lee maintained his position that it was unlikely that a full chest examination was done. He also said that two sets of observations was the minimum that should have been done and he would have liked to have seen more so that comparison could be made to monitor the progress of the patient.

Particular 1(k)

31.          Ms Collins submitted that a GCS of 14/15 had been recorded by the Registrant so there was a lower level of consciousness at that point and it was a matter for the Panel, she said, to decide whether the Registrant had considered the impact this could have had on the patient’s ability to recount accurately what had happened.

Particular 2

32.          Ms Collins submitted that the scoop should have been divided up, but that it had not been. Instead it had been used purely for transportation with no straps or head blocks used. Ms Collins said it went back to the question of whether Patient X should have been immobilised and that it was an issue for the Panel to decide whether the Registrant “made the right decision.”

The Panel’s decision

33.          The Panel considered the submissions with care and accepted the advice of the Legal Assessor, who referred to the cases of R v Galbraith [1981] 1 WLR 1039 and R v Shippey [1988] Crim.L.R. 767 and the HCPTS Practice Note on ‘Half-time submissions’. The Panel decided to only decide at this stage whether sufficient evidence had been adduced to prove the facts alleged and that it would hear any further submissions on the statutory grounds and current impairment if the parties wished to make any such submissions following its decisions on the facts.

34.          The HCPC’s case relied heavily on the expert evidence of Mr Lee. Mr Lee provided a Report. In that Report he made reference to the documents he considered when writing the Report and they included the Registrant’s statement dated February 2020. The Panel noted, however, that Mr Lee had not referred to, or offered an opinion on, much of the detail provided by the Registrant in that statement. When giving his evidence Mr Lee said that he did see the statement when writing his report, although he became vague about when he saw the statement and at one stage appeared to suggest he may not have seen the statement prior to writing part of the Report.

35.          The Panel had its doubts about whether Mr Lee had in fact seen the Registrant’s statement prior to making his report given the lack of reference to much of the detail provided by the Registrant in response to the matters alleged against him. Consequently, in order to clarify matters, the Panel asked Mr Lee questions based on the explanations given by the Registrant in his statement. Mr Lee’s answers to those questions, and others put to him by Mr Padley, contradicted the expert evidence he had previously given and called into question his reliability as an expert witness. Furthermore, Mr Lee (not unreasonably) relied on documentation in a case where the Registrant accepted that he had failed to maintain adequate records, so the records were of limited assistance.

36.          It is important to note that the Panel had not been provided with any witness evidence from anybody at the scene where Patient X was found, other than the evidence provided by the Registrant. For example, there was no statement from the ECA who was with the Registrant when he attended the emergency call. Furthermore, there was no evidence from any witnesses who received the pre-alert call and/or handover and no evidence from any witnesses at the hospital. Amanda Davidson carried out the investigation but was not a witness to any of the matters alleged. In her investigation reference was made to witnesses who would have been key in this case but the Panel was not provided with any evidence from them, other than third-hand hearsay, which the Panel considered carried little weight since it could not be verified or tested.

37.          The Panel considered in turn each of the Particulars Mr Padley submitted were not supported by the evidence and, like Mr Padley, approached them in reverse order.

Particular 4

38.          There was no witness evidence provided to support this Particular and Ms Collins, on behalf of the HCPC, conceded as much. There was no witness statement from the person taking the pre-alert call, no witness statement from the person taking the handover and no evidence from anybody at the hospital to say that Patient X did not receive treatment in a timely manner. The only evidence was tenuous at best in that it was third-hand hearsay which, as stated above, could not be verified or tested and therefore carried little weight. In the absence of any cogent evidence it was clear that this Particular must fail.

Particular 2

39.          The allegation in 2 is that the Registrant used the scoop stretcher to move Patient X in an incorrect manner. Mr Lee talked the Panel through the usual way in which the scoop stretcher is used by splitting it, before then joining the two halves together under the patient. Mr Lee said he had seen it used differently, such as for a log roll, but that was when up to five people would roll the patient on to it. That was not the case here. The Registrant used the scoop like a long board by tilting Patient X onto it because, he said, the ground was lower on one side. Mr Lee’s evidence and the ‘Users Manual’ of the scoop make it clear that the scoop should be separated and placed under a patient from each side before then being connected together and the patient lifted. This was not the way in which the Registrant used it, as he readily accepted. When interviewed by the Trust the Registrant said “If he had definitely fallen from the tree, I would have formally mobilised him on the scoop. I would have split the scoop rather than ease him onto it, it was not the most comfortable.”

40.          In his oral evidence, however, Mr Lee said that the way in which the Registrant used the scoop, when not considering the need for spinal immobilisation, was appropriate. Since the Registrant’s assessment at the time was that there was no need for spinal immobilisation it followed that, according to the HCPC’s own expert witness, what the Registrant did was not incorrect.

41.          In light of Mr Lee’s qualification to his earlier evidence and his acceptance that what the Registrant did was appropriate if he was not considering spinal immobilisation, the Panel concluded that there was insufficient evidence to find this fact proved.

Particular 1(a)

42.          When deciding the sub-particulars in Particular 1, the Panel referred back to the stem each time, which stated: “On 5 July 2018, you attended to Patient X and you did  not provide Patient X with adequate care and treatment, in that you:” This was the opinion part of the allegations referred to by Mr Padley and which relied exclusively on the evidence provided by Mr Lee.

43.          1(a) alleged that the Registrant did not immobilise Patient X prior to moving him. The Registrant accepted that he did not immobilise Patient X, because he gave priority to the issue of Patient X’s respiration.

44.          Mr Lee said that to treat someone in a sitting up position can be adequate if the assessment made is that there is a respiratory issue. Mr Lee confirmed that the observations recorded suggested that there was a respiratory issue. Mr Lee said that the need to ensure a patient is breathing takes priority over all other issues so that even if there was a spinal concern it might not have been wrong not to have immobilised Patient X, but rather to focus on the respiratory issue. It could not then be said that the Registrant’s decision not to immobilise Patient X amounted to a lack of adequate care and treatment.

45.          The Panel therefore accepted Mr Padley’s submission that there was no case to answer in respect to Particular 1(a).

