Robert Rawcliffe

Preliminary Matters

Service / Privacy

1. The Panel was provided with a hearing bundle which contained a Notice of Hearing dated 29 July 2021 and contained an appropriate notice of the hearing, which had been addressed to the Registrant. The Registrant had attended the hearing and no issues were raised on the matter of service of notice.

2. The Panel considered that appropriate notice of the hearing had been served.

3. Mr Olphert, on behalf of the Registrant applied for the Panel to sit partly in private, when it received evidence regarding the Registrant’s health and private life.

4. The Panel heard and accepted the advice of the Legal Assessor, that the Rules provided that hearings, by default, should be held in public. However, this was subject to the proviso that the Panel may sit wholly or partly in private if it is satisfied that the interests of justice or for the protection of the private life of the Registrant, the complainant, any person giving evidence or of any patient or client, the public should be excluded (Rule 10(1)(a)).

5. The Panel decided that it struck an appropriate balance between the public interest and the Registrant’s interests, for it to sit in public, but to move into private session, when receiving evidence which concerned the Registrant’s health and private life.

Background

6. The Registrant is a registered Paramedic for North West Ambulance NHS Trust (“The Trust”). He has been employed by the Trust since March 2010.

7. It was alleged that on 26 September 2020 the Registrant had failed to clinically treat and assess Person A’s mother (known as Patient X), following a ‘999’ call to Patient X’s house. Person A’s evidence also alleged that the Registrant’s failures included that he had dismissed information provided about Patient X. It was alleged that the dismissed information was that Patient X had been diagnosed with an irregular heartbeat, was at high risk of stroke, had been prescribed Apixaban and had worn a bracelet and carried a card to inform anyone of this. It was alleged that the Registrant had failed to recognise the seriousness of Patient X’s condition and symptoms or recognise the serious medical presentation and act accordingly. Having been taken to hospital, Patient X had been placed in an induced coma but, sadly, died.

8. On 21 December 2020 Person A made a referral to the HCPC in respect of the above concerns against the Registrant and after investigation the matter was listed for a hearing.

The Hearing

9. The Registrant having admitted the facts of the Allegation at the start of the hearing, the parties agreed that the Panel could proceed to hear evidence on the facts, misconduct and impairment together in one session. The Panel agreed that this course was appropriate, although it would make its decisions in discrete sequential steps by first deciding facts, then considering statutory grounds, then finally impairment, moving through the stages as required.

10. The Panel heard live evidence from the following witnesses called on behalf of the HCPC:
• Person A, daughter of Patient X and an eye-witness;
• Person B, daughter of Patient X and an eye-witness;
• Person C, son of Patient X and an eye-witness;
• CK, investigation officer within the Patient Safety Team for the Trust;
• David Lee, an advanced paramedic Expert Witness in the field of ambulance clinician instructed by the HCPC.

11. The Panel heard live evidence from the Registrant. It read and took into account the testimonials of character witnesses on behalf of the Registrant.

Summary of evidence

Person A

12. Person A is a regional manager for a company supporting people with Learning Disabilities and Mental Health issues. She is the daughter of Patient X. Person A stated that Patient X had been 74 years of age, at the time of the incident, fit and in work. She had been prescribed Apixaban two weeks before the incident, due to an irregular heartbeat. The drug carried a risk of bleeding on the brain and sudden and severe headache.

13. Person A stated that on 26 September 2019, she had been called to her parents’ house and found Patient X collapsed on her side on the sofa. Patient X was unable to rise and was vomiting with a severe headache. Person A called ‘999’ at 07.15 am. Person A stated that she informed the Call Centre in particular of Patient X’s recent medical history and that “she was complaining of the worst headache in her life, had slurred abnormal speech, the side of her mouth was dropped”. Person A’s brother and sister arrived at the house prior to the arrival of the ambulance.

14. Person A stated that the ambulance arrived at 08.14, the Registrant and an Emergency Medical Technician (“EMT1”) in attendance. Person A stated that she may have led the communication, with her siblings also relaying information. Person A stated that they mentioned Patient X’s medication and high risk of stroke. Person A stated that she felt the ambulance men were not listening to any of them. In oral evidence, Person A did not accept that there had been a lot of people talking across each other.

15. Person A said that Patient X’s blood pressure was recorded as 220, and the crew commented it was the highest they had seen in a long time. She also stated that they said that Patient X would be ‘fine’ once her blood pressure was reduced. She stated that Patient X was complaining of extreme pain, but the crew was dismissive. Person A stated that the EMT1 asked for two paracetamol tablets. These were administered to Patient X orally, even though she continued to vomit.

16. Person A stated that the EMT1 took the lead, and the Registrant took notes, although at the time it was not clear to her which one was the paramedic. She found the lack of urgency quite frustrating.

17. Person A stated that, after performing a few checks, the ambulance crew decided to take Patient X to hospital. One of the crew asked Patient X to stand and walk to the ambulance, but this caused her distress. Person A said that her brother insisted they use a wheelchair, but this had no head support. Person A stated she had to support Patient X’s head herself and moving her head caused Patient X more pain.

18. Person A stated that she travelled with Patient X in the back of the ambulance. She said that the Registrant said it was his turn to drive and she sat next to the EMT1 who was beside Patient X. Person A stated that the EMT1 gave Patient X gas and air, but Patient X was not strong enough to hold the mask, and she was not permitted by the EMT1 to hold the mask for her mother. The ambulance did not drive with ‘blue lights’ and the EMT1 did not appear to provide any treatment or checks during the journey.

19. Person A stated that no-one was ready to receive Patient X at the hospital: there was no sense of urgency. After some scans revealed a severe bleed on the brain, Person A stated, her mother was placed in an induced coma. Sadly, Patient X did not recover.

20. Person A stated that they made a complaint to the Trust on 09 October 2019, due to the crew’s dismissive attitude and lack of urgency. She felt that they did not care. Person A said that they tried to tell the crew several times about the Apixaban but were not listened to. The family was not satisfied with the outcome of their complaint. Person A said that she had seen the initial reflections of the Registrant but these had not been sufficient in her view. Person A could not recall whether she had seen later reflections from the Registrant, in which he was said to have stated he would do things differently in future.

Person B

21. Person B is a school Science Teacher and is Patient X’s daughter. She was alerted to events on 26 September 2019 by her daughter. Person B stated that she arrived at Patient X’s house to find Person A calling ‘999’. Person B’s niece was also present. Person B stated that Patient X was on the sofa, unable to get up; she was vomiting and crying. Person B stated that Patient X “wanted to die. My mum was in great pain”. Person B stated that she also spoke to the Call Centre handler. She said she also relayed information about the recent diagnosis, new medication, and high risk of stroke.

