Jasmine Fletcher

Preliminary Matters

Application to amend the Allegation

1. At the outset of the hearing Mr Bridges, on behalf of the HCPC, made an application to make a minor amendment to Particular 7 to correct the date of the alleged incident from 6 February 2017 to 6 April 2017. Mr Hockton, on behalf of the Registrant, did not oppose the application.

2. The Panel considered the application with care and took into account the advice provided by the Legal Assessor. The Panel was satisfied that it was appropriate to allow the amendment, which was clearly a typographical error transferred from an error in a witness statement. From the exhibits it was clear the correct date was 6 April 2017 rather than 6 February 2017.

Background

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

4. On 30 May 2016 the Registrant joined the South Western Ambulance Service NHS Foundation Trust (“the Trust”) as a graduate Paramedic, having completed a Paramedic degree at the University of Worcester. She was assigned a mentor/preceptor with whom she was to undertake two weeks of shifts. She completed a local induction, a manual handling assessment and an emergency driving course.

5. However, the Registrant did not in fact receive the full supported practice she was entitled to as a preceptee, having only worked a few shifts with her preceptor before the preceptor went off sick. A preceptorship period of six-months is something that all staff,
including newly qualified paramedics undergo at the Trust. It allows them to work under the supervision of a more experienced paramedic for an initial set of eight shifts and then once a month for the rest of the six-month period. Newly qualified paramedics can be given any assistance and support they might need during this initial period and then hopefully signed off as able to practice independently after this period.

6. On 29 August 2016, the Registrant’s one-month and three-month probation reviews were completed. The one-month review had been delayed due to a shortage of managers at the relevant time. During the reviews it was highlighted that the Registrant was having confidence issues, possibly relating to the fact that she was dyslexic. Human Resources (“HR”) were contacted and asked to advise on what support was available for the Registrant. At this stage it appeared the lack of a proper preceptorship was overlooked.

7. On 2 November 2016, the Registrant submitted a Datix incident form following a medication error. She attended a patient suffering from a severe asthma attack and administered what she believed to be hydrocortisone, a steroid drug indicated as part of the treatment for severe asthma. It would appear the drug was prepared by an Emergency Care Assistant (“ECA”), however it was the Registrant’s responsibility to have checked it before administering it to the service user. After the incident, the Registrant realised she had administered benzylpenicillin in error. The service user, Service User 6, reported an allergy to penicillin, and although suffering no ill effects as a result of the incorrect drug administration, the service user was not provided with the relief they should have been. As soon as the error was realised, the hospital and service user were informed.

8. On 3 November 2016, the Registrant’s Operations Manager, RG, was informed of the error. On discussion with the training department it became apparent that the Registrant had also made a medication error approximately four days earlier, where she allegedly incorrectly administered a half dose of tranexamic acid (as opposed to a full dose). It had not been possible to identify the service user involved in that error. Following the earlier error the Registrant had a supportive conversation with a Learning and Development Officer about the importance of checking medication and dosages prior to administration and the ‘med check’ process was discussed.

9. In light of the second error occurring so soon after a prior error and learning input, a restriction of practice (“ROP”) teleconference was held and the Registrant was placed on restricted practice pending further support.

10. The Registrant was placed with SH, a Practice Placement Educator (“PPE”), and qualified Paramedic, for the majority of her shifts leading up to the ROP review. The review coincided with a repeat Learning and Development Review (“LDR”) planned for 18 November 2016.

11. The LDR was initially arranged to support the Registrant after a lack of underpinning knowledge around unwell children was identified and to support the Registrant with her dyslexia.

12. On 18 November 2016 the Registrant’s ROP was reviewed. During the review it was discussed that she had demonstrated she was able to use the ‘med check’ to safely administer appropriate medication to service users.

13. It also transpired that the Registrant had not received the proper period of preceptorship after she joined the Trust. It was said that she had received four observation shifts and had a further four shifts planned with her preceptor. However, due to short-notice sickness, the Registrant had not then spent the planned shifts with her preceptor. Outstanding concerns were identified with the Registrant’s ability to make clinical decisions whilst under pressure (i.e. during life-threatening situations).

14. However, as the reason for the ROP (the ability to use the ‘med check’ process) had been addressed, the restriction was lifted and the Registrant was placed with another PPE, JS, for a period of two weeks (six shifts). JS was advised to escalate any issues identified during that period of time. It appears that as far as RG was concerned this was to be period of preceptorship to replace that which was missed. However, this was not what JS was led to believe and she treated it like a period of supervision.

15. On 27 November 2016, the Registrant, together with JS, attended Service User 5, a young man who was experiencing seizures. Whilst with Service User 5 it is said that the Registrant failed to recognise that he was experiencing seizure activity as shown by facial spasms. She was prompted by JS to look at Service User 5’s face and see if she noticed anything. She did not and JS therefore had to intervene.

16. On discussing the incident with the Registrant, JS reported that she was very much of the impression that a seizure was something that affected the entire body and could not just be localised to one area. This was a cause of concern, since if the Registrant were unable to recognise seizure activity she would not be able to treat it properly.

17. On 29 November 2016, JS sent an email to those involved in supporting the Registrant, documenting that she continued to use the ‘med check’ process appropriately and without being prompted. However, a number of learning needs were identified, namely:

• a gap in fundamental knowledge surrounding the assessment of neurological service users

• ECG interpretation

• recognition of/treatment of sepsis

• recognition of/treatment of a seizure

18. As a result an ROP teleconference was convened and the Registrant’s practice was once again restricted to working under the supervision of another Paramedic. A training needs analysis was arranged and further support was put in place.