Particular 1(b)

46.          Patient X had a pain score of 10/10. Mr Lee said with a score that high you should give pain relief as soon as possible. This would not only start to relieve the pain but would also have other beneficial effects such as reducing stress levels and making it easier for the Patient to communicate. It was not disputed by the Registrant that the pain relief was not given before moving Patient X. Mr Lee did not disagree with the Registrant’s subsequent decision to use IV paracetamol, but considered that it should have been given before moving Patient X, given the high threshold of pain reported by the patient. However, Mr Lee also said that as soon as possible might mean after you have moved the patient. He said that it was a difficult call to make, it was a judgement call to be made by the clinician on the scene at the time and one could argue the matter both ways. In other words it was arguable that pain relief should have been given prior to moving him and also arguable that it was adequate to have given it after moving him.

47.          With the expert accepting it could be argued both ways, the Panel concluded that there was insufficient evidence to prove that the Registrant’s decision to move Patient X before giving pain relief amounted to the provision of inadequate care or treatment. Certainly there appeared to the Panel to have been an excessively long wait before Patient X was finally given pain relief, but that is not what is alleged here. The allegation was focused on whether pain relief should have been given before moving Patient X and Mr Lee, the expert, said it could be argued both ways. Mr Lee said it was not what he would have done but that it was credible and justifiable not to have given pain relief before moving Patient X. That being the evidence, the Panel could not see how this could amount to a lack of adequate care and treatment provided to Patient X.

48.          The Panel thus accepted Mr Padley’s submission in relation to Particular 1(b).

Particular 1(c)

49.          Mr Padley submitted that there was no evidence of what went on in the ambulance to undermine what the Registrant now said in his statement about trying to put a mask on Patient X and Patient X resisting it. However, in the Trust interview on 11 July 2018 the Registrant said “I didn’t put a face mask on the patient to give him more oxygen as I felt it would agitate the patient, I felt I could end up taking too much time trying to get the spo2 to work when there was other things to be doing. I realise now I should have tried an oxygen mask as the only way to know if he would tolerate it would have been to try it.”  Furthermore, in the Trust interview the following day the Registrant acknowledged that he had presumed the patient wouldn’t tolerate an oxygen mask and this is why he remained with a nasal cannula but admitted he should have tried high flow oxygen with a non-rebreathe mask in line with JRCALC guidelines.

50.          There was, then, evidence before the Panel that the Registrant had not applied an oxygen mask to Patient X and this did, therefore, undermine the Registrant’s later assertion that he did try to put a mask on the patent but that the patient resisted.

51.          Mr Lee said “The JRCALC Clinical Practice Guidelines 2016, Oxygen Administration, state that high levels of supplemental oxygen must be delivered through a reservoir oxygen mask so that a target saturation of 94-98% SPO2 is achieved in all cases of major pulmonary haemorrhage and Hypovolaemic shock. There is however a risk of a respiratory depression in patients with Chronic Obstructive Pulmonary Disease (COPD) however there was no evidence to suggest that Patient X had COPD therefore high levels of supplemental oxygen should have been delivered.” No challenge was made to this evidence.

52.          The Panel was thus satisfied that there was sufficient evidence to prove Particular 1(c) and Mr Padley’s submission on this Particular therefore failed.

Particular 1(f)

53.          It was accepted by both parties that the Registrant did not convey Patient X to the nearest MTC. However the Panel could not say this amounted to a lack of adequate care given the time it would have taken to get to the nearest MTC, which was said to have been an hour away.

54.          The Panel was taken to the Major Trauma Triage Tool used by the Trust, which stated that “If you cannot reach a Major Trauma Centre within 45 minutes, transport to nearest Trauma Unit and inform EOC.” There was no evidence to say that the Pilgrim Hospital did not have a Trauma Unit and that therefore, with the nearest MTC being more than 45 minutes away, it could not be said that the Registrant had done the wrong thing in conveying Patient X to the Pilgrim Hospital. It follows that it could not be proved that the care and treatment given by not going to the nearest MTC was inadequate.

55.          The Panel therefore accepted Mr Padley’s submission on Particular 1(f).

Particular 1(g)

56.          Mr Lee said a full assessment would be a primary and secondary survey. The Registrant did not therefore conduct a full assessment. However, when dealing with a trauma patient, Mr Lee said it is often the case that you will not do a full assessment since once you have carried out your primary survey and treated any life threatening injuries you are then focused on getting the patient to hospital. It was not then possible to say that the lack of a full assessment meant that an inadequate standard of care had been provided.

57.          The Panel therefore accepted Mr Padley’s submission on Particular 1(g).

Particular 1(h)

58.          Mr Lee was taken to the Registrant’s account of what he said he did, although the Registrant accepted that he did not document it.  Mr Lee said, “What he has said is a valid examination, I agree with the approach taken and what was looked for. If that was performed it was a valid examination.” The Panel noted the absence of any such explanation in the ePRF, but also noted the Registrant’s acceptance that his record keeping was of a poor standard. The Panel thus looked to see if there was any evidence to gainsay the latest account given by the Registrant in his February 2020 statement and put to Mr Lee in evidence.

59.          In his interview on 11 July 2018, within a week of the incident, the Registrant said, “In the vehicle I listened to the patient’s chest sounds and found there to be diminished sounds to the upper right side of the chest, and good air entry on the left.” He then went on to say “I did a second top to toe survey and found equal chest rise and fall.” This was evidence that he had done a further assessment post observing the diminished chest sounds. However, the Panel did not consider this to have been adequate to rule out a tension pneumothorax, because  as stated by Mr Lee in his expert Report the chest assessment is to “identify reduced air entry or possible audible crackles which may suggest fluid (blood). This is done by feeling the chest for crepitus (bone fractures), looking at the symmetry as the patient breathes and listening for a change in sounds both by stethoscope and percussion. Consideration to an accurate oxygen saturations reading however if this fails then to resort to gaining an ETCO2 reading.”

60.          Furthermore, later in the interview the Registrant was asked “Did you have any concerns about the patient’s work of breathing?” The Registrant replied, “No, his respiratory rate was normal.” However, the observations recorded on the ePRF were inconsistent with this response and indicated that there was an issue with Patient X’s respiration.