22. Person B stated that she observed the ambulance crew arrive and that they appeared relaxed. Person B stated that the crew tried to perform a series of tests, for example, whether Patient X could stand or raise her hand above her head. Patient X had been groaning and still vomiting. Person B stated that the EMT1 called Patient X a ‘drama queen’. Person B stated that every time the siblings pleaded for the crew to take Patient X to hospital, they said she would be fine once they sorted out her blood pressure. Person B stated that the crew had ignored the information about the risk of stroke and insisted on doing their tests. After the tests, she said, the ambulance crew decided to take Patient X to hospital. They put Patient X in a wheelchair without head support and Person A had to support her head. Person B thought that it had been the paramedic who had made the comment about the headache abating once the blood pressure was ‘sorted out’. She said she had mentioned the blood pressure numerous times but recalled being told to “pipe down”. Person B agreed that the interactions had been fraught.

23. Person B said the ambulance was not ‘blue lighted’ on the journey and the hospital was unprepared for Patient X’s arrival. She stated that the nurse conducting triage ignored the warnings of high risk of stroke. Person B stated that scans confirmed a bleed on the brain, Patient X was placed in an induced coma but passed away two days later. Person B stated that a doctor confirmed that the bleed was due to the new medication.

Person C

24. Person C is a retired engineer and Patient X’s son. He stated that he had received news of Patient X’s condition by telephone from Person B. He attended Patient X’s home and found Person A there. Person C stated that his mother was on her side on the sofa, unable to rise, groaning with pain and vomiting. He said that the ambulance seemed to take a long time to arrive, but he was not sure how long.

25. Person C stated that, when the ambulance arrived, two men came in and took Patient X’s blood pressure, though this was difficult because Patient X could not lift her arms. He said that the Registrant stated that the blood pressure was the highest he had ever seen. Person C stated that he had told the crew that they needed to get Patient X to hospital. He stated that it seemed ‘like they were taking forever’ to perform tests on Patient X. Person C stated that the crew did not appear to respond to the information that Patient X was on blood thinning medication.

26. Person C stated that Patient X had been in continuous pain, and the siblings asked for pain relief. The crew asked for and administered two paracetamol tablets, even though Patient X had been vomiting. Person C stated that the crew did not appear to regard the situation as serious and the EMT asked if Patient X was a drama queen, probably in jest. Person C said the family had denied this, that Patient X was never ill and would not over dramatize a headache. Person C agreed that the situation had been fraught at the scene, but this was due to concern over the very high blood pressure reading.

27. Person C stated that the crew did not appear to advert to red flags of a stroke, nor the medical history or medication. Person C stated that he insisted on the use of a wheelchair when the crew had tried to walk Patient X to the ambulance. Person C stated that it was clear that the ambulance crew had no concerns for Patient X, did not want to take her to the hospital. The hospital was unprepared for their arrival.

28. Person C stated that the Registrant and EMT did not pay attention to anything the siblings said. They were not interested in hearing about the medication or risk of stroke, he stated.

CK

29. CK is an investigation officer with the Trust. She stated that the Trust received a complaint from the family of Patient X on 09 October 2019. CK had been asked to investigate the complaint.

30. CK detailed the investigation carried out and exhibited a redacted copy of her report. She had interviewed the Registrant, amongst others, and exhibited a copy of a statement taken from the Registrant.

31. CK stated that the Trust provided a written response to the family on 30 January 2020. She stated that the family, not being happy with the outcome, had referred the matter to the Parliamentary Health Service Ombudsman. The Ombudsman had requested local resolution, which was dealt with in writing, followed by a virtual meeting between the Trust and the family in November 2020.

32. CK stated that, despite the Trust upholding the complaint, the family was still unhappy with the outcome, and did not feel that there was any remorse on the part of the crew and that self-reflection was not sufficient.

Mr David Lee

33. David Lee, an Expert Witness in the field of ambulance clinician, provided to the Panel a written report dated 10 February 2022. Mr Lee stated in his report that he took the facts from the complaint submitted by the family to the Trust, the statement dated 19 November 2019 taken from the Registrant by the Trust, the Registrant’s reflective account and the Patient Report Form (PRF) together with the HCPC evidence bundle.

34. Mr Lee stated that headache, vomiting, slurred words and a facial droop are all signs and symptoms of an Acute Stroke/Transient Ischaemic Attack (“TIA”). He noted that it was recorded on the PRF that Patient X was ‘FAST negative’ which suggested that either symptoms had reverted to normal, or that they were not observed by the Registrant, or Person A was misinformed at the time of the initial ‘999’ call.

35. Mr Lee stated that, given the symptoms recorded on the Mobile Data Terminal (“MDT”), no competent paramedic would fail to consider treating for a cerebral event, either a haemorrhagic stroke, a TIA, or stroke from vascular origin. According to the headache guidelines presented in JRCALC Clinical Guidelines 2019 (“JRCALC”), ‘red flags’ signs and symptoms included an escalating headache of an unusual nature, meningeal irritation, photophobia, orthostatic headache, a substantial change in the characteristics of a headache and vomiting without other obvious cause.

36. Mr Lee stated that there was evidence to suggest that the Registrant recognised and recorded three ‘red flag’ symptoms on the PRF. However, there was no evidence that he acted on these as critical matters. He stated that failure to recognise any red flag symptoms falls below the standard reasonably expected of a treating paramedic.

37. Mr Lee stated his opinion that a National Early Warning Score (“NEWS”) score of 9 indicates “a high clinical risk” and a failure to recognise the severity of such a high score falls below the standard reasonably expected of a treating paramedic. Failure to alert a hospital to the imminent arrival of a patient at a high clinical risk also falls below the standard reasonably expected of a treating paramedic.

38. Mr Lee similarly was of the view that administering oral paracetamol instead of intravenous paracetamol to a patient in severe pain when Morphine Sulphate is contra-indicated falls below the standard reasonably expected of a treating paramedic.

39. Mr Lee’s opinion was that there was evidence to suggest the Registrant had made a diagnosis of Hypertension and did not identify the severity of other presenting symptoms. Nevertheless, Mr Lee’s opinion was that the signs and symptoms from an assessment can identify whether a patient is time critical or not, even absent the lack of equipment to confirm a diagnosis.

40. Mr Lee stated that failure to administer the anti-emetic, Ondansetron, to a nauseous and vomiting patient is against the recommendation of the JRCALC. He also stated that delegation of the care to the EMT1 had been against Trust policy.

41. Mr Lee was critical of the completion of the PRF for Patient X, stating that “there were a number of elements missing, some of which are key to the assessment and treatment of Patient X.” He stated that it was the responsibility of the senior clinician at the time to ensure the elements were factually correct, and the PRF fell below the standard expected.