19. By this stage the Registrant was approaching the end of her six-month probation period. However, in light of the concerns raised it would not be possible for her to successfully complete her probation and so RG extended her probation by three months. It was decided that the Registrant would receive two months of support from a PPE where possible. At the end of the two-month period a decision would be made about whether to progress to a probationary hearing or to sign off the Registrant’s probation.

20. On 9 January 2017, JS and the Registrant attended on Service User 1, who was an elderly patient said to be experiencing septic shock. A Paramedic is expected to recognise that a service user might be suffering from sepsis on the basis of what they can observe of the service user’s presenting condition. Service User 1 was said to have presented with a raised heart rate, confusion and being unsteady on her feet, all of which are indicators of sepsis. However, when JS discussed these observations with the Registrant, she said she did not recognise this or offer any explanation of what Service User 1 was suffering from. She was encouraged to reassess Service User 1, but still failed to recognise the signs of sepsis, nor that she had an elevated National Early Warning Score (“NEWS”), which should have alerted the Registrant to the possibility of sepsis.

21. JS said that once she told the Registrant that Service User 1 was potentially septic, she did then instigate an appropriate treatment plan, so it was clear she knew how to treat a septic patient.

22. JS said that at the time sepsis had been a big issue in the NHS and a lot of emphasis had been placed on being able to spot it. Furthermore, she had taken the Registrant through the sepsis markers before as there had been issues with her recognising it.

23. JS added that as part of the treatment plan the Registrant put in place she correctly said she would pre-alert the hospital of Service User 1’s condition, so that the hospital would know they were on their way with a critical patient. JS was driving the ambulance but had told the Registrant to pre-alert the hospital. However, this she failed to do and when they arrived at the hospital, the staff were completely unprepared for them.

24. On 10 January 2017, JS and the Registrant attended on Service User 2, a young boy who was unwell with a high fever. In such a situation a comprehensive assessment is required to rule out meningitis. The Registrant carried out a basic assessment but was unable to complete a more detailed assessment and JS had to complete it. It was said that the Registrant failed to assess Service User 2 for photophobia (an aversion to light), the presence of rashes or dehydration, or to consider Service User 2’s general behaviour.

25. JS added that the Registrant did not seem to have an awareness of the ‘red-flags’ that indicate the possibility of severe illness, such as the heart rate, respiratory rate and temperature being significantly higher than they should be.

26. JS also made reference to additional tests called Kernig’s and Brudzinski’s signs that are linked to meningitis and can be used as part of a neurological assessment. However, she said, the Registrant did not include these in her assessment and did not appear to know what they were.

27. In fairness to the Registrant, JS said that she did communicate “brilliantly” with Service User 2 and his family and her basic assessment was fine. She also put an appropriate care plan and safety net in place by referring the family to the out of hours service and by providing advice on what to do if his condition deteriorated.

28. On 13 January 2017, a review of the ROP was arranged to clarify arrangements over the Registrant’s level of supervision. This followed the incident where it was said she did not recognise a service user (Service User 1) had sepsis and did not complete a pre-alert call to the hospital, despite being advised to do so.

29. Further knowledge shortfalls and concerns regarding her personal welfare were identified and it was decided that the Registrant should only continue to operate as a Paramedic under direct supervision. In other words, she could only be in the back of an ambulance with a service user if another clinician were also in the back of the ambulance with her.

30. On 25 January 2017, SH, as a PPE, and the Registrant attended on Service User 3, a very distressed female patient who had dislocated her knee and was suffering intense pain. SH said that in such circumstances pain relief was the urgent priority. He said that, whilst ordinarily a set of observations (“obs”) should be completed before administering certain pain relieving medication, in this situation Entonox can be given prior to completing a full set of obs. However, the Registrant thought that a complete set of obs had to be completed before Entonox could be administered and she had to be corrected by SH.

31. SH said that it was not necessarily a major flaw that the Registrant had not proceeded to administer Entonox straightaway, but it could have provided Service User 3 with some pain relief earlier, instead of potentially making her go through a complete set of obs first. He said this is something the Registrant should have been aware of through her university training.

32. SH said that after assessing Service User 3, they decided it was appropriate to administer Ondansetron and Morphine intravenously. He prepared both of these drugs before handing them to the Registrant to administer. He said he checked the Joint Royal Colleges Ambulance Liaison Committee Guidelines (“JRCALC guidelines”) for any relevant indications and any contra-indications/side effects, so that he knew it was appropriate to give those drugs to Service User 3. However, it is also the responsibility of the administering clinician to satisfy themselves by checking the JRCALC guidelines, but the Registrant failed to do this when administering the first drug until SH told her to and then failed to do so again with the second drug.

33. SH said that the Registrant was aware that he was there to assess her and even if she knew he had checked the JRCALC guidelines she should still have carried out her own checks or at the very least asked him if he had done them or indicated that she was aware he had done so.

34. In fairness to the Registrant, SH said that apart from the issues raised, she did a good job in calming Service User 3 down once the medication was given. He added that Service User 3 was not the easiest patient to handle and communicate with and this may have influenced the Registrant’s overall ability to deal with the job. He felt that in a calmer situation she may have thought more strategically and logically.

