Mr Piotr Nowakowski

Profession: Paramedic

Registration Number: PA42789

Hearing Type: Review Hearing

Date and Time of hearing: 10:00 16/03/2022 End: 17:00 16/03/2022

Location: Virtual Hearing via Video Conference

Panel: Conduct and Competence Committee
Outcome: Suspended

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Allegation

While registered as a Paramedic with the Health and Care Professions Council and employed with the East Midlands Ambulance Service NHS Trust, you:

1. On 11 March 2018:

a. In relation to Patient A, you:

i. Did not properly investigate Patient A’s chest pain and/or document Patient A’s OPQRSTA history within the Patient Report Form.

ii. Did not administer pain medication for Patient A’s chest pain.

iii. Did not pull the curtain closed during the abdominal and respiratory examination.

iv. Not proved.

v. Did not gain informed consent before administering Ondansetron.

vi. Administered Ondansetron incorrectly, in that you administered it over 60-65 seconds.

vii. Not proved.

viii. Administered 250mL Sodium Chloride incorrectly, in that it was not clinically indicated and/or was not administered correctly.

ix. Provided an incorrect handover to hospital by booking Patient A in with a clinical impression of dehydration.

b. In relation to Patient A, did not correctly complete the Patient Report Form in that you:

i. Did not record the patient’s gender - Not proved; and/or full next of kin contact details - proved.

ii. Did not document the patient’s breathing category, pulse rate - Not proved; and/or if there was external or internal bleeding - proved.

iii. Left the patient capacity section blank.

iv. Did not document your failed cannulation, or the time, location and clinician ID of the second cannulation.

c. In relation to Patient B:

i. Not proved.

d. In relation to Patient B, did not correctly complete the Patient Report Form in that you:

i. Not proved.

ii. Did not document that the patient was unable to give a pain score.

iii. Noted the patient had no nausea - Proved; or facial and arm weakness - Not Proved, when they were incapable of expressing this.

iv. Did not record the route of administration of oxygen and/or Clinician ID.

e. In relation to Patient C:

i. Did not offer stronger pain medication to Patient C.

ii. Did not assess distal circulation - Not proved, and/or sensation and/or movement before - proved; and/or after mobilisation and/or at skin level.

iii. Left Patient C’s Patient Report Form on the dashboard of the ambulance.

f. In relation to Patient C, did not correctly complete the Patient Report Form in that you:

i. Did not record patient GP contact details and/or next of kin details and/or if the next of kin had been informed of patient’s admission to hospital.

ii. Not proved.

iii. Did not record the time both sets of observations were taken.

iv. Did not record oxygen saturation levels and/or the patient’s pain score on the second set of observations.

2. You did not reach the required standard in the following three assessments:

a. Paramedic Level ECG recognition test, by scoring 44%.

b. Trauma Life Support scenario.

c. Online drugs paper test, by scoring 78%.

3. The matters described in paragraphs 1-2 constitute misconduct and/or lack of competence.

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

Finding

Preliminary Matters

Service

1. The Notice of Hearing dated 18 February 2022 was emailed by the HCPC to the Registrant’s HCPC registered address. This Notice confirmed that the hearing would take place by video conference today. The Panel is satisfied that there has been good service of the Notice of Hearing, in accordance with Rules 3 and 6 of the Procedure Rules.

Proceeding in Absence

2. The HCPC applied for the hearing today to proceed in the Registrant’s absence under Rule 11 of the Procedure Rules. The HCPC has not received any correspondence from the Registrant since June 2020. There is no evidence before the Panel to suggest that an adjournment would secure the attendance of the Registrant. The HCPC therefore submits that the Registrant is voluntarily absent from this hearing and any disadvantage to him is outweighed by the public interest in proceeding today.

3. The Panel received and accepted the advice of the Legal Assessor to consider the HCPTS Practice Note entitled Proceeding in the Absence of the Registrant and the guidance in: R v Jones [2002] UKHL 5, R v Hayward [2001] EWCA Crim 168, GMC v Adeogba and GMC v Visvardis [2016] EWCA Civ 162. The Panel must exercise utmost care and caution and consider all the circumstances of the case, when considering a decision to proceed in a Registrant’s absence, balancing fairness to the Registrant with fairness to the HCPC, and the interests of the public.