42. In oral evidence, Mr Lee expanded on his report. He told the Panel that it was difficult to be definitive as to when ‘blue lights’ were necessary; there were a number of relevant elements, such as route and road conditions. However, the use of ‘blue lights’ and sirens would be appropriate in a time critical case.

43. Mr Lee commended the CPD undertaken by the Registrant and said that they were appropriate to the concerns in the case. Mr Lee confirmed that, in his opinion, Patient X had been critically ill, based on her history, the observations and potential for deterioration.

44. Mr Lee was asked about the references in his report to things that “no competent paramedic” would fail to do, compared with the opinion that conduct had fallen “below the standard reasonably expected of a registered paramedic”. He told the Panel that these were effectively the same standard. Mr Lee stated that he did not think that each of the issues, although falling below the standards, did not fall significantly below them, as for example, would be the case where a patient was “bleeding catastrophically”. Mr Lee confirmed that he could comment on where the conduct had fallen below standard, but he could not say, if all the aspects of the conduct were considered together, whether that conduct was significantly below the standards. Mr Lee said that given the patient observations and the seriousness of the past medical history, the treatment of Patient X had been time critical.

45. Mr Lee considered that the ambulance crew had spent a reasonable amount of time with Patient X at her home, and would not say that they had delayed at her home.

Mr Robert Rawcliffe – The Registrant

46. The Registrant had provided a witness statement shortly before the first day of the hearing, in which he addressed the particulars of the Allegation in detail and admitted the facts of particulars 1 and 2. Mr Olphert, on behalf of the Registrant, confirmed at the start of the hearing that the Registrant admitted the facts in particulars 1 and 2. In addition, the Registrant gave oral evidence to the Panel.

47. The Registrant stated that he had worked for Northwest Ambulance Service (“NWAS”) since March 2010. He had qualified with a DipHe in Paramedic Practice in 2017 and commenced work as full-time paramedic.

48. The Registrant stated that on 26 September 2019, he had been working with an Emergency Technician level 1 and had been assigned to Patient X’s case as a ‘category 2’ incident. He stated that, on arrival, he found Patient X at the house with a number of family members and it was “quite a frantic scene”.

49. The Registrant provided his responses to the factual allegations. He accepted that he had not recognised the severity or red flag indicators involved with Patient X’s history of the headache. He accepted that he had not considered changes with the presentation of the headache.

50. The Registrant accepted that the episode of vomiting and photophobia, the orthostatic headache were missed red flags. He accepted that Patient X’s increased NEWS2 score had not been appropriately recognised or acted upon.

51. The Registrant accepted that he had failed to recognise that Patient X was critically ill at the time and that he had not made an appropriate diagnosis of her condition. He accepted that he should have administered intravenous paracetamol and an anti-emetic. The Registrant told the Panel that, after the administration of oral paracetamol in his presence, nothing further could be given.

52. The Registrant accepted that he should not have delegated the care of Patient X. He stated that he was present whilst his colleague had performed initial observations and assessments and throughout the visit other than when he collected the wheelchair from the ambulance. He stated that both he and his colleague agreed that the FAST test had been negative. However, the Registrant accepted that he should have been the attending clinician in the rear of the ambulance.

53. The Registrant accepted that Patient X had been transported to a wheelchair without support to her head. The Registrant stated that he had tried to support the Patient’s head but it had required Person A to step in. The Registrant accepted having not provided a pre-alert notification to the Hospital and that he should have activated ‘blue lights’ and a siren.

54. The Registrant accepted that he had not noted Patient X’s irregular heartbeat and not paid particular attention to the risk of stroke. He stated that he had been unaware of the recent medication changes and had not noticed she was wearing a medical alert band. The Registrant stated that he had no recollection of family members discussing the irregular heartbeat during the assessment.

55. The Registrant provided his reflections on the events and the effect on the family members of Patient X. He stated that he understood why family members would feel angry and frustrated. The Registrant gave details of improvements to his practice since the events.

56. [Redacted].

57. In oral evidence, the Registrant told the Panel that he had been in the role of a fairly new paramedic. Looking back now, he said, he would not do everything the same, contrary to his initial reflections. For example, he would now travel with ‘blue lights’ and pre-alert the hospital. The Registrant said that he could avoid repetition of the past events, by use of the JRCALC and checking local guidelines. He would now double-check the PRF. He understood why the family was upset and was saddened by this. He was now more conscious of how his demeanour would appear to service users.

58. Details of the Registrant’s remediation work since the events was provided, in the form of CPD undertaken by him. The Registrant also provided very positive written testimonials from a number of character witnesses. These included letters from three senior paramedic team leaders, an advanced paramedic, a specialist practitioner and another colleague.

Decision on Facts

59. Before making any findings on the facts, the Panel heard and accepted the advice of the Legal Assessor. The Panel carefully considered the witness statements and oral evidence. It read and considered the bundle from the HCPC and the Registrant’s bundle.

60. In reaching its decision on the facts, the Panel bore in mind that the HCPC has the burden of proving the facts, and it is for the HCPC to prove the Allegation. The standard of proof is the balance of probabilities, which means that the Panel may take a fact as proved if it considers it more likely than not to have occurred.

 

1) On or around 26 September 2019, you did not carry out an adequate assessment and/or provide adequate care and treatment to Patient X in that you:

a) Did not recognise the severity or identify red flags in respect of Patient X’s symptoms, including but not limited to;

i. History of headache;

ii. Changes in the headache;

iii. Nausea and/or an episode of vomiting;

iv. Orthostatic headache;

v. Photophobia; and

vi. National Early Warning Score (NEWS) score of 9

61. The Panel noted from the evidence that the Call Log for the ‘999’ emergency call had logged Patient X as having a ‘terrible headache’, ‘feels sick’, ‘irregular heart’, ‘PT slurring words’, ‘side of face droopy’, ‘EMD ran stroke diagnostic’, ‘clear evidence of CVA’, ‘anti-coagulant/heart tablets’, ‘her pulse is less than 50’. The logs also showed that the information was sent to the MDT and was recorded as read within the log. The Panel noted that the information sent to the MDT was detailed within the chief executive’s letter to the family at a later date. The PRF recorded the headache had been experienced ‘3/7’ and the Panel took this to mean a duration of 3 days.

62. Person A’s evidence was that on 26 September 2019, Patient X had said the headache was the worst she had ever experienced and she was vomiting. The Panel noted that the PRF recorded ‘nausea’ and ‘vomit bile once’. The evidence from Person B was that Patient X was on her side on the sofa and vomiting.