35. On 26 January 2017, SH and the Registrant attended on Service User 4, an elderly man experiencing breathing difficulties and with a history of motor neurone disease. SH said it was immediately clear that Service User 4 was experiencing severe breathing difficulties. He was unable to talk in complete sentences and had low oxygen levels. SH said that initially the Registrant attempted to obtain a detailed patient history by asking Service User 4 questions. However, this was inappropriate as Service User 4 was unable to speak in full sentences. SH said his concern was that the Registrant should have been able to recognise a deteriorating patient and that when they are that unwell they will be unable to give any more details. In those circumstances it is a ‘load and go’ situation to get the patient on the ambulance and to hospital as soon as possible.

36. SH said he advised the Registrant to call for back up as an ambulance was needed to convey the patient to hospital. They were in a Rapid Response Vehicle (“RRV”) and so not in a position to transport Service User 4 to hospital. He thus told the Registrant they needed to get a Double Crewed Ambulance (“DCA”) heading to their location immediately. He asked the Registrant what level of priority back up she would request, expecting her to say P1 (Priority 1), the highest priority to reflect the severe respiratory distress Service User 4 was displaying. However, the Registrant said she would ask for P2 back up, which although appropriate for some emergency situations, was not, in SH’s view, high enough for this one.

37. In fairness to the Registrant, SH said that knowing the correct priority of back up to call when you are in an RRV is not something that is really covered as part of a Paramedic’s training. Instead it is more reliant on the Paramedic’s own interpretation of back up and the different priority levels. He said that determining what level of priority a patient requires can be difficult and not as clear cut as topics that are covered in basic training. He conceded that other colleagues may have considered a P2 response to have been adequate in that situation, but he felt it required a P1 response.

38. SH went on to say that to her credit the Registrant did recognise when transporting Service User 4 to hospital that he was seriously unwell and she did pre-alert the hospital to let them know they were on their way. She also provided a good handover to the clinical staff when they arrived at the hospital. He concluded by saying that the Registrant did generally display a “really good attitude” during her practice placement with him and was receptive to the feedback he gave to her.

39. On 2 February 2017, the Registrant’s ROP was revised again. During that review it became apparent that further fundamental learning needs had been identified surrounding the assessment of care and trauma for service users. Those supporting the Registrant advised the ROP panel that there continued to be issues with regards to recognising, assessing and treating critical illness.

40. On 6 April 2017, JS, in her role as PPE, and the Registrant attended on Service User 7, an elderly lady who had been described as experiencing back pain. JS said that when they started to move Service User 7 into a standing position in order to transport her, she collapsed onto her knees. JS said it was clear she was experiencing a cardiac arrest as she had collapsed, became unresponsive with agonal/ineffective breathing and no central pulse. JS said that the Registrant failed to recognise that Service User 7 had collapsed due to cardiac arrest and rather than starting immediate basic life support, the Registrant’s reaction was to talk to the service user.

41. JS said that this was the most serious incident that she observed whilst with the Registrant, as when a patient goes into cardiac arrest they require immediate intervention and any delay could potentially pose a serious risk to the patient’s health.

42. When assessing the Registrant overall, JS said that she has great interpersonal skills but tends to be less confident and would “take the back seat” with obstructive and verbal patients. JS described the Registrant as “very cautious with her decisions, however she hasn’t displayed any dangerous practice when dealing with stable, routine or non-critical patients.”

43. On 1 May 2017, at her own request, the Registrant was redeployed as an Emergency Care Assistant (“ECA”). She left the Trust in December 2017 and has not worked in a Paramedic or ECA role since.

Decision on Facts

44. In reaching its decisions on the facts the Panel took into account all the evidence provided, including the oral evidence of RG, JS, SH and the Registrant. The Panel also took into account the submissions made by Mr Bridges on behalf of the HCPC and those made by Mr Hockton 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. Whilst it was not for the Registrant to disprove the allegations, the Panel took into account the Registrant’s admissions to all the alleged facts.

1) On or around 2 November 2016, while attending Service User 6, you:

a) Did not carry out a drugs check (“Med check”) before administering drugs to Service User 6.

b) Incorrectly administered Benzylpenicillin to Service User 6 instead of hydrocortisone.

45. The Panel found these allegations proved in full on the basis of the evidence provided by RG, as detailed in the background above, and the admissions made by the Registrant. The Registrant was clearly under a duty to carry out the check herself as the person administering the medication and this she failed to do, resulting in the incorrect medication being administered.

2) On or around 27 November 2016, while attending Service User 5, you did not recognise that Service User 5 was experiencing partial seizure activity.

46. The Panel found this allegation proved on the basis of the evidence provided by JS, as detailed in the background above, and the admissions made by the Registrant, who agreed she did not recognise the localised facial seizure.

3) On or around 9 January 2017, while attending Service User 1, you:

a) Did not recognise that Service User 1 was possibly septic.

b) Did not recognise that Service User 1 had an elevated National Early Warning Score

c) Did not provide a pre-alert to the hospital.

47. The Panel found these allegations proved in full on the basis of the evidence provided by JS, as detailed in the background above, and the admissions made by the Registrant.

48. In her oral evidence, the Registrant was fairly adamant Service User 1’s differential diagnosis was Diabetic Ketoacidosis (“DKA”), the condition suggested by the mobile data terminal on the basis of the information received from the person calling the ambulance and ‘drilled into her’ on the way to the job by JS. However, the Panel preferred the evidence of the more experienced JS that the Registrant was fixated on the DKA and that is what she stuck to, without considering the possibility of it being sepsis. JS was particularly concerned with the Registrant struggling to adapt to a patient presenting in a different manner.