61.          In such circumstances, whereby the nearly contemporaneous account was contradicted by an account given much later and after time for reflection and post further training, the Panel concluded there was sufficient evidence to find this Particular proved on the basis of the responses given in interview in July 2018.

Particular 1(j)

62.          Mr Lee accepted that a full assessment of Patient X’s injuries before moving him would not be expected and that once any life threatening injuries had been identified the patient would be moved to the ambulance and conveyed to hospital as a matter of priority.

63.          The Panel therefore accepted Mr Padley’s submission on Particular 1(g).

Particular 1(k)

64.          According to the ePRF the recorded GCS was 15/15, thus providing no recorded evidence of a reduced alertness level. However, in his Trust interview the Registrant said: “We did a primary survey and found the patient to be conscious and breathing with a GCS of 14 – 15. I scored him 14 as sometimes he was hesitant with his answers to my questions but he was alert to person and situation. We were unsure at this time if the patient had any history of dementia or Alzheimer’s or any memory impairment. The patient was complaining of right shoulder pain. He appeared to be distracted by this shoulder pain. He appeared pale, ashen but not white. He was cool and clammy to touch, not hot as if he had been in the garden and sun for a long time.” This account showed that the Registrant had considered Patient X’s GCS, but not that his alertness had necessarily been reduced, simply that some of his answers were hesitant.

65.          In his evidence Mr Lee said that he considered that the Registrant had considered that Patient X’s reduced alertness level could have impacted his ability to recount accurately what had happened.

66.          There was, therefore, no evidence to support this allegation and the Panel accepted Mr Padley’s submissions that there was no case to answer in respect of 1(k).

Half-time submission on the statutory grounds

67.          Following the Panel’s decisions on the half-time submissions on the facts, Mr Padley made a half-time submission that, even if all the remaining facts were found proved they would be insufficient to amount to either misconduct of a lack of competence

68.          Mr Padley submitted that this was not a lack of competence case as there was no fair sample of the Registrant’s work and this was not one of those cases that were exceptionally serious and warranted a finding of lack of competence.

69.          Mr Padley also submitted that there was insufficient evidence to support a finding of misconduct. He said it was not just a question of making a mistake, people are allowed, he said, to make a mistake, it was about making a mistake with serious consequences. In this case he said there had been no consequences so there could not be misconduct. Mr Padley said that whilst the ePRF was clearly incomplete, there was no evidence before the Panel that a full transfer of vital information was not provided to the hospital, who then took over the care of Patient X. He added that there was no evidence that because of the faults with the ePRF the treatment received by Patient X was affected in any way. Furthermore, he submitted, there was no evidence from the hospital about how the failings affected the treatment received, or whether they caused any additional injuries. There was, he said, no evidence to show that the failures could have caused any additional harm.

70.          Mr Padley said that in relation to Particular 1(c) , this was not a case, even taken at its highest, where the Registrant had failed to give any oxygen, but rather about delivery of the oxygen at the right level. He said there was no evidence of any consequences flowing from a mask not being used.

71.          Mr Padley highlighted that Particular 1(h) represented one erroneous assessment, one mistake, in the context of an incident where other assessments could not be faulted. He said the Registrant gave reasons for why he did not immobilise, which the expert considered appropriate. He knew the indications and contra indications of medication pain relief, which is why he provided intra-venous paracetamol. Mr Padley said that in order to establish misconduct there had to be negligence to a high degree, which was not the case here and the high bar for misconduct had not been met.

HCPC response

72.          Ms Collins opposed the application and maintained that the remaining matters alleged were so serious they amounted to misconduct. She said it was the potential risk factors of each allegation which made it stand out and that actual consequences were not required. When addressing the Panel on lack of competence Ms Collins said there were three remaining allegations and each was so serious they could pass the threshold of lack of competence. She said that whilst there were no eye witness accounts from the hospital, it was possible to say the records were not adequate and they should be stand alone documents. She submitted that the tests were thus met and the alleged failings are so serious that they could be seen as misconduct or lack of competence.

The Panel’s decision

73.          The Panel considered the submissions with care and accepted the advice of the Legal Assessor. The Panel was cognisant of the fact that it was not deciding at this stage whether either alleged statutory ground was actually made out, but rather whether there was sufficient evidence, taking the HCPC’s case at its highest, to be able to find either statutory ground to be well founded.

74.          The Panel did not consider there to be sufficient evidence presented to support the statutory ground of lack of competence. The Legal Assessor advised that “lack of competence implies a standard of professional performance which is unacceptably low and which (save in exceptional circumstances) has been demonstrated by reference to a fair sample of the registrant’s work. A single instance of negligent conduct, unless very serious indeed, would be unlikely to constitute a lack of competence.”

75.          This was an isolated incident, relating to one patient on one occasion and on no basis could it be considered to be a fair sample of the Registrant’s work. Furthermore, whilst the alleged failings were, in the Panel’s view, serious, they did not amount to exceptional circumstances that would merit a finding of lack of competence.

76.          The Panel therefore agreed with Mr Padley that the statutory ground of lack of competence was not well founded.

77.          The Panel then considered whether the facts, if all found proved, could amount to misconduct.

78.          Taking the HCPC’s case at its highest, the Registrant said in his interview with the Trust that he made the positive decision not to use an oxygen mask because he thought this might agitate Patient X. That decision, if true, meant that Patient X was deprived of receiving the higher level of oxygen that he needed, according to Mr Lee. It is true to say that some oxygen was administered by way of the nasal cannula, but on the Registrant’s initial account he did not even ask Patient X if he would allow a mask to be used. There was no doubting the fact that a mask would have provided the greatest amount of oxygen to Patient X and thereby the best care. In his later statement in 2020, the Registrant said he did try and put a mask on the patient but that Patient X resisted its use. This was a factual conflict that could be explored if the Registrant chose to give evidence, but was not something the Panel could resolve at this stage of the proceedings.