63. Person A gave evidence that the pain Person A experienced was extreme and affected by movement of her head. The Registrant’s witness statement had recorded that Patient X had told him that lifting her head made the headache worse. The PRF entry had an entry recording that Patient X had photophobia. The PRF also recorded NEWS scores of ‘9’ timed at 08.15 and 08.40.

64. The Panel found Person A’s, Person B’s and Person C’s evidence credible and reliable, and in accordance with the documentary record, where relevant. The facts having been accepted, the evidence of Persons A, B and C was not particularly challenged by the Registrant.

65. The Panel found that the ‘red flag’ conditions had been present at the time of the Registrant’s attendance on 26 September 2019. The Panel took into account that, having admitted the facts, the Registrant did not challenge the evidence.

66. The Panel had regard to the expert evidence of Mr Lee, whose opinion was that the Registrant had adverted to the existence of just three red flag issues, but had not taken sufficient steps in relation to those he had identified. The Panel took from Mr Lee’s report, citing the JRCALC Guidelines 2019, that he regarded the matters (i) to (vi) inclusive as red flags relating to Patient X’s condition.

67. Mr Lee stated the Registrant failed to recognise that the signs and symptoms of Patient X were time critical. He said that no competent paramedic would fail to recognise red flag symptoms when assessing a patient with a headache, or that a NEWS score of more than 7 represented a high clinical risk.

68. The Registrant, in his witness statement stated, in the case of each of 1(a)(i) to 1(a)(vi) inclusive that he accepted, having read Mr Lee’s report that he had missed each as a red flag indicator. The Panel noted that the Registrant admitted this part of the Allegation.

69. The Panel concluded that the Registrant had not responded appropriately and/or at all to each of the red flag indicators in 1(a)(i) to 1(a)(vi) inclusive. The Panel decided that this amounted to an inadequate assessment of Patient X, which had resulted in her inadequate care and treatment.

70. The Panel found particular 1(a)(i) to (vi) inclusive proved.

 

b) Did not recognise that Patient X was critically ill at the time you conducted your assessment;

71. The Panel took into account Mr Lee’s evidence in his report that a NEWS score of over 7 indicated that Patient X was of a high clinical risk. The Panel also accepted Mr Lee’s oral evidence that, based on the history and observations of Patient X, taken together with the potential for deterioration, she was a ‘critically ill’ patient.

72. The Panel took into account Mr Lee’s evidence that the Registrant had not taken appropriate action in relation to the red flag indicators, and also the Registrant’s initial statement that only Patient X’s blood pressure had concerned him. The Panel considered the undisputed evidence that the Registrant had not issued a pre-alert to the hospital, had not travelled in the rear of the vehicle, had not transported with ‘blue lights’ or a siren in use and the evidence from Person A that the hospital were not acting with urgency on their arrival.

73. The Registrant, in his evidence, accepted that he had failed to recognise that Patient X was critically ill, when he had assessed her. The Panel noted that the Registrant admitted this part of the Allegation.

74. The Panel found that the Registrant had not recognised that Patient X was critically ill, when he had assessed her and that this had been an inadequate assessment which had resulted in her inadequate care and treatment.

75. The Panel found particular 1(b) proved.

 

c) Did not make an appropriate diagnosis of Patient X’s condition, in that you stated that “Patient X’s headache was as a result of her high blood pressure reading” or words to that effect

76. The Panel acknowledged that there was some difference in the evidence over which of the crew had stated that Patient X’s headache resulted from high blood pressure. Person A’s evidence was that it had been the EMT, Person B attributed similar words to ‘the paramedic’ and Person C referred to “they” (meaning the ambulance men) believed the headache would resolve once the blood pressure reduced.

77. Mr Lee stated in his report that no competent paramedic would fail to consider a differential diagnosis when dealing with a patient who is hyperventilating.

78. The Registrant stated in his witness statement that he did state to Patient X and her family members that the headache could have been caused by the increased blood pressure but was not the sole contributing factor. The Registrant accepted that he did not make an appropriate diagnosis of Patient X’s condition, having read Mr Lee’s report.

79. In his oral evidence, the Registrant accepted that he had used words to the effect of saying that the headache resulted from high blood pressure but the Panel took into account that the Registrant had admitted this factual allegation.

80. The Panel decided that the Registrant had not made an appropriate diagnosis of Patient X’s condition in that he had stated words to the effect that “Patient X’s headache was as a result of her high blood pressure reading”. The Panel concluded that this had been an inadequate assessment of Patient X which had resulted in inadequate care and treatment.

81. The Panel found particular 1(c) proved.

 

d) Did not adequately treat and/or manage Patient X’s symptoms, specifically you did not administer Patient X with:

i. Intravenous Paracetamol; and/or
ii. Intravenous Ondansetron to Patient X for the nausea;

82. It was not in dispute that the Registrant had not administered Patient X with (i) intravenous Paracetamol and (ii) Intravenous Ondansetron. The Registrant, in his witness statement, had admitted that he had not administered intravenous paracetamol because he was aware that Patient X had already taken oral paracetamol. In his oral evidence, the Registrant said that it had been his decision to administer oral paracetamol but that he did not have sufficient information.

83. The Registrant stated that he did not administer an anti-emetic because he was not aware of Patient X actively vomiting and to his recollection, she had not felt nauseated. However, he stated, this did not suggest that Patient X had not felt nauseated. In this event, he accepted, guidance recommended the administration of Ondansetron.

84. The Panel had evidence from Persons A, B and C that Patient X had been vomiting prior to and at the time of the ambulance attendance. It had also been recorded on the PRF that Patient X had vomited once and was nauseous. The Panel considered that on the balance of probabilities, it was more likely than not that Patient X had been nauseous, if not actively vomiting at the time of the Registrant’s attendance.

85. The Panel took into account Mr Lee’s opinion that administering oral paracetamol instead of intravenous paracetamol to a patient in severe pain where morphine Sulphate was contra-indicated fell below the reasonable standard for a paramedic. Mr Lee accepted that intravenous paracetamol would have been the more appropriate treatment plan.

86. The Panel took into account Mr Lee’s opinion that a failure to administer an anti-emetic (Ondansetron) to a patient who is nauseous and vomiting fell below the standard reasonably expected from a treating paramedic.

87. The Registrant, in his witness statement accepted Mr Lee’s opinion and by his admission, accepted the allegation. The Panel decided that the Registrant had not adequately treated and managed Patient X’s symptoms as a result. Further, the Panel decided that this amounted to inadequate care and treatment of Patient X.

88. The Panel found particular 1(c)(i) and (ii) proved.

 

e) Inappropriately delegated the care and/or assessment of Patient X, to Colleague Y, an Emergency Medical Technician, in that whilst transporting Patient X to the Hospital you drove the ambulance rather than sit at the back of the ambulance with Patient X who was critically ill at the time;

89. The Panel had been provided in evidence with the NWAS Trust policy document headed “Appropriate delegation of patient care observation and handover” (“the Policy”). This stated expressly that “where a Paramedic is present, they are responsible for the patient and the default position must be that they continue providing care on the journey to hospital”.