49. The Acute Care Referral form for Service User 1 showed a NEWS score of 7, which the Registrant said in her oral evidence she recognised, but still considered it was DKA not sepsis, with both conditions having similar symptoms. On the balance of probabilities, however, the Panel preferred the evidence of the more senior Paramedic, JS, who said the Registrant did not recognise the fact that Service User 1 had an elevated NEWS, as recorded in JS’s near contemporaneous email sent on 11 January 2017. The Registrant, on the other hand, was relying on her memory, some six years later.

50. The Registrant confirmed she did not provide a pre-alert to the hospital, having allowed herself to be distracted by taking a further set of observations on route to the hospital.

4) On or around 10 January 2017, while attending Service User 2, you:

a) Did not assess Service User 2 for:

i) Photophobia
ii) Rashes
iii) General Behaviour
iv) Dehydration

b) Did not display knowledge of:

i) The importance of red flags in Paediatric fever and/or illnesses.
ii) Kernigs and/or Brudzinski signs.

51. The Panel found these allegations proved in full on the basis of the evidence provided by JS, as detailed in the background above, and the admissions made by the Registrant, who accepted she should have carried out a full assessment.

5) On or around 25 January 2017, while attending Service User 3, you:

a) Did not administer Entonox to Service User 3 until you were advised by a colleague to do so and/or did not recognise that Entonox could be administered prior to taking a set of observations.

b) Did not consult the Joint Royal Colleges Ambulance Liaison Committee Guidelines until prompted to do so by a colleague before administering:

i) Ondansetron
ii) Morphine

52. The Panel found these allegations proved in full on the basis of the evidence provided by SH, as detailed in the background above, and the admissions made by the Registrant. With a patient in severe pain there is a duty to offer the correct pain relief at the earliest opportunity, which in this case was Entonox. This the Registrant failed to do, not recognising that Entonox could be administered prior to taking a full set of obs.

53. With respect to (b) it is always the duty of the administering clinician to carry out the necessary checks before administration and the Registrant accepted this, although at the time she said she was aware that SH had carried out the necessary checks and so she relied on that.

6) On or around 26 January 2017, while attending Service User 4, who was in severe respiratory distress, you:

a) Used an inappropriate method to gain information in that you attempted to have a conversation with Service User 4.

b) Requested an inadequate level of back up.

54. The Panel found these allegations proved in full on the basis of the evidence provided by SH, as detailed in the background above, and the admissions made by the Registrant. The Registrant accepted that she had been on ‘auto-pilot’ and said that she could not believe that she had continued to try to take a full history whilst the patient was struggling to breathe. With the level of back up requested, the Registrant accepted she had asked for P2 rather than P1 and that, on the advice of SH, P1 would have been the appropriate level of back up to have requested.

7) On or around 6 February 2017, while attending on Service User 7, you did not communicate to your colleague that Service User 7 was experiencing a cardiac arrest.

55. With reference to Service User 7, JS said that they were in a small bathroom when the patient went into cardiac arrest in front of them. She said it was obvious that the patient had stopped breathing as she had been breathing very audibly and this changed and the patient collapsed. She said she could not move Service User 7 on her own and needed help to start life support and whilst she had identified the patient had gone into cardiac arrest, she had been expecting the Registrant to have also noticed it. However, the Registrant was still talking to the patient and so JS had to say to her “no, don’t talk to her, we need to move the lady so that we can continue with our job as the situation has drastically changed.”

56. JS said she did not know whether the Registrant had by that time had any experience of dealing with a cardiac arrest. She was taken by Mr Hockton to some correspondence about a cardiac arrest case the Registrant had attended with SH, but she pointed out that that case had been different as the patient was already in cardiac arrest when they arrived. The case referred to in the allegation went from being a lady with respiratory issues to a cardiac arrest. JS said that her concern was that the Registrant struggled to be flexible, so if they were attending a situation that changed she could not dynamically react to it.

57. JS accepted that she probably reacted more quickly than the Registrant due to her experience, however the Registrant, she said, did not react in a timely fashion and her actions suggested she had not recognised the patient had gone into a cardiac arrest, because she was still talking to her.

58. In her oral evidence, the Registrant said that she accepted she had not communicated to JS that Service User 7 was experiencing a cardiac arrest. However, she said, JS had been at the head end of the patient whilst she was at the waist and thus JS had been in the best position notice the patient was no longer breathing. The Registrant said that JS said to her that the patient had gone into cardiac arrest and so they rolled her over and life support was commenced immediately. There was, therefore, no need for her to have also communicated to JS that the patient was experiencing a cardiac arrest. The Registrant said she was able to deal with cases involving cardiac arrest as “this is a basic skill and probably the most necessary skill we have as Paramedics.” In all the circumstances, she did not feel there was anything incorrect in her management of this case.

59. When cross-examined on this point JS said they were both equally near the patient’s head, but she was the one facing her.

60. To find this allegation proved, the Panel had to be satisfied that the Registrant was under a duty to communicate to JS that the patient was having a cardiac arrest, as alleged. The Panel was not so satisfied. It was difficult to see why the Registrant would need to have said the patient was experiencing a cardiac arrest when it was already obvious to JS that was the case and that immediate action was being taken. Furthermore, if it was JS who was at the head end of the Patient in the small bathroom and the Registrant at the waist, it would therefore have been JS who was in the best position to have first recognised that the patient was no longer breathing. In such circumstances the Panel considered there would have been no need (and therefore no duty) for the Registrant to have communicated to JS that Service User 7 was experiencing a cardiac arrest.

61. The Panel therefore found this allegation not proved.

Decision on Grounds

62. The Panel next considered whether the facts found proved amounted to a lack of competence. In so doing it took into account all the evidence and the submissions made by Mr Bridges and those made by Mr Hockton. The Panel accepted the advice of the Legal Assessor, who advised that a lack of competence implies a professional standard that is unacceptably low and which has been demonstrated by reference to a fair sample of the Registrant’s work.