4. The Registrant has failed to engage with the HCPC and he has not attended this hearing despite being sent a notice of hearing. There is no good reason for the matter not to proceed in his absence. The Panel determined that it is fair, proportionate and in the interests of justice that the matter should proceed in the absence of the Registrant. The Registrant is aware of the hearing and has voluntarily waived his right to attend.

Background

5. The Registrant, a registered Paramedic, is a Polish national. He joined the East Midlands Ambulance Service (EMAS) as part of an international recruitment scheme. He commenced employment on 16 January 2017 and was subject to a nine-month probationary period. Within his first few months at EMAS concerns were raised about the Registrant’s practice, specifically in relation to his knowledge of the English language, and his knowledge and skills as a Paramedic. In October 2017, a formal review was undertaken of his probation and it was determined that this would be extended for a period of two months.

6. In or around December 2017 the Registrant took part in a capability development programme and a SMART Action Plan for 12 weeks. The Registrant was assessed on 11 March 2018 during a “ride out” with SW a Clinical Support Manager. Further assessments followed on 14 and 15 March 2018, these raised further concerns about the Registrant’s Paramedic skills and knowledge.

Decision of the substantive hearing panel

7. The Registrant did not attend the substantive hearing and did not submit any written submissions or documents. The evidence of three witnesses and a copy of the Registrant’s terms and conditions established the Registrant was registered as a Paramedic with the HCPC when he was employed by EMAS.

8. The panel stated that a number of the facts found proved were of such minor consequence that they constituted neither misconduct nor lack of competence.

9. The panel decided the following factual particulars arose from the Registrant’s lack of competence: 1(a)(i), 1(a)(ii), 1(a)(iii), 1(a)(v), 1(a)(vi), 1(a)(viii), 1(a)(ix), 1(b)(i) (in part), 1(b)(iii), 1(b)(iv), 1(d)(iv) (in part), 1(e)(ii) (in part), 1(f)(i), 1(f)(iii), 1(f)(iv), 2(a), 2(b) and 2(c). The panel did not consider any of the matters found proved constituted misconduct but found the Registrant failed to reach the standards required of a Newly Qualified Paramedic.

10. The matters found proved related to a wide range of issues. A number of which were repeated in respect of each patient. They related, for example, to documentation, assessment, medication administration, handover, and not meeting the required standards in assessments. The HCPC witnesses referred to the Registrant’s lack of knowledge, which did not reach the standard expected of a registered Paramedic. SL, the Registrant’s mentor for a 12-week period, estimated that 50% of the Registrant’s issues stemmed from poor command of the English language and 50% from lack of clinical knowledge. The witnesses agreed that the Registrant was, as a result, not capable of safe, autonomous practice.

11. The Registrant failed a capability review due to insufficient knowledge, skills, competence and ability and, as a consequence, poor judgement. There was sufficient evidence to constitute a fair sample of the Registrant’s work and the acts and omissions found proved constituted an overall lack of competence on the part of the Registrant.

12. The Registrant had not submitted any material to the panel for its consideration. There was thus no evidence of insight, no reflection into what occurred, and no evidence to address the lack of competence or steps taken to resolve or remedy the lack of competence. The Registrant had put patients at unwarranted risk of harm. Due to the lack of any evidence of insight or remediation, the risk of repetition of the lack of competence is high.

13. The panel considered that the Registrant did not meet the following HCPC Standards of Proficiency for Paramedics (2014):

1 be able to practice safely and effectively within their scope of practice.
3 be able to maintain fitness to practise.
3.1 understand the need to maintain high standards of personal and professional conduct.
4 be able to practise as an autonomous professional, exercising their own professional judgment.
8 be able to communicate effectively.
10 be able to maintain records appropriately.
13 understand the key concepts of the knowledge base relevant to their profession. 14 be able to draw on appropriate knowledge and skills to inform practice.