79.          The real gravamen of this case is that Patient X had a serious chest injury and the Registrant appears not to have properly identified that fact. This is encapsulated within Particular 1(h), which alleges that the Registrant did not carry out further investigation to rule out tension pneumothorax when he observed diminished chest sounds on Patient X’s right side. As detailed in its reasons above, the Panel was satisfied that there was sufficient evidence presented thus far to allow a positive finding in relation to that Particular. If found proved, the Panel considers that would be a serious falling short of the standard expected of a competent Paramedic. Identifying chest injuries in fundamental to a Paramedic’s practice. The Registrant should have known how to conduct a thorough chest examination having observed the diminished chest sounds, and should have done so. This is fundamental in managing trauma. If it were to be found proved that he had not done so this would be quite shocking and could, in the Panel’s view, amount to misconduct. The Panel acknowledged that it has yet to hear from the Registrant and that this Particular has yet to be proved. However, the test at this stage of the proceedings is to take the HCPC’s case at its highest and at its highest the Registrant would have failed in a significant way in the care and treatment of Patient X.

80.          The Panel was concerned with the Registrant’s overall conduct in relation to Patient X. On that basis the alleged failure to place an oxygen mask and the very poor standard of (admitted) record keeping in conjunction with the matters alleged at Particular 1(h), if found proved, could amount to a serious failing in the care and treatment of Patient X. It is not possible to say definitively whether any of those alleged failures meant that that Patient X suffered more than he should have done, but there was certainly a risk that he did. The Panel did not agree with Mr Padley’s characterisation of misconduct requiring there to be consequences since an increased risk of consequences could be sufficient to amount to misconduct.

81.          The Panel therefore rejected Mr Padley’s submission that there was no case to answer in relation to the statutory ground of misconduct.

 

Decision on facts

82.          In reaching its decisions on the remaining facts the Panel took into account all the evidence provided, including the oral evidence of Mr Lee and that provided by the Registrant. The Panel took into account the Registrant’s experience in a long career without incident and his good character, as supported by a number of testimonials provided.

83.          The Panel also took into account the submissions made by Ms Collins on behalf of the HCPC and those made by Mr Padley on behalf of the Registrant. The Panel accepted the advice of the Legal Assessor and bore in mind that it was for the HCPC to prove its case on the balance of probabilities. It was not for the Registrant to disprove the allegations.

1(c) did not place an oxygen mask on Patient X and/or administer a higher amount of oxygen to address his low oxygen saturations - proved

84.          In his Report, Mr Lee said:

“The JRCALC Clinical Practice Guidelines 2016, Oxygen administration states that Oxygen assists in reversing hypoxia. It is documented on the ePFR that Patient X had a low SPO2 reading using more than one monitors. On the balance of probability this was due to Patient X experiencing peripheral shutdown due to their hypotension.

TW recorded that Patient X had an elevated respiration rate (26bpm) a raised heart rate (110bpm), a low systolic blood pressure (74mmhg) following a traumatic event. No competent Paramedic would fail to recognise the readings as signs of Hypovolaemic Shock.

The JRCALC Clinical Practice Guidelines 2016, Oxygen Administration, state that high levels of supplemental oxygen must be delivered through a reservoir oxygen mask so that a target saturation of 94-98% SPO2 is achieved in all cases of major pulmonary haemorrhage and Hypovolaemic shock. There is however a risk of a respiratory depression in patients with Chronic Obstructive Pulmonary Disease (COPD) however there was no evidence to suggest that Patient X had COPD therefore high levels of supplemental oxygen should have been delivered.

It is recorded on the ePRF that TW delivered 2 litres of oxygen per minute through a Nasal Cannula to Patient X. There is no recorded reason for why a nasal cannula was used on Patient X and on the balance of probability would have done little to improve their hypoxia.

No competent Paramedic would fail to administer high levels of supplemental oxygen to a patient who has fallen showing signs and symptoms of trauma and Hypovolaemic Shock.”

85.          During cross-examination the account given by the Registrant in his 2020 statement was put to Mr Lee and he agreed that you could not force a patient to put on an oxygen mask if they did not want to do so.

86.          In his 2020 statement the Registrant said:

“Unfortunately during transfer the patient couldn't tolerate the 02 re-breathe mask despite my best efforts. I therefore reverted to the use of nasal cannula and established 02 therapy with 2 L/min 02. Higher flow of 02 is not permissible via nasal cannula (JRCALC).”

87.          When dealing specifically with Particular 1(c), the Registrant said:

“On this point, if presented with a similar situation, I would provide 'blind' oxygen therapy immediately at scene and reassess the need for supplemental oxygen when the patient was loaded into the vehicle and reliable Sp02 could be measured. This would be supported by the ITLS protocol.

My patient record shows that the patient's Sp02 at scene was measured at 92%, and therefore the patient was hypoxic.

However, I did not have full confidence in this reading as pulse oximetry can be affected by strong ambient light11 and as described previously, it was a very bright day. Furthermore, the Trust had reliability issues with the pulse oximeter probes at the time of this incident. Cables were being damaged from being coiled into the pockets of the monitor. Subsequently, these cables are now fitted onto spools to prevent this.

At the time, I made the decision to re-evaluate the saturations once on the vehicle. Having done so, I confirmed the patient was hypoxic and provided oxygen therapy with a non-rebreather mask set at 15L/min. However, the patient could not tolerate the mask on his face and pulled it away. Whilst I considered the oxygen necessary to provide optimal patient care, the patient could not be persuaded to leave the mask in position.Whilst I appreciated that it would provide sub-optimal therapy, I then tried the 28% venturi face mask to see if the patient would tolerate this- rather than be without supplemental oxygen. Unfortunately, the patient could not and pulled the mask away again.

Again, fully aware that it was sub-optimal, I resorted to providing oxygen therapy via a nasal cannula - rather than have the patient denied of supplemental oxygen altogether. As such, I consider that I was adapting best practice in the patient's best interests.

I fully accept and regret that I did not document this course of action or explain my rationale on the patient record. I do, however, recall there being this variety of oxygen masks laying on the ambulance trolley when my crewmate and I took the gentleman into the receiving hospital, to corroborate this sequence of events.”

 

88.          The Registrant adopted this account in his evidence and then provided even more detail about how, in the garden, he first tried using a 100% non-rebreathe mask on Patient X, but that Patient X said he did not want it on. He then tried a 25% Venturi mask, but that too was rejected by the patient. He added that he tried the masks about four times without success, including in the ambulance.