63. The matters alleged, which were admitted and that the Panel had found proved, related to five different service users over a period of approximately three months and highlighted different concerns about the Registrant’s practice. The Panel was satisfied that this represented a fair sample of the Registrant’s work. The question, therefore, was whether her acts and omissions implied a standard of professional performance which was unacceptably low.

64. The Panel considered there to be breaches of the following parts of the Standards of Proficiency for Paramedics (2014):

1 be able to practise safely and effectively within their scope of practice

1.1 know the limits of their practice and when to seek advice or refer
to another professional

1.3 be able to use a range of integrated skills and self-awareness to
manage clinical challenges independently and effectively in
unfamiliar and unpredictable circumstances or situations

1.4 be able to work safely in challenging and unpredictable environments, including being able to take appropriate action to
assess and manage risk

3 be able to maintain fitness to practise

3.3 understand both the need to keep skills and knowledge up to
date and the importance of career-long learning

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

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

4.5 be able to use a range of integrated skills and self-awareness to
manage clinical challenges effectively in unfamiliar and
unpredictable circumstances or situations

4.8 be able to make a decision about the most appropriate care
pathway for a patient and refer patients appropriately

8 be able to communicate effectively

8.3 understand how communication skills affect assessment of, and
engagement with, service users and how the means of communication should be modified to address and take account
of factors such as age, capacity, learning ability and physical
ability

12 be able to assure the quality of their practice

12.6 be able to evaluate intervention plans using recognised outcome
measures and revise the plans as necessary in conjunction with the service user

13 understand the key concepts of the knowledge base relevant to their profession

13.6 understand the theoretical basis of, and the variety of approaches to, assessment and intervention

13.7 understand human anatomy and physiology, sufficient to
recognise the nature and effects of injury or illness, and to
conduct assessment and observation in order to form a
differential diagnosis and establish patient management strategies

13.8 understand the following aspects of biological science:

– disease and trauma processes and how to apply this
knowledge to develop appropriate treatment plans for the
patient's pre-hospital or out-of-hospital care

14 be able to draw on appropriate knowledge and skills to
inform practice

14.5 know the indications and contra-indications of using specific
paramedic techniques in pre-hospital and out-of-hospital care,
including their limitations and modifications

14.6 be able to modify and adapt practice to meet the clinical needs
of patients within the emergency and urgent care environment

14.7 know how to select or modify approaches to meet the needs of
patients, their relatives and carers, when presented in the
emergency and urgent care environment

14.9 be able to gather appropriate information

14.11 be able to undertake and record a thorough, sensitive and
detailed assessment, using appropriate techniques and
equipment

14.12 be able to conduct a thorough and detailed physical examination of the patient using appropriate skills to inform clinical reasoning and guide the formulation of a differential diagnosis across all age ranges

14.16 be able to analyse and critically evaluate the information collected

65. With reference to Service User 6 (Particular 1), this was a medication error as a result of the Registrant not carrying out the checks that she should have. To her credit the Registrant quite rightly reported it and was subsequently put on restricted practice. During that time she was supervised and subsequently assessed as competent to carry out med checks and thus this issue was considered to have been satisfactorily dealt with. However, checking before administering any drug is absolutely essential. Giving the wrong drug could be catastrophic. Clinical safeguarding is paramount and the first rule before giving any drug is that checks must be made by the individual administering it. This was, therefore, a serious failure on the part of the Registrant. That said, viewed in isolation and in light of the fact that it had been thought the matter had been dealt with by the Registrant satisfactorily, the Panel did not consider this would amount to a lack of competence. However, approximately three months later, the Registrant once again administered medication without carrying out the necessary checks with the JRCALC guidelines, as detailed in Particular 5(b). This suggested that she had not in fact satisfactorily embedded such checks into her practice. Thus, when viewed within the context of her overall performance, as reflected in all the matters found proved (save for 6(b), see below), the Panel was satisfied that this amounted to a lack of competence.

66. In her oral evidence JS said she had been assigned to assist the Registrant as a PPE due to previous errors, rather than as a preceptor (as was RG’s intention when placing the Registrant with her). She acknowledged the roles were different, although considered they overlapped as both involve offering support, although preceptorship was more focused on support than supervision. JS denied any bias in her approach to the Registrant as a result of the issues raised with her beforehand and said she approached her “fresh from day 1” with a view to forming her own opinion from witnessing the Registrant at work.

67. JS said that it was not unusual for young, newly qualified Paramedics to have areas of their practice that need developing and she welcomed questions being asked as this was the way to learn. However, she said there were certain standards that had to be met for safety purposes and this was where her concerns lay.

68. With Service User 5 (Particular 2), JSs’ concern was that the Registrant did not recognise that the patient was experiencing partial seizure activity. She acknowledged that after the incident the Registrant “did a lot of reflection and classroom work” with a colleague on the Learning and Development team.

69. In her oral evidence the Registrant said that the partial seizure was in fact just an eye twitch, very localised and she had not experienced that before so did not spot it. However, as soon as it was pointed out to her she said she responded appropriately and no harm was caused to the patient.
70. In the Panel’s view, recognising a partial seizure is important because a failure to do so means the practitioner would not be ready for a full seizure when it comes. So, even allowing for the fact that the Registrant may not have encountered anything like this before and it was not easy to notice, this was still something that, as a qualified Paramedic she ought to have picked up on and which the Panel viewed as a serious failure.