14. Taking into account the matters found proved, the Registrant brought the profession into disrepute and had breached fundamental tenets as set out above and there is a high risk of bringing the profession into disrepute and breaching fundamental tenets in the future. The Registrant’s wide-ranging lack of competence struck at the heart of the trust placed in Paramedics to carry out their role, often in difficult and testing circumstances, while being able to safeguard the safety and wellbeing of their patients at all times and being able to work autonomously with the requisite skill and competence. A member of the public, in possession of all the facts and information about this case, would be concerned if there were no restrictions on the Registrant’s practice, in light of the wide-ranging and sustained lack of competence despite the support and supervision provided to the Registrant. The need to uphold proper professional standards and maintain public confidence in the profession would be undermined if a finding of impairment was not made. The Registrant’s fitness to practise was impaired on the personal and public components.

15. The panel identified the following aggravating factors: lack of evidence of current insight and remediation; limited engagement with the regulatory process and an active decision to disengage with the substantive hearing. The mitigating factors are no previous fitness to practice history relating to the Registrant and he demonstrated some limited insight. A Striking off Order was not an available sanction. The Panel concluded that, the Registrant’s lack of competence was not minor in nature, it was wide-ranging and sustained and there is a high risk of repetition. Furthermore, there was no evidence to demonstrate that the Registrant has taken any of the steps required to address that lack of competence; such as training or Continuing Professional Development since 2018. The lack of competence found proved is in principle, remediable. However, the Registrant’s lack of engagement and the lack of evidence to demonstrate any insight, means there is no indication that he would be willing to comply with conditions. The Registrant currently resides in Poland and there is no information about his current work arrangements. A Suspension Order for 12 months was the only appropriate and proportionate sanction. The panel stated that the Registrant has been given the opportunity to reflect, to obtain and demonstrate insight and remediation, and provide evidence of his current practice, including testimonials, in order to engage with the regulatory process.

Today’s Hearing

Submissions by the HCPC

16. Ms Khorassani summarised the background of the case as recorded in the decision of the previous panel. She submitted that the current Suspension Order should be extended for another 12 months as the Registrant has not engaged with the HCPC process since June 2020. She submitted that he does not appear to have taken the necessary steps to allow a Panel to decide that his fitness to practice is no longer impaired on both the personal and the public components of fitness to practise. Since the Substantive Hearing concluded on 19 March 2021, the Registrant has continued to fail to engage with the HCPC. Extending the period of the Suspension Order for 12 months would allow the Registrant another chance to engage with the HCPC process before potentially being struck off the register.

Legal Assessor’s advice

17. The Legal Assessor advised that the Panel is dealing with a Review under Article 30(1) of the Health Professions Order 2001 and should take into account the HCPTS Practice Note on Review of Article 30 Sanction Orders. Article 30(1) provides that a Conditions of Practice Order or Suspension Order must be reviewed before it expires and that the reviewing Panel may extend, or further extend the period for which the order has effect or make an order which could have been made when the order being reviewed was made or, replace a Suspension Order with a Conditions of Practice Order. An order made following an Article 30(1) review only takes effect from the date on which the order under review expires, so the Registrant must continue to comply with the expiring order until then.

18. The decision reached today must be proportionate, striking a fair balance between interfering with the Registrant’s ability to practise and the overarching objective of public protection. Given that part of the Panel’s task is to assess whether the fitness to practise of the Registrant remains impaired, the Panel should also take into account the HCPTS Practice Note on Finding Impairment and the HCPC Sanctions Policy.

19. This review process is not a mechanism for appealing against or ‘going behind’ the original finding that the Registrant’s fitness to practise is impaired. The purpose of the review is to consider if the Registrant’s fitness to practise remains impaired; and, if so, whether the existing order or another order needs to be in place to protect the public. The key issue for the Panel is what has changed since the current order was made.

20. There is an obligation upon the Registrant to address the concerns raised. The Article 30 Practice Note states the reviewing Panel’s task “is to consider whether all the concerns raised in the original finding of impairment... [have] been sufficiently addressed”. The decision in Abrahaem v GMC [2008] EWHC 183 (Admin) states there is a “persuasive burden” on the Registrant to demonstrate at a review hearing that he has fully acknowledged the deficiencies which led to the original finding, and has addressed that impairment sufficiently “through insight, application, education, supervision or other achievement...” The factors to take into account include the steps the Registrant has taken to address any specific failings or other issues identified in the previous decision, the degree of insight shown and whether this has changed. The steps which the Registrant has taken to maintain or improve his professional knowledge and skills, whether any other fitness to practise issues have arisen and whether the Registrant has complied with the existing Suspension Order.