89.          This account, however, had to be contrasted with the near contemporaneous account he gave to the Trust on 11 July 2018, when he said:

“I didn’t put a face mask on the patient to give him more oxygen as I felt it would agitate the patient, I felt I could end up taking too much time trying to get the spo2 to work when there was other things to be doing. I realise now I should have tried an oxygen mask as the only way to know if he would tolerate it would have been to try it.” 

90.          He was also asked:

“Did you have any concerns about the patients work of breathing?

No, his respiratory rate was normal.”

91.          Furthermore, in the Trust interview the following day, with a different person, the Registrant acknowledged that he had presumed the patient wouldn’t tolerate an oxygen mask and this is why he remained with a nasal cannula but admitted he should have tried high flow oxygen with a non-rebreathe mask in line with JRCALC guidelines.

92.          A further interview took place on 11 October 2018. That interview was apparently recorded and a transcript of what was said was provided to the Panel. At the beginning of that interview Amanda Davidson, the Investigating Officer, said the purpose of that interview was to clarify matters because the Registrant had picked up what he felt were inaccuracies in his original statements made in July 2018. With reference to the provision of oxygen the following exchange took place:

TW – If you do it on both it would just show gives you a little bit more reassurance, the oxygen saturations was low.

AD – At 92% saturations and the patient does not have COPD, so a patient who is not used to low saturations, how does that impact their thought process?

TW – Well obviously it cannot disturb their thought process, if they are high proxy. I think I put a couple…. did I put 2 leads on?

AD – I think you put on a nasal cannula.

TW – A nasal cannula.

AD – but you didnt go for a full oxygen mask and high flow.

TW – Again, I dont know whether it was said or whether or not it was… but it was tolerated, but again I would not have known if he would have tolerated if I had put a full mask on.

AD – Why did you not give it a go?

TW – I dont know what the thought process was there. I dont know whether to carry on talking or listening, I dont know whether this is going to make him a little more worried.

 

93.          At the conclusion of that interview Ms Davidson said to the Registrant:

"I do need to tell you before we finish up, that the coroner has requested these statements so my aim would be if you are happy I would take the recording, put it into coroners form and then send it to you for you to amend to make sure it is reflected of your account in your thought processes and then when you are happy ittruly reflective of you, you then sign it so it then goes to the coroner and I will tell you who to send it to and then you send me to keep in file as well.”

 

94.          The Registrant was asked about the inconsistencies between his accounts given to the Trust much closer to the time and the account he was now giving. He said that he did not believe the accounts of the interviews were accurate. He also said that in the July interviews the accounts provided were overviews and summaries, not a full account of what he had said. He told the Panel that he had not seen any of the interviews at any stage prior to receiving the initial bundle in this case from the HCPC. He was adamant, for example, that he would never have said there was not an issue with the breathing when there clearly was. With reference to the October 2018 interview he said he did not have a good recollection of that meeting and he did not recognise some of the questions and answers that were supposed to have been given. The Registrant accepted that none of the information about his attempts to use an oxygen mask and the reasons why he had been unable to had been recorded in the ePRF, which he acknowledged they should have been. He described his record keeping as dreadful on that day.

95.          The Registrant said that he never received a copy of the October interview to amend, as referred to by Ms Davidson.

96.          In the Panel’s view there was simply no way of reconciling the two accounts. Just days after the event he was, according to the records, telling the Trust in clear terms that he had made a decision not to try and put on an oxygen mask as it might agitate the patient. Again, according to the records, he repeated that account the following day on 12 July 2018, to a different person. Three months later in what appears to have been a recorded interview and which was designed to clear up matters he took issue with, the Registrant was still saying he had not tried an oxygen mask. This was said to the Investigating Officer, so a third person in the chain. This repeated account was diametrically opposed to the account he provided in his statement approximately 18 months later, when he said he had tried a mask and Patient X resisted its use. That account was then further embellished when he gave his evidence and was speaking about events that occurred nearly four years ago.

97.          The Panel found the Registrant’s explanation for the inconsistency in his accounts to be unconvincing. It was not plausible, in the Panel’s view, for three different people to have all recorded the Registrant’s answers incorrectly and yet be consistent with each other. The Panel considered the accounts given by the Registrant just days after the incident (and confirmed three months later in the more formal interview with Amanda Davidson) were, on the balance of probabilities, more likely to be accurate than his account given 18 months later when he had had time to reflect on what had gone wrong that day. The Panel did take into account his good character and positive testimonials, but on the strength of the evidence concluded that he had decided to change his account to paint a more favourable picture of himself in an attempt to avoid full responsibility for his failures that day.

98.          The Panel was thus satisfied that the Registrant had not placed an oxygen mask on Patient X nor had he administered a higher amount of oxygen to address his low oxygen saturations. This was not a case where he had done nothing and the Panel accepted that by using the nasal cannula the Registrant had provided some level of oxygen to Patient X. However, it was incumbent upon him to have provided the highest level possible given the presenting conditions and by not even attempting to use a mask he had failed to provide an adequate standard of care and treatment to Patient X.

99.          The Panel therefore found Particular 1(c) proved.

1(h) did not carry out further investigation to rule out tension pneumothorax when you observed diminished chest sounds on Patient X’s right side - proved

100.       In his Report, Mr Lee said:

“A Paramedic dealing with a trauma scenario would be expected to manage the scene, manage the patient and identify any potential life threatening conditions within the first few minutes of assessment. This is done through the primary survey which if followed correctly would have identified that Patient X had a chest injury, not a shoulder injury and hypovolaemic shock.