71. With regard to Service User 1 (Particular 3), JS agreed that her statement should more accurately have read was ‘potentially’ experiencing septic shock, since she was unaware if sepsis was ever actually diagnosed. However, she said this was an elderly patient who had septic markers. She agreed that on the way to the job the mobile data terminal had indicated it was possibly a case of DKA and that they had discussed that on route, but emphasised that what they found on scene was often different from that suggested by the mobile data terminal and that her concern was with the Registrant’s lack of ability to adapt to the situation on the ground. JS accepted that DKA was a potential differential diagnosis, but that given the elevated NEWS of 7 (anything over 3 is said to be indicative of sepsis), the high temperature, increased respiration rate and the history of a two-week productive cough, the Registrant ought to have recognised these as sepsis markers.

72. It was put to JS that the Registrant accepted she overlooked pre-alerting the hospital, but was asked whether it was possible she was distracted by the need to carry out a further full set of obs once in the ambulance. JS agreed this was possible. JS believed the Registrant did provide some reflection on sepsis to the Learning and Development team.

73. The Registrant said that this job came through as a diabetic emergency and whilst on route JS had ‘drilled’ her vigorously about the signs and symptoms of DKA, so that was in the forefront of her mind. She said that when they arrived an RRV was already there and a colleague said it was a case of DKA, so she believed it was DKA. She recalled JS saying it was a possible case of sepsis and she said she was aware of sepsis markers, this being an area she felt confident in. However, she said, the patient had not been taking their diabetic medicine for several days, had a high blood sugar reading, high tachycardia and high respiration rate, so she thought it was DKA. Her view on this did not change when she was taken to the records that referred to a two-week productive cough with white phlegm. Had it been green phlegm that, she said, would have been indicative of infection, but not white phlegm. The Registrant said no harm came to the patient as the treatment was the same for both conditions, namely urgent transport to hospital, which is what they did. She did not, therefore, think it was a major incident.

74. With reference to her failure to pre-alert the hospital, the Registrant said that she was about to when JS asked her to do a second set of obs and she did those on the way to the hospital. By the time she had finished that they were two streets away from the hospital and she was then preparing the patient for hospital. She accepted it was her mistake for not making the call.

75. The Panel was concerned that even now the Registrant was saying as far as she was concerned it was a case of DKA. Whether it was DKA or sepsis, and the actual outcome was not known, the evidence of the more senior experienced Paramedic, as supported by the medical records, was that there were several sepsis markers which the Registrant ought to have picked up on. JS was concerned about the Registrant being fixated on one idea and then being unable to adapt to the environment that actually presented itself and the Panel shared this concern. Failing to recognise that Service User 1 was possibly septic was, in the Panel’s view a serious matter, as was the failure to recognise the elevated NEWS and the Registrant’s limited insight with this patient was a cause of concern. The Panel was concerned that the Registrant did not seem to able to accept that there was more than one possible diagnosis that she should have been considering. In addition, failing to pre-alert the hospital was a serious failing because it meant the hospital were not able to prepare for their arrival.

76. With reference to Service User 2 (Particular 4), JS said, “A comprehensive assessment of Service User 2 which took into account what we call 'red flags' was necessary, because he had presented to us with a high fever. This meant he could potentially have been suffering from meningitis or another paediatric fever. If meningitis is a potential diagnosis, you have to first rule this out and then treat the patient appropriately. Only then could we decide whether Service User 2 could potentially be referred to other healthcare providers, e.g. his GP, rather than us transporting him to hospital.”

77. JS said the Registrant carried out a basic assessment of Service User 2 which was “okay”, however she was “unable to complete a more detailed assessment. I had to finish the assessment of Service User 2 and demonstrate to Jasmine Fletcher the areas that she either lacked or had no knowledge of.”

78. The Registrant said this was a case of a young boy who did not look significantly unwell and who was bouncing around on the sofa. She said it was not an urgent case and the boy was left at home with his GP being advised. She said he did not have meningitis because if he did they would have taken him to hospital. She said she accepted she should have assessed for meningitis markers and she had provided a reflection on this. She went on to say, however, that there were no red flags, just one amber as his heart rate was increased, but that, she said, could just have been as a result of the boy running around. She said no harm resulted and her failure to fully assess Service User 2 had not affected the treatment given.

79. Notwithstanding the appearance of Service User 2 as not looking particularly unwell, in the Panel’s view the high temperature alone in a child warranted a full assessment for meningitis. A failure to identify such a possibility could be crucial and thus the failure to fully assess Service User 2 and a failure to display a knowledge of the importance of red flags in Paediatric fever and or illness was, in the Panel’s view serious. Furthermore, the limited insight of the Registrant in this case was a case of concern.

80. JS told the Panel that she had not expected the Registrant to be perfect and to know everything as the role of a Paramedic involved continuous learning. However, she did expect a safe standard and for the Registrant to have demonstrated that during their time together. She said there were things that the Registrant was “brilliant at” but others where she needed some work, particularly the ability to adapt to the environment and to change her thought process quite rapidly. JS said that with the Registrant “it was very much the case that we would go through things and it was my interpretation she had absorbed, reflected and learnt from them. She would then demonstrate that she had, but then after a few days off she would come back to shift and it would feel like we were back to square one and she would be making similar mistakes of lacking confidence and not remembering what we had talked about.” JS said there were some real positives in the Registrant’s practice but that she was just very inconsistent.