Decision

21. The Panel accepted the advice of the Legal Assessor that there is a persuasive burden on the Registrant to demonstrate to this reviewing Panel that he has taken sufficient steps to develop his insight and to remedy his lack of competence. The matters found proved related to a wide range of issues, a number of which were repeated in respect of each patient. They related, for example, to documentation, assessment, medication administration, handover, and not meeting the required standards in assessments. The HCPC witnesses referred to the Registrant’s lack of knowledge, which did not reach the standard expected of a registered Paramedic. SL, the Registrant’s mentor for a 12-week period, estimated that 50% of the Registrant’s issues stemmed from poor command of the English language and 50% from lack of clinical knowledge. The witnesses agreed that the Registrant was, as a result, not capable of safe, autonomous practice. The Registrant’s failures found proved at the substantive hearing were therefore wide-ranging and concerned fundamental aspects of Paramedic practice. He is not safe to practice as an autonomous practitioner, is lacking in fundamental aspects of Paramedic practice. If he were permitted to resume practising this would put patients at risk.

22. The Registrant is currently living in Poland and has not engaged with the HCPC for nearly 2 years. He has failed to demonstrate remorse, undertake CPD or offer an apology for his failings.

23. The Panel considers that there has been no change since the substantive hearing. The Registrant had not submitted any material to this Panel. There was thus no evidence of insight, no reflection into what occurred, and no evidence to address the lack of competence or steps taken to resolve or remedy the lack of competence. The Registrant had put patients at unwarranted risk of harm. Due to the lack of any evidence of insight or remediation, the risk of repetition of the lack of competence was high. The Registrant brought the profession into disrepute, had breached fundamental tenets and there is a real risk of bringing the profession into disrepute in the future. The Registrant’s wide-ranging lack of competence struck at the heart of the trust placed in Paramedics to carry out their role, often in difficult and testing circumstances, while being able to safeguard the safety and wellbeing of their patients at all times and being able to work autonomously with the requisite skill and competence.

24. Further, the Panel considered that a member of the public, in possession of all the facts and information about this case, would be concerned if there were no restrictions on the Registrant’s practice, in light of the wide-ranging and sustained lack of competence despite the support and supervision provided to the Registrant. The need to uphold proper professional standards and maintain public confidence in the profession would be undermined if a finding of impairment was not made.

25. The Panel therefore concluded that the Registrant’s fitness to practice remains impaired on the personal component. Also on the public component because members of the public would not have confidence in the profession, or in the regulator, if the Registrant is permitted to return to unrestricted practice.

26. The Panel has considered the available sanctions in ascending order of severity. The Registrant has not demonstrated any remediation or insight. In reviewing sanction, the Panel found that nothing had changed since the last Order. To take no action or to impose a caution would not be appropriate because the lack of competence is too serious. Imposing a Conditions of Practice Order would also not be suitable. No workable Conditions of Practice are capable of being formulated in this case due to the lack of engagement and the wide-ranging lack of competence. A further Suspension Order is the only appropriate sanction option today. The Order made today will be reviewed before it expires and the next panel will have all sanction options available. A Striking off Order is not available to the Panel today because the Registrant has not been suspended for two years and this is a lack of competence not a misconduct case.

27. The Panel has decided to extend the existing Order. Any lesser sanction would not be sufficient to protect the public or safeguard the public interest. A further Suspension Order is necessary. The next reviewing panel is likely to be assisted by the Registrant’s attendance at the hearing and engagement with the review process.

Order

ORDER: The Registrar is directed to further suspend the registration of Mr Piotr Nowakowski for 12 months, upon the expiry of the existing Suspension Order.

Notes

This order comes into effect on 16 April 2022.

Hearing History

History of Hearings for Mr Piotr Nowakowski

Date Panel Hearing type Outcomes / Status
16/03/2022 Conduct and Competence Committee Review Hearing Suspended
18/03/2021 Conduct and Competence Committee Final Hearing Suspended
07/12/2020 Conduct and Competence Committee Final Hearing Adjourned part heard