 

Based on the recorded observations, a Paramedic must follow the CABCD mnemonic, with assessment and management of the catastrophic haemorrhage, Cervical Spine, airway, breathing, circulation and disability

 

In the absence of obvious blood loss and a secure airway then a Paramedic must assess the breathing rate, administer early oxygen therapy through a high concentration mask, and assess the chest to identify reduced air entry or possible audible crackles which may suggest fluid (blood). This is done by feeling the chest for crepitus (bone fractures), looking at the symmetry as the patient breathes and listening for a change in sounds both by stethoscope and percussion. Consideration to an accurate oxygen saturations reading however if this fails then to resort to gaining an ETCO2 reading

 

Assessment of a pulse site to ascertain rate, strength, regularity and whether it is present. Evidence suggests that Patient X was showing signs and symptoms of hypovolaemic shock and if injuries allow to consider raising the legs. Patients with time critical injuries where significant internal or external haemorrhage is suspected, Tranexamic Acid should be considered to help reduce the bleeding.”

 

101.       Mr Lee was taken to the Registrant’s account in his 2020 statement of what he said he did, although the Registrant accepted that he did not document it.  In relation to that account Mr Lee said, “What he has said is a valid examination, I agree with the approach taken and what was looked for. If that was performed it was a valid examination.” The Panel noted the absence of any such explanation in the ePRF.

102.       In his 2020 statement the Registrant said in relation to this allegation:

“Again, I concede that my documentation of my assessment is inadequate, but this assessment was completed. My auscultation of the chest wall had noted the reduced air entry in the right upper lobe.

I exposed the patient down to skin and noted equal bilateral chest expansion. In keeping with the ITLS protocols I noted that there was no obvious deformity, contusions, abrasions, puncture wound, tenderness, obvious instability, crepitus, burns, lacerations or swelling. The patient denied any pain on the chest wall other than the pain from the right shoulder.

I had looked for signs of tension pneumothorax, but did not find tracheal deviation, jugular vein distension (although I appreciate the patient was hypotensive), cyanosis, subcutaneous emphysema or a deteriorating respiratory rate which would have been consistent with this chest pathology.

If presented with a similar situation, I would also perform percussion of the chest wall to elicit hyperresonance indicative of a pneumothorax. I concede that I did not perform this assessment on this occasion.

Moving forward, a Clinical Support Manager from the Trust constructed an action plan which allowed me to demonstrate my understanding of various chest pathologies (including tension pneumothorax), which I completed successfully.”

103.       This account, however, had to be contrasted with the account he gave in his interview on 11 July 2018, within a week of the incident, where the Registrant said, “In the vehicle I listened to the patient’s chest sounds and found there to be diminished sounds to the upper right side of the chest, and good air entry on the left.” He then went on to say “I did a second top to toe survey and found equal chest rise and fall.” This was evidence that he had done a further assessment post observing the diminished chest sounds. However, the Panel did not consider this to have been adequate to rule out a tension pneumothorax, because  as stated by Mr Lee in his expert Report the chest assessment is to “identify reduced air entry or possible audible crackles which may suggest fluid (blood). This is done by feeling the chest for crepitus (bone fractures), looking at the symmetry as the patient breathes and listening for a change in sounds both by stethoscope and percussion. Consideration to an accurate oxygen saturations reading however if this fails then to resort to gaining an ETCO2 reading.”

104.       Furthermore, later in the interview the Registrant was asked “Did you have any concerns about the patient’s work of breathing?” The Registrant replied, “No, his respiratory rate was normal.” However, the observations recorded on the ePRF were inconsistent with this response and indicated that there was an issue with Patient X’s respiration.

105.       When asked questions about these inconsistencies, the Registrant said  that he did not believe the overviews and summaries provided of the interviews were accurate and he stood by the account he was now giving about what action he took. As stated above he flatly denied saying that there was no problem with the breathing.

106.       The Panel did not find this to be a plausible explanation for the inconsistencies. In such circumstances, whereby the nearly contemporaneous account was contradicted by an account given much later and after time for reflection and post further training, the Panel concluded that, on the balance of probabilities, the earlier account was likely to be the more accurate one. As with his account in relation to the use of an oxygen mask, the Panel was of the view that the Registrant, having had time to think about his earlier responses, decided to provide a much more detailed account of what he said he had done, in order to minimise his conduct in an attempt to avoid full responsibility for his failures that day.

107.       The Panel therefore found this Particular proved.

3. On 05 July 2018, you did not maintain adequate records, in that you did not complete the electronic Patient Report Form for Patient X in an adequate manner, specifically you did not:

(a) record your decision making and why immobilisation was not used;

(b) record that you gave Patient X fluids;

(c) record that you had considered Patient X’s low saturations and/or tachycardia and/or low blood pressure and/or the fact that Patient X was cold on a hot day;

(d) document that you completed a further top to toe survey with equal air entry evident on Patient X;

(e) document the possibility that Patient X had fallen from a height

(f)  record the potential for a significant chest injury based on the observations;

(g) record consideration that Patient X’s low blood pressure was an indication of a spinal injury and/or other injuries;

(h) record consideration of transport to a Major Trauma Centre and/or the use of a helicopter;

(i)   record an assessment of Patient X’s pelvis and/or abdomen and/or chest. - admitted and found proved

108.       Mr Lee gave evidence that the ePRF was deficient in many respects as reflected in the Particulars above. The Registrant accepted that his record keeping was inadequate as alleged, describing it as dreadful,  and did not dispute any of the matters detailed in Particular 3(a) to (i). The Panel therefore found this Particular proved in its entirety.

Decision on statutory ground

109.       The Panel next considered whether the facts found proved amounted to misconduct. In so doing it took into account all the evidence and the submissions made by Ms Collins and those made by Mr Padley. The Panel accepted the advice of the Legal Assessor. Mr Padley conceded that if the Panel found 1(h) proved it was likely to find misconduct.

110.       The Panel found there to be a breach of the 2016 Standards of Conduct, Performance and Ethics applicable to all HCPC registrants, namely:

Standard 2 – Communication with service users and cares. Namely you must give service users and carers the information they want or need, in a way they can understand. This applied to the failure of the Registrant to actually ask Patient X if he would allow an oxygen mask to be used, rather than just make an assumption that Patient X would be agitated by the use of a mask.

Standard 6 – Identify and minimise risk

6.1 You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible. This applied to both the failure to try using an oxygen mask and the failure to carry out adequate further investigation to rule out tension pneumothorax.