81. SH’s oral evidence was that the errors or concerns that he witnessed whilst out with the Registrant were the sort of things that were not unexpected in a newly qualified Paramedic. With reference to Service User 3 (Particular 5) and the use of Entonox, SH said that he would never be critical of a Paramedic that wanted to take a full set of obs before administering any medication and he accepted that this was probably what had been “drummed into them” at university. However, with experience, he said, a Paramedic learns that there are fewer contra-indications for using Entonox than, for example Morphine, and that therefore a full set of obs is not necessary before giving this form of pain relief.

82. SH said that whilst he had checked the JRCALC guidelines before handing over the Ondansetron and Morphine to the Registrant to administer, it was still important for the Registrant, as the administering clinician, to have done her own checks.

83. SH said he was pleased that the Registrant had been receptive to his advice and took feedback in a positive way and acted upon it, as later demonstrated by, for example, ensuring she checked the JRCALC guidelines before administering medication.

84. The Registrant said she accepted the qualified criticisms made by SH in relation to the fact that she could have administered Entonox prior to obtaining a full set of obs. However, she said, as a newly qualified Paramedic just out of university where they were told they must follow a structured assessment and take a full set of obs before giving any medication that is what she thought she had to do. She said that with the benefit of hindsight and reflection she now knows she could administer Entonox prior to obtaining a full set of obs. She said no harm came to the patient.

85. With reference to the failure to check the JRCALC guidelines, the Registrant accepted she should have done so, but she was aware that SH had done so and that the correct drugs and the correct dose were given. She said that in the following case she did check the guidelines before administering the medication prepared by SH and she accepted that this was best practice.

86. Whilst the Registrant said that no harm came to Service User 3 as a result of her actions the patient, who was in severe pain, suffered that pain for longer than they needed to. In the Panel’s view it is not competent to leave a patient in severe pain for longer than is absolutely necessary. Whilst there are some checks that must be carried out before Entonox can be given, there is no need to take a complete set of obs before administering it. It is a key function of Paramedics to provide pain relief in a timely manner and a failure to do so is, in the Panel’s view, a serious matter.

87. Furthermore, it is most important that before any medication is administered the JRCALC guidelines are checked by the person doing the administering. This is paramount. The person administering should not delegate this responsibility or rely on checks that anyone else has made, since this is when errors occur. In the Panel’s view this was also a serious failure.

88. With reference to Service User 4 (Particular 6), the patient in severe respiratory distress, SH considered it was probably due to a lack of experience that the Registrant had continued to try and take a history from him. As soon as SH mentioned to her that Service User 4 was not really in a fit state to be able to provide a history, the Registrant took this on board and instead focused on taking the patient’s obs. SH was then full of praise for the way the Registrant dealt with Service User 4 in the ambulance, being proactive in having equipment ready in the event that he stopped breathing, in pre-alerting the hospital and in providing her handover to the hospital staff.

89. With reference to requesting an inadequate level of back up, SH said the Registrant would have heard about the three levels, P1, P2 and P3, during her time as a Paramedic with the Trust, but this may have been the first time she had actually had to make such a call, having not been in an RRV before, and he accepted it was very much a subjective response. He said there were other colleagues who would have considered a P2 response appropriate in such a situation and so he was not overly critical of the Registrant.

90. Overall SH was very positive about the Registrant’s abilities and keenness to learn. He considered her to be like “one of many” who come out of university at a young age and who initially struggle.

91. The Registrant said that she had attempted to get a history from Service User 4 when it was not really feasible given his condition and she accepted that. She said that the patient was “quite short of breath, however I went into auto-pilot and tried to complete a primary and secondary survey as we always did at university. I should have realised a secondary survey was not appropriate, but I was just used to doing it automatically.” She added, “I look back on it now and can’t believe I continued to ask him questions.” She said she would not do that now. She said no harm came to the patient as a result of her actions and the management of the patient was not affected.

92. With reference to the level of back up called for, the Registrant said she was not familiar with the levels having never worked in an RRV before. She said she had always worked in a DCA, so it was a new experience being asked to call for back up. She said she had not been given any training on the different priorities and she was not aware of any document setting out a protocol on the matter. The Registrant said she took on board what SH had said about the need to have called for a P1 back up in the particular circumstances.

93. In the Panel’s view it was inappropriate for the Registrant to have been trying to have a conversation with a service user who was struggling to breath and that it was important that Paramedics think about appropriate interventions, rather than going into ‘auto-pilot’. This therefore represented a serious failing on her part.

94. However, with reference to the inadequate level of back up requested, the Panel did not deem this to be incompetent on the Registrant’s part, as she could have believed she was calling for the correct level of back up. She did request back up and it was SH’s evidence that the level of back up is very subjective. Indeed, his concession that a colleague may have considered a level 2 response to be sufficient in such circumstances demonstrated the differing views that could be taken by attending Paramedics. In such a situation the Panel did not believe it was fair to conclude that the Registrant’s actions amounted to a lack of competence.

95. The Panel therefore concluded that, except for Particular 6(b), the other facts found proved did amount to a lack of competence.

Decision on Impairment

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

97. In reaching its decision on current impairment, the Panel took into account the fact that at the relevant time the Registrant was a newly qualified Paramedic, fresh out of university and so inevitably of limited experience. The Panel also took into account the fact that, other than a few shifts, the Registrant had not received her preceptorship and therefore she had not had the full benefit of the support offered to newly qualified practitioners. Following her ROP review on 18 November 2016, RG decided to place the Registrant with JS to complete her preceptorship. JS, however, did not seem to appreciate that she was required to complete the Registrant’s preceptorship and thought she was there in her role as a PPE. JS said there was some overlap between the two roles, but acknowledged that preceptorship was more about support than supervision. Furthermore, it was recognised at the time that the Registrant was going through a difficult time emotionally due to personal matters at home and this too may have had an impact upon her performance and confidence. However, she was still a fully qualified Paramedic and a certain standard of performance was nevertheless to be expected of her to ensure patient safety.