90. The Panel took into account the submission by Mr Smart, that the evidence from Person A was that the Registrant had stated that it was “his turn to drive” and that this was expressly stated to be a ‘common error’ in decision making in the Policy. It was stated that the Trust could not support the delegation of care being influenced in this way.

91. Mr Lee’s opinion was that making the decision to drive whilst leaving a clinically high-risk patient with the EMT1 fell below the reasonably expected standard for a paramedic.

92. The Panel took into account that there were no observations recorded in the PRF, apart from Patient X’s temperatures, after the ambulance left Patient X’s home. The Panel noted Person A’s evidence that little was done for Patient X on the journey to hospital and the family’s complaint that Patient X had received no real pain relief before arriving at hospital.

93. The Panel noted that in his witness statement and in his oral evidence, the Registrant accepted that he should have been the attending clinician in the rear of the ambulance. The Registrant accepted Mr Lee’s opinion that he had inappropriately delegated the care of Patient X and had admitted this part of the Allegation.

94. The Panel, taking all of the evidence into account, decided that the Registrant had inappropriately delegated the care and assessment of Patient X to the EMT1 during the journey to the hospital. Further, the Panel decided that this amounted to inadequate care and treatment of Patient X.

95. The Panel found particular 1(e) proved.

 

f) Transferred Patient X to a wheelchair with no support to her head;

96. The Panel noted that this allegation addressed the transfer of Patient X to the wheelchair, without supporting her head. The Panel noted that the Registrant had admitted not supporting Patient X’s head in the transfer to the ambulance, but in his oral evidence, this appeared to relate to the transfer once Patient X was in the wheelchair. The Panel accepted that the Registrant had given some support once Patient X was in the wheelchair, using the Registrant’s torso. The Panel noted the evidence that it had found that Patient X was suffering from an orthostatic headache and pain. Person B recalled Patient X wailing in pain as she was strapped into the wheelchair, on it being tipped back. Therefore, being unsupported in the transfer to the wheelchair had caused her pain. The Panel noted that the Registrant admitted this part of the Allegation.

97. The Panel decided that the Registrant had not provided appropriate support on transfer into the wheelchair and the Panel decided that this amounted to inadequate care and treatment of Patient X.

98. The Panel found particular 1(f) proved.

 

g) did not provide a pre-alert notification to the Hospital;

99. It was not disputed that the Registrant had not provided a pre-alert to the Hospital. Person A’s evidence, which the Panel accepted and which was not challenged, was that the hospital had not been pre-prepared for Patient X’s arrival and there was a delay before she was seen by a doctor.

100. The Panel decided that the Registrant had not provided a pre-alert notification to the hospital. Further, the Panel decided that this amounted to inadequate care and treatment of Patient X.

101. The Registrant stated in his witness statement that he accepted that he should have pre-alerted the hospital even though the FAST test had been negative. He described how he had amended his future practice. The Panel noted that the Registrant admitted this part of the Allegation.

102. The Panel decided that this amounted to inadequate care and treatment of Patient X.

103. The Panel found particular 1(g) proved.

 

h) Did not activate blue lights and/or sirens whilst on route to the Hospital with Patient X who was critically ill at the time.

104. It was not in dispute that the Registrant had not activated ‘blue lights’ (and therefore sirens) on the way to the hospital. Mr Lee’s evidence was that he could not comment on whether ‘blue lights’ had been required in this case, due to the variability of factors. He did consider that Patient X was a ‘time critical patient’. The Registrant, in his witness statement, said he could not now recall the road conditions, but in future would use ‘blue lights’. In oral evidence, the Registrant accepted that use of ‘blue lights’ would have been appropriate. The Panel noted that the Registrant admitted this part of the Allegation.

105. The Panel decided that, taking into account the evidence that the treatment of Patient X was time-critical, it was likely that the use of ‘blue lights’ would have provided for quicker transport to hospital. It took into account the Registrant’s admission and his alteration of his future practice. The Panel decided the lack of activation of blue lights and sirens amounted to inadequate care and treatment of Patient X.

106. The Panel found particular 1(h) proved.

 

2) On or around 26 September 2019, when you attended Patient X, you did not communicate effectively with Person A and/or Patient X and/or her family in that you did not take into consideration the information Person A and/or her family provided about Patient X’s medical history and/or ensure that the information was documented on the Patient Report Form, specifically that, Patient X;

a) had irregular heartbeat;

b) was at risk of suffering from a stroke;

c) was prescribed Apixaban, a blood thinning medicine;

d) wore a band alerting that she was at high risk of stroke.

107. The Panel noted that the PRF had recorded none of the listed information in particulars 2(b) to (d) inclusive, although “AF” (Atrial Fibrillation) had been noted under ‘Suspected ACS’ (Acute Cardiac Syndrome). Those factors were recorded on the Call Log to the call centre as having been advised to the Call Handler. The evidence from Person A was that the family had tried to explain about the new medication, the high risk of stroke and the bracelet. Person C stated that the crew had dismissed the information about medication and the high risk of a stroke. Person B stated that the family kept telling the crew to look at the band, which indicated Patient X was prone to a stroke.

108. It was the evidence of Persons A, B and C that the ambulance crew would not listen to them about Patient X’s medical history. The Registrant told the Panel in oral evidence that he had been unaware of the information either because he had not taken it on board, or because it had become ‘lost in translation’. The Registrant described walking into “quite a frantic” situation on arrival and the family being adamant that Patient X should be taken to hospital straight away. The Registrant stated that he could not recall the conversation with his colleague, who would have had control of the MDT, as the Registrant had been driving. He could not recall the ‘headline’ from the system for the call.

109. The Registrant stated that he had been unaware of Patient X’s medications. He had not noticed the wrist band and was unaware of the risk of stroke being presented to them. He did not recall the family mentioning the irregular heartbeat. The Registrant stated that the PRF form had been completed by his colleague and he was unaware of the entry “AF”.

110. The Panel took into account Mr Lee’s opinion that no competent treating paramedic would fail to listen to relatives, friends or associates of the patient. The Panel was prepared to take as a given that the Registrant was obliged to note any information relevant to Patient X’s care on the PRF form if provided to him. The Panel noted that the Registrant admitted this part of the Allegation.

111. The Panel concluded that it was more likely than not that the family had tried to impart the information in particulars 2(a) to (d) inclusive to the Registrant, during the ambulance crew attendance. The Panel concluded that the Registrant had not taken into consideration this information and had not gone on to ensure that this was recorded on the PRF. The Panel decided that this amounted to a failure to communicate effectively and amounted to an inadequate assessment of Patient X, which had resulted in her inadequate care and treatment.