Standard 10 – Keep accurate records

10.1 You must keep full, clear and accurate records for everyone you care for, treat, or provide other services to

10.2 You must complete all records promptly and as soon as possible after providing care treatment and other services

111.       The Panel also found the Registrant had breached the following Standards of Proficiency for Paramedics (2014):

Standard 4 – be able to practice as an autonomous professional, exercising their own professional judgement

(4.1) be able to assess a professional situation, determine the nature and severity of the problem and call upon the required knowledge and experience to deal with the problem

(4.2) be able to make reasoned decision to initiate, continue, modify or cease treatment or use the techniques or produces, and record the decision and reasoning

(4.3) be able to initiate resolution of problems and be able to exercise personal initiative

(4.4) recognise that they are personally responsible for and must be able to justify their decisions

Standard 10 be able to maintain records appropriately

(10.1) be able to keep accurate, comprehensive and comprehensible records in accordance with applicable legislation, protocols and guidelines

(10.2) recognise the need to manage records and all other information in accordance with applicable legislation, protocols and guidelines

112.       The Panel found Particular 1(c) proved on the basis of the account given by the Registrant in his Trust interviews, namely that he made a positive decision not to use an oxygen mask because he thought it might agitate Patient X. That decision meant that Patient X was not even given the option of a mask and was thereby deprived of receiving the higher level of oxygen that he so clearly needed. It is true to say that some oxygen was administered by way of the nasal cannula. However, there was no doubting the fact that a mask would have provided the greatest amount of oxygen to Patient X and thereby the best care. In his later statement in 2020, the Registrant said he did try and put a mask on the patient but that Patient X resisted its use. For the reasons given above the Panel rejected this later account.

113.       The Panel considered the real gravamen of this case to be that Patient X had a serious chest injury and that, notwithstanding his current account, the Registrant did not properly identify that fact at the time. This is encapsulated within Particular 1(h), which alleged that the Registrant did not carry out further investigation to rule out tension pneumothorax when he observed diminished chest sounds on Patient X’s right side. For the reasons given above, the Panel rejected the Registrant’s much more detailed ‘text-book’ account given in his statement in 2020 (and subsequently repeated in his oral evidence to this Panel) and preferred his near contemporaneous account given to the Trust. The Panel considered his failure to carry out adequate further investigation to rule out tension pneumothorax represented a serious falling short of the standard expected of a competent Paramedic. Identifying chest injuries is fundamental to a Paramedic’s practice. The Registrant should have known how to conduct a thorough chest examination having observed the diminished chest sounds, and should have done so. This is fundamental in managing trauma. The Panel considered members of the public would be shocked to hear that a Paramedic had failed in this way. It was a serious failing in the care and treatment of Patient X and, in the Panel’s view, this amounted to misconduct on its own.

114.       However, the Panel was concerned with the Registrant’s overall conduct in relation to Patient X. On that basis the failure to place an oxygen mask and the very poor standard of (admitted) record keeping in conjunction with the facts proved in relation to Particular 1(h) amounted to a serious failing in the care and treatment of Patient X. It is not possible to say definitively whether any of these failures meant that Patient X suffered more than he should have done, but there was certainly a risk that he did.

115.       In all the circumstances, the Panel was satisfied that the combination of failures, as contained within Particulars 1(c), 1(h) and 3 (in its entirety) were serious failures and amounted to misconduct.

Decision on current impairment

116.       Having found the statutory ground of misconduct to be well founded, the Panel went on to consider whether the Registrant’s current fitness to practise was impaired as a result of that misconduct. In doing so it took into account the submissions made by Ms Collins and those made by Mr Padley. The Panel accepted the advice of the Legal Assessor.

117.       The Panel considered that the matters found proved were all capable of remediation. It is also right to say that the Registrant returned to work and received additional training and there are a series of references speaking to his positive qualities post that period. On 12 June 2019 his manager wrote:

“The Division have confirmed that Trevor is fit to practice and they have no continuing concerns. There are no current restrictions on Trevor’s practice.”

118.       However, the Registrant subsequently resigned from the Trust in late 2019 and has not worked as a Paramedic since. He currently works for Marie Curie assisting nurses with the provision of pain relief for end of life patients. In addition he has worked in vaccination centres during the pandemic.

119.       The Panel was concerned about the lack of specific remediation around oxygen therapy and treating tension pneumothorax. There was a lack of targeted Continuing Professional Development (CPD) or reflection and the Panel was concerned about whether the Registrant could apply in practice what he is now saying he in fact did. In the Panel’s view the Registrant, on attending the scene, did not have the weighted index of suspicion necessary and should have considered the worst case scenario, namely that Patient X had fallen from a height. This would have ensured oxygen was given at the necessary level and the proper examination carried out. Accordingly, the Panel was concerned that although the Registrant is now able to recite what should have been done, he has not been able to demonstrate the application of that knowledge to a patient in a real life scenario.

120.       Accordingly, notwithstanding the view taken by his manager, the Registrant has not accepted that he had failed in respect of the application of an oxygen mask and by not carrying out further investigation to rule out tension pneumothorax and there was, therefore, a concern that such failures could be repeated in the future. The Registrant had demonstrated some insight but this was, in the Panel’s view, a developing insight and he would need to take full responsibility for his actions and recognise the findings of this Panel in order to demonstrate full insight. Furthermore, he had shown no insight into the impact upon the family or the wider profession of his actions and exhibited little by way of remorse for Patient X and his family. In such circumstances, given the lack of insight and remediation, the Panel considered there was a real risk that the Registrant might repeat his behaviour and that a finding of impairment on public protection grounds was required.

121.       The Panel then went on to consider whether this was also a case that required a finding of impairment on public interest grounds in order to maintain confidence in the profession and also to maintain standards within the Paramedic profession. The Registrant’s failings, whilst isolated, were serious and fundamental to the role of a Paramedic. The Panel considered that with the continuing risk that the Registrant might repeat his conduct, members of the public would have their confidence in the profession and the HCPC undermined if a finding of impairment were not made.

122.       The Panel therefore found the Registrant’s current fitness to practise to be impaired on both public protection and public interest grounds.