112. The Panel found particulars 2(a) to (d) inclusive proved.

Decision on Grounds

113. Having all the facts found proved, the Panel next considered whether the proven facts amounted to misconduct. The Panel bore in mind that to find misconduct as a statutory ground of impairment, it had to be satisfied that this was serious professional misconduct.

114. Mr Smart, on behalf of the HCPC, had submitted that misconduct may be committed deliberately or recklessly. He reminded the Panel that in the case of Nandi v GMC [2004] EWHC 2317 (Admin) it had been described as conduct which fellow professionals would regard as ‘deplorable’. Mr Smart submitted that it may involve conduct to which some degree of moral blameworthiness and import of opprobrium attaches.

115. Mr Smart submitted that the Panel should take into account the entirety of the expert’s conclusions and it could make its own assessment of the seriousness of its findings. He suggested the relevant Standards of Conduct and Standards of Proficiency that the Panel might find had been breached.

116. Mr Smart submitted that the events in the particulars of the Allegation as a whole could be viewed as sequential, and the various elements of the Allegation ‘flowed through’. This had been not a simple mistake but, taken in the round, a serious falling short of standards.

117. Mr Olphert submitted that the Registrant had admitted the factual allegations and accepted criticism of his practice. He had attended with the intention of assisting Patient X. He accepted that significant errors had been made. Mr Olphert further submitted that the Registrant’s position had changed over time and that this “goes to” the Registrant’s developing insight and reflections.

118. Mr Olphert submitted that the adjective ‘serious’ had to be given its proper weight in the assessment and reminded the Panel that in Nandi the court used the term ‘deplorable’ conduct. Mr Olphert submitted that only negligence of a high degree might be sufficient.

119. Mr Olphert submitted that in Schodlok v GMC [2015] EWCA Civ 769 Vos, LJ had stated that “in the normal case I do not think that a few allegations of misconduct individually not serious can or should be regarded as collectively serious misconduct”. Accordingly, he submitted it would not be appropriate to roll up the particulars of the Allegation which were not serious into serious professional misconduct.

120. Mr Olphert submitted that the opinion of the expert witness had to be given appropriate weight. He submitted that Mr Lee had given the Panel an example of misconduct which might be serious misconduct, but the matters in this case were not that situation. Mr Olphert submitted that this was very telling about the case.

121. The Legal Assessor advised the Panel that whether the facts amounted to misconduct was a matter for the Panel’s own judgement, not involving a burden of proof. For the statutory ground the Panel had to decide whether this was serious professional misconduct. Although the courts had provided some illustration, the judgement of seriousness was up to the Panel, he advised. He re-iterated the judgment in Schodlok.

122. The Panel considered its findings of fact in relation to particulars 1 with care. It accepted that, per Schodlok, it would be wrong to aggregate disparate non-serious misconduct into a finding of misconduct globally. However, in this case, the Panel considered that it was dealing with a series of actions over a single treatment episode which were closely connected with each other, albeit separately particularised for clarity.

123. The Panel took into account that the allegations all addressed conduct towards Patient X, and her family, and were all in relation to a single episode of care and treatment by the Registrant. The allegations further related to a single date and continuous time period.

124. Further, it appeared to the Panel that the allegations related to matters which were sequential and built upon one another. Thus, the failure by the Registrant to advert to the red flag indicators, and not communicating effectively with the family, had led the Registrant to fail to recognise that Patient X was critically ill. In turn, this had led to the Registrant not administering medication appropriately or undertaking time-critical actions.

125. The Panel took into account Mr Lee’s evidence that the Registrant’s failures were below the standard to be reasonably expected of a competent paramedic, or actions that no competent paramedic would do. It accepted Mr Lee’s evidence that there was not a real difference between his two descriptions.

126. The Panel also took into account Mr Lee’s oral evidence, in which he stated that the failings had occurred against a background of a series of observations and a serious medical history, which meant that treatment was particularly time critical. The Panel accepted his evidence. It considered that the decision as to the seriousness of the misconduct was ultimately for the Panel itself to make.

127. The Panel concluded that the inadequate assessment, care and treatment that the Registrant had provided to Patient X on 26 September 2019 had been serious professional misconduct, taking into account the various ways in which the Registrant had fallen below the standard. The inadequate assessment led to a failure to recognise a critically ill patient and take appropriate action, including failing to be present in the rear of the ambulance, failing to pre-alert the hospital and not travelling with ‘blue lights’.

128. The Panel noted that the courts had provided various descriptions of the level of seriousness involved, but ultimately this a matter for it to assess on the evidence. The Panel concluded that fellow professionals would regard the misconduct as ‘deplorable’ and this was a further indicator of its seriousness.

129. In addition, the Panel considered that the failure to advert to the several red flags; the lack of recognition that Patient X had been critically ill; the lack of appropriate diagnosis; inadequate assessment, treatment and care; inappropriate delegation of treatment; and lack of pre-alert and use of ‘blue lights’ were of particular concern and were individually also serious professional misconduct. Whilst noting Mr Lee’s opinion on this point, the Panel determined that, in all the circumstances, the Registrant’s failures did not simply fall below the standards expected of a registered paramedic but did so seriously. The clinical presentation of Patient X was not an unusual presentation and therefore there is an expectation for any attending clinician to be able to recognise and act upon the information available, in the various respects specified above. In addition, the Panel was satisfied that the Registrant and his colleague key information available to them prior to arrival which should have assisted in the treatment and care of Patient X.

130. The Panel considered that, had it solely been the case of transferring Patient X to the wheelchair with no support to her head, this alone would not be serious professional misconduct, in that, in all the circumstances the transfer to the wheelchair had been difficult to achieve. Nevertheless, the Panel considered that this was part of the care and treatment, which overall amounted to serious professional misconduct.

131. The Panel took into account that this misconduct had breached several of the Standards of conduct, performance and ethics [2016] issued by the HCPC. In particular, the Panel considered that it had engaged the following:

“1.1 You must treat service users and carers as individuals, respecting their privacy and dignity.
1.2 You must work in partnership with service users and carers, involving them, where appropriate, in decisions about the care, treatment or other services to be provided.”

132. The Panel considered that the Registrant had not respected the position of the family and had not worked with them for Patient X’s benefit.

133. Further:

“4.1 You must only delegate work to someone who has the knowledge, skills and experience needed to carry it out safely and effectively.
4.2 You must continue to provide appropriate supervision and support to those you delegate work to.”

134. The Panel had found that the Registrant had inappropriately delegated the care of Patient X to the EMT1 and had not continued to provide appropriate supervision as he was engaged in driving the ambulance.

135. Further:

“6.1 You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.
6.2 You must not do anything, or allow someone else to do anything, which could put the health or safety of a service user, carer or colleague at unacceptable risk.”

136. The Panel considered that the Registrant had not reduced the risk of harm for Patient X, as he should have done. He had created an increased risk by failing to appreciate how ill she was.

137. In addition, the Registrant had breached parts of the Standards of Proficiency – Paramedics [2014] which had applied at the time, in particular:

“1 be able to practise safely and effectively within their scope of practice
…
1.4 be able to work safely in challenging and unpredictable environments, including being able to take appropriate action to assess and manage risk”

138. The Panel considered that the Registrant had failed to assess and manage the risk to Patient X.

139. Further:

“4 be able to practise 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 decisions to initiate, continue, modify or cease treatment or the use of techniques or procedures, and record the decisions and reasoning appropriately
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
…
4.8 be able to make a decision about the most appropriate care pathway for a patient and refer patients appropriately.”

140. The Panel considered that the Registrant’s practice and judgement had been flawed in relation to his care for Patient X.

141. The Panel concluded that particular 1 of the Allegation, amounted to serious professional misconduct.

142. In relation to particular 2 of the Allegation, the Panel acknowledged Mr Lee’s evidence. It had also accepted the evidence from Persons A B and C that the family members had important information in the matters set out in particulars 2(a) to (d) inclusive, which had been imparted to the Call Centre and presented on the ambulance MDT, and which the family had attempted to convey to the Registrant. The Panel considered that the information, if coming to the Registrant’s attention, would have had a serious bearing on his further care of Patient X. The Panel was also satisfied that it had been the Registrant’s obligation to obtain this information, notwithstanding the frantic situation in Patient X’s home. The Panel was satisfied that this was a serious failing.

143. The Panel took into account that this misconduct had breached several of the Standards of conduct, performance and ethics [2016] issued by the HCPC. In particular, the Panel considered that it had engaged the following:

“2.1 You must be polite and considerate.
2.2 You must listen to service users and carers and take account of their needs and wishes.
2.3 You must give service users and carers the information they want or need, in a way they can understand.
2.4 You must make sure that, where possible, arrangements are made to meet service users’ and carers’ language and communication needs.”

144. The Panel considered that there had been a serious failure of communication with Patient X and her family, in this case.

145. In addition, the Registrant had breached parts of the Standards of Proficiency [2014], which had applied at the time. In particular:

“8 be able to communicate effectively
8.1 be able to demonstrate effective and appropriate verbal and non-verbal skills in communicating information, advice, instruction and professional opinion to service users, colleagues and others
…
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.”

146. The Panel considered that the Registrant had failed in his obligation to communicate with the family of Patient X and also in his obligation to ensure all relevant information had been recorded on the PRF.

147. The Panel also considered that the lack of effective communication with the family alleged in particular 2 of the Allegation was serious professional misconduct.

Decision on Impairment

148. Having decided that particulars 1 and 2 amounted to the statutory ground of misconduct, the Panel next considered whether, by reason of his misconduct, the Registrant’s fitness to practise is impaired.

149. Mr Smart submitted that the Panel should have regard to the Practice Note on Impairment updated in 2022. He reminded the Panel that the issue is as to ‘current’ impairment. However, there were two aspects: the personal and public components.

150. Mr Smart reminded the Panel of the test of impairment in the wider public interest, restated in the case of CHRE v NMC & Grant [2011] EWHC 927 (Admin), and also the judgment of the court in Fopma v GMC [2018] EWHC 714 (Admin). Mr Smart accepted that the Registrant had not set out to harm Patient X. However, he submitted the Registrant’s actions had been reckless and a finding of impairment was justified.

151. Mr Olphert submitted that the Panel should take into account the Registrant’s previous good character. He had accepted his errors and made clear admissions. Mr Olphert submitted that, in considering impairment, the case of Meadows v GMC indicated that the Panel had to look forward.

152. Mr Olphert submitted that there was no evidence of deep-seated attitudinal issues, incapable of remedy. There was clear evidence that the Registrant is now a different clinician, compared to the past. He submitted that the test of impairment in Grant importantly refers to the liability of causing harm in the future. Mr Olphert submitted that the Registrant is not likely to cause harm in the future.

153. Mr Olphert submitted that, when considering the ‘public component’ it was important to put matters into context. He submitted that a member of the public would be aware of all relevant information, including that the errors dated back to 2019, the remediation since undertaken and the references provided. Mr Olphert submitted that an informed member of the public would not be shocked in all the circumstances if there was no current impairment found.

154. The Legal Assessor advised the Panel that impairment is a matter for the Panel’s own judgement. He advised the Panel to have regard to the Practice Note on Impairment devised by the HCPC.

155. The Panel accepted the advice of the Legal Assessor and considered its findings so far, together with the submissions of the parties.

156. The Panel considered the guidance set out in the Practice Note. It looked first at the ‘personal component’ of impairment and considered whether there was a risk of repetition of the misconduct.

157. The Panel considered that the misconduct was potentially remediable. Although the misconduct was serious, it related to the Registrant’s professional practice as a paramedic and, since there had been no previous incidents nor repetition since the events in question, the Panel considered that it did not have indications of attitudinal issues.

158. The Panel considered, as the guidance states, that insight is an important consideration. The Panel was concerned by the indications in the Registrant’s initial responses, where he had suggested he would manage a patient with same/similar symptoms in a similar way save that he would travel in the back of the ambulance, pre-alert the hospital and use the blue light procedure. However, in his witness statement, produced in June 2023 and before this Panel, the Registrant had indicated a major change in attitude. He had made full admissions to the allegations, acknowledged his past errors and provided his reflections.

159. The issue for the Panel was, bearing in mind that this change had been relatively recent, how timely and genuine it was and how deep-seated. The Panel considered that it had to take into account on this matter the considerable number of testimonials from fellow professionals, who had personal knowledge of and had worked with the Registrant. In addition, it was clear to the Panel that, since the events of September 2019, the Registrant had continued to work as a paramedic for the Trust for almost four years and no further repetition of the conduct had occurred. The Panel considered this had also to be taken into account.

160. The Panel also considered that, at the time, the Registrant was a newly qualified paramedic but was nearing the end of a two-year preceptorship period. It also accepted that it was likely that his personal circumstances, of which the Registrant had given evidence, had an effect on the Registrant at the time.

161. The Panel accepted that the Registrant had provided suitable reflections on the incident, and was saddened to know of the effect on the family of Patient X, although the Panel had not seen an apology from the Registrant. It accepted what the Registrant had told the Panel about the steps he had taken to improve the personal issues he had been facing and to reduce the risk of any further effect.