Decision on sanction

123.       In reaching its decision on sanction, the Panel took into account the submissions made by Ms Collins and those made by Mr Padley, together with all the written evidence and all matters of personal mitigation. The Panel also referred to the guidance issued by the Council in its Sanctions Policy. The Panel had in mind that the purpose of sanctions was not to punish the Registrant, but to protect the public, maintain public confidence in the profession and maintain proper standards of conduct and performance. The Panel was also cognisant of the need to ensure that any sanction is proportionate. The Panel accepted the advice of the Legal Assessor.

124.       The Panel considered the aggravating factors in this case to be:

•   lack of insight

•   lack of remorse

•   lack of candour during the hearing

125.       The Panel considered the following mitigating factors:

•   previous good history since 1992

•   admissions to some of the matters alleged

•   isolated incident

•   positive testimonials

126.       In light of the seriousness of the conduct, the Panel did not consider this was an appropriate case to take no further action or consider mediation, since neither would protect the public from the risks identified by the Panel.

127.       The Panel then considered whether to caution the Registrant. However, the Panel was of the view that such a sanction would not reflect the seriousness of the misconduct in this case nor protect the public. The Registrant’s failings put Patient X at risk of harm and the Panel has already concluded that there is a risk of such behaviour being repeated if the Registrant were to return to full-time, unrestricted practice. Notwithstanding the indication given by the Registrant’s manager in 2019 that she considered he was fit to practise following this incident, that was a decision reached prior to the findings of this Panel. The Registrant has not in fact practised as a Paramedic since 2019 and, as already indicated, he has, in the Panel’s view, a lack of insight into what exactly went wrong that day in July 2018 and consequently there remain matters which require remedy.

128.       The Panel was also of the view that public confidence in the profession, and the HCPC as its regulator, would be undermined if such failings were dealt with by way of a caution.

129.       The Panel next considered whether to place conditions on the Registrant’s registration. As already indicated, the Panel considers the failings to be remediable. The Panel was concerned about the lack of specific remediation around oxygen therapy and treating tension pneumothorax. There was also a lack of targeted CPD or reflection and the Panel was concerned about whether the Registrant could apply in practice what he is now saying he in fact did. In the Panel’s view the Registrant, needs to have the weighted index of suspicion necessary when attending a scene in order to ensure he addresses the concerns raised in this case. The Panel considered it important that the Registrant reflect on what went wrong that day and that whilst a tension pneumothorax is a rare condition, the Registrant needs to be aware of the circumstances when such a condition might be of concern. This would require some critical analysis by the Registrant into his decision making. The Registrant also needs to demonstrate that he can maintain proper records.

130.       The Panel noted that the Registrant is not currently working as a Paramedic. However, the Sanctions Guidance makes it clear that while conditions of practice may be imposed on a Registrant who is currently not practising, before doing so, panels should consider whether there are equally effective conditions which could be imposed and which are not dependent on the Registrant returning to practice. For example, not all training, reflection or development requires a Registrant to be in practice or have a workplace-based mentor.

131.       The Panel was therefore satisfied that it could formulate workable, realistic and appropriate conditions to protect the public, whilst allowing the Registrant to return to work as a Paramedic, should he choose to do so. The Panel was confident that such an order would reflect the seriousness of the misconduct and provide the necessary degree of protection for the public.

132.       The Panel considered a Suspension Order would be both disproportionate and unduly punitive in a case where the errors are remediable, could be easily addressed by a Conditions of Practice Order, related to an isolated incident and were seen within the context of an otherwise long and unblemished career. The Panel considered that, in all the circumstances, it would not be in the public interest to suspend a previously competent Paramedic.

133.       Accordingly, the Panel made an order directing the Registrar to place conditions on the Registrant’s practice for a period of 12 months. The Panel considered this would allow sufficient time for the Registrant to decide if he wanted to return to practice as a Paramedic and if so to demonstrate to a review Panel that he is safe to practise without restrictions on his registration. Whilst these conditions only come into effect if the Registrant takes up a post as a Paramedic, there are elements of them that he could comply with in his current role and the Panel encouraged him to do so.

134.       This order will be reviewed before its expiry.

Order

Order: The Registrar is directed to annotate the Register to show that, for a period of 12 months from the date that this Order comes into effect (“the Operative Date”), you, Trevor M Walsh, must comply with the following conditions of practice:

  1. You must undertake CPD, development and reflective practice on oxygen therapy, chest trauma and related clinical decision making together with record keeping, and provide evidence of this to the reviewing Panel.

 

  1. You must work directly at all times with another registered health care professional and follow their advice and recommendations.

 

  1. You must identify a supervisor to the HCPC, within three weeks of the Operative Date of this Order, and work with that supervisor to formulate a Personal Development Plan designed to address the deficiencies in the following areas of your practice:

 

  • oxygen therapy

  • chest trauma

  • clinical decision making

  • record keeping

  • reflective practice

 

  1. Within three months of the Operative Date you must forward a copy of your Personal Development Plan to the HCPC.

 

  1. You must meet with your supervisor on a monthly basis to consider your progress towards achieving the aims set out in your Personal Development Plan.

 

  1. You must allow your supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan.

 

  1. You must provide a reflective piece on the impact of your actions on the family of Patient X, your colleagues, the profession and the public.

 

  1. You must promptly inform the HCPC if you take up any employment as a Paramedic.

 

  1. You must promptly inform the HCPC of any disciplinary proceedings taken against you by your employer.

 

  1. You must inform the following parties that your registration is subject to these conditions:

 

  1. any organisation or person employing or contracting with you to undertake professional work;

  2. any agency you are registered with or apply to be registered with (at the time of application); and

  3. any prospective employer (at the time of your application).

Notes

Interim Order

The Panel makes an Interim Conditions of Practice Order under Article 31(2) of the Health Professions Order 2001, the same being necessary to protect members of the public and being otherwise in the public interest. 

This order will expire: (if no appeal is made against the Panel’s decision and Order) upon the expiry of the period during which such an appeal could be made; (if an appeal is made against the Panel’s decision and Order) the final determination of that appeal, subject to a maximum period of 18 months.

Hearing History

History of Hearings for Trevor M Walsh

Date Panel Hearing type Outcomes / Status
06/06/2022 Conduct and Competence Committee Final Hearing Conditions of Practice