162. The Panel also accepted that the Registrant had undertaken a number of relevant CPD courses in 2020 and 2023 which addressed some of the issues in this case and were likely to have assisted in developing insight. The Registrant had given evidence of how he would deal differently in the situation in the future.

163. In the result, the Panel was prepared to accept that the Registrant has developed insight which is genuine and was part of his remediation. In addition, by undertaking his CPD, the Registrant has further developed his skills appropriately and reduced the risk of repetition.

164. In summary, the Panel considered that, to an appropriate degree, the Registrant has accepted that his past behaviour had fallen below professional standards, understood how and why it occurred and its consequences. He has also demonstrated the action he has taken to address those failures in a manner aimed at addressing past harm and avoiding repetition.

165. The Panel decided, placing particular weight on the very positive testimonials, and bearing in mind that there has been no repetition and no previous fitness to practise history over a considerable period, that it is highly unlikely that the Registrant would repeat his past misconduct.

166. The Panel therefore concluded that the Registrant’s current fitness to practise is not impaired on the personal component.

167. The Panel next considered whether a finding of impairment was necessary in the wider public interest, bearing in mind the seriousness of the misconduct itself. In doing so, the Panel was mindful that, as stated by the court in CHRE v NMC & Grant [2011] EWHC 927 (Admin) the Panel had to consider not only whether the practitioner continues to present a risk to members of the public, but also whether the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular circumstances.

168. The Panel bore in mind the submission made by Mr Smart, based on the judgment in Fopma v GMC [2018] EWHC 714 (Admin) (para. 39) in which Baker J said that to not find impairment is “tantamount to an indication on behalf of the profession that conduct of the kind in question need not have regulatory consequences” which made a similar point as in Grant, as above.

169. The Panel considered that the particular misconduct, in the cumulative serious failings in which the Registrant had, in particular, failed to notice very serious red flag indicators, failed to realise that Patient X was critically ill and therefore failed to care for the patient accordingly, plus his failure to communicate with the family to obtain important information, was very serious.

170. The Panel accepted Mr Olphert’s submission that an informed member of the public would be aware not just of the misconduct itself, but also the Registrant’s remediation history and the Registrant’s personal circumstances applying at the time of the incident. The Panel had accepted that the passage of time had allowed the Registrant to remediate and reduce the risk of repetition.

171. However, the Panel took into account the catalogue of serious failings made by the Registrant. Patient X was an elderly, vulnerable and critically ill patient, in significant pain, who required immediate interventions and care. The Registrant failed to recognise the seriousness of Patient X’s condition and therefore failed to reduce her pain and treat her appropriately. These were fundamental and serious errors.

172. The Panel concluded, in all the circumstances, that the misconduct in this case had been so serious that the public would lose confidence in the profession as a whole and professional standards would not be appropriately declared and upheld, unless the Panel made a finding of impairment in this case.

173. The Panel decided that the Registrant’s fitness to practise is currently impaired on the public component.

Decision on sanction

174. The Registrant provided the Panel with the following additional documents relevant to the decision on sanction:
• an apology statement dated 5 December 2023;
• two supportive testimonials from professional colleagues;
• CPD reflections on “Delayed hospital handover”, “Paracetamol IV against oral” and “PGD drug updates”.

175. The Panel took into account the submissions on behalf of the HCPC and the Registrant.

176. The Panel was guided by the HCPC’s Sanctions Policy and accepted the advice of the Legal Assessor. The Panel was mindful that the purpose of a sanction is not to punish the Registrant but to protect the public and the wider public interest in upholding proper standards, safeguarding the reputation of the profession and maintaining public confidence in the profession and its Regulator. The Panel applied the principle of proportionality, balancing the interests of the Registrant with those of the public, and considered the available sanctions in ascending order.

177. With regard to aggravating factors, the Panel referred back to its earlier decision on the Registrant’s current impairment, where it stated that: “Patient X was an elderly, vulnerable and critically ill patient, in significant pain, who required immediate interventions and care. The Registrant failed to recognise the seriousness of Patient X’s condition and therefore failed to reduce her pain and treat her appropriately. These were fundamental and serious errors”. In addition the Panel noted that the Registrant’s initial response to the complaints was that he would manage a patient with same/similar symptoms in a similar way save in two respects, as noted above at paragraph 158.

178. The Panel found the following mitigating factors:
• the Registrant was a recently qualified paramedic at the time of the incident;
• there were distressing circumstances in his personal life at the time which may have contributed to his errors of judgement, albeit that he has not sought to use those matters by way of an excuse in these proceedings;
• he made full admissions to the particulars of allegation at the outset of the hearing;
• he has continued to work as a paramedic for the Trust for over four years since the relevant matters and there have been no concerns about his practice or clinical competence during that period;
• he has provided appropriate reflections on the previous shortcomings in his practice during this incident and has, in the course of these proceedings, developed insight into his past failures;
• he has provided an apology for his misconduct, albeit delayed;
• he has provided a number of supportive testimonials from professional colleagues, who have personal knowledge of, and have worked with him;
• he has undertaken relevant training and CPD.

179. The case is too serious for the Panel to take no action.

180. Mediation could only be considered if the Panel would otherwise consider taking no further action.

181. With regard to a Caution Order, the Sanctions Policy states as follows:

“A caution order is likely to be an appropriate sanction for cases in which:
• the issue is isolated, limited, or relatively minor in nature;
• there is a low risk of repetition;
• the registrant has shown good insight; and
• the registrant has undertaken appropriate remediation.”

182. The Panel decided that a Caution Order sufficiently reflects the need to address the public interest in upholding proper standards of conduct and maintaining public confidence in the profession and the HCPC as its Regulator. Given the serious nature of the Registrant’s departure from the standards of conduct required, and the risk to Patient X associated with that lapse, the period of the Caution Order will be four years. This will send a message to the public and the profession as to the serious nature of the Registrant’s failings.

183. In the Panel’s judgement a Conditions of Practice Order would be irrelevant because the Registrant has fully remediated the shortcomings in his practice and it is very unlikely that they will be repeated.

184. The Panel considered that a Suspension Order would be disproportionate and punitive. It would also be contrary to the public interest in preventing a committed and competent practitioner from continuing in unrestricted practice.

Order: The Registrar is directed to annotate the Register to show that Mr Robert Rawcliffe is subject to a Caution Order for a period of four years.

No notes available

History of Hearings for Robert Rawcliffe

Date	Panel	Hearing type	Outcomes / Status
07/12/2023	Conduct and Competence Committee	Final Hearing	Caution
11/09/2023	Conduct and Competence Committee	Final Hearing	Adjourned part heard