98. What was readily conceded by both JS and SH was that there were many aspects of the Registrant’s practice where she was competent or even excelled. SH in particular considered the issues he identified were essentially due to a lack of experience and that this was not unusual in a newly qualified young Paramedic. JS, however, was more critical and considered there to be issues with the Registrant’s ability to adapt to a changing environment and to recognise and respond appropriately to serious, potentially life-threatening situations.

99. The Panel was of the view that the deficiencies identified in the Registrant’s practice were eminently remediable and was
encouraged by the comments made by both JS and SH about the Registrant’s willingness to listen and learn from her mistakes. This was also evidenced in the reflective pieces she wrote at the time. There was no doubting that there was much about her practice that was to be commended and indeed both PPEs spoke glowingly about her performance in many areas. The real concerns seem to relate to time critical patients and an apparent inability, thus far, to be flexible and adapt to the situation on the ground. The Panel was confident that with the proper support and time these deficiencies could be rectified.

100. Generally speaking the Registrant had shown good insight into her failings, she had taken on board the criticisms made of her practice and had reflected upon them and made admissions to the factual matters alleged. In some instances she had demonstrated at a practical level that she had learned from them, for example by consulting the JRCALC guidelines before administering medication. However, the Panel had some residual concerns about the Registrant’s insight into the patient with sepsis markers and the young boy who should have been assessed for meningitis and this suggested her insight was not yet fully developed and there was more work to be done.

101. The Panel noted that there were personal issues in the Registrant’s life around the time of these matters and they may have impacted upon her ability to perform to the requisite standard. The Panel was pleased, therefore, to hear that those matters are now behind the Registrant and that she is “in a better place” in her life now.

102. In conclusion, because of the Panel’s findings, the fact that the Registrant had not worked as a Paramedic for many years and has done no Continuing Professional Development since 2019, the Panel could not be satisfied that she was yet able to demonstrate safe and effective practice and thus there remained a risk of harm to patients if she were to repeat her errors. The Panel therefore determined that the Registrant’s current fitness to practise is impaired on public protection grounds.

103. 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 were serious and fundamental to the role of a Paramedic. The Panel considered that with the continuing risk that the Registrant might repeat her conduct, members of the public would have their confidence in the profession and the HCPC undermined if a finding of impairment were not made.

104. 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

105. In reaching its decision on sanction, the Panel took into account the submissions made by Mr Bridges and those made by Mr Hockton, together with all the relevant 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.

106. The Panel considered the only aggravating factor in this case to be:

• insight not yet fully developed

107. The Panel considered the following mitigating factors:
• no previous adverse findings

• lack of a proper preceptorship at the start of her career as a Paramedic with the Trust

• early admissions to all the matters alleged

• good insight, although with more to be done (as highlighted above)

• appropriate reflective pieces written at the time

• many areas of practice that have been praised

• matters in the Registrant’s private life which may have impacted upon her performance at the time (and which are no longer extant)

• genuine remorse

• positive testimonials as well as many positive comments from the HCPC’s witnesses

108. In light of the risk to public identified as a result of the lack of competence, the Panel did not consider this was an appropriate case to take no further action or consider mediation. Neither disposal would protect the public from the risks identified by the Panel, nor would they provide the support the Registrant needs in order for her to be able to return to safe and effective practice.

109. The Panel then considered whether to caution the Registrant. However, the Panel was of the view that such a sanction would not adequately address the ongoing concerns identified and therefore would not provide the necessary degree of protection for the public. Equally, it would not provide the Registrant with the support that she clearly needs.

110. The Panel thus considered whether conditions could be formulated to address the concerns identified, protect the public and provide the Registrant with the necessary support and a structured return to the workplace. The Panel has already referred to the many positives in the Registrant’s practice, as identified by JS and SH when supervising her. It is clear to the Panel that she has much to offer the ambulance service and that steps should therefore be taken to assist her with a return to practice. However, the Panel could not ignore the fact that she has not practised for some considerable time and that she has to be able to demonstrate that she is capable of delivering safe and effective practice to those in her care. The Panel was confident that with the right support in place this could be achieved. The Panel was therefore satisfied that conditions could be formulated in this case.

111. The Panel noted that because of the time she has been out of practice (in excess of five years), the Registrant will have to complete the HCPC’s return to practice requirements. These requirements are flexible, minimum requirements that aim to protect the public by making sure a Registrant has up-to-date knowledge and skills. It is a self-directed process with it being a Registrant’s responsibility to ensure they meet the appropriate requirements and can practise safely and effectively within their scope of practice, in line with the HCPC’s standards and, in this case, the standards required to be adhered to by Paramedics. The amount of updating (ie the number of activities carried out to update one’s practice) needed by the HCPC is a minimum requirement. This means that Registrants can carry out more updating if they need to.

112. This process will require the Registrant to renew her registration, declaring that she has not practised as a Paramedic, and complete 60 days of updating within six months of renewal. The guidance states:

“Your period of updating knowledge and skills can be made up of any combination of:

– supervised practice;

– formal study; or

– private study.

You do not need to carry out updating of all three types. Our only requirement is that private study must not make up any more than half the period.

For example, if you needed to do 30 days of updating, you could do this by completing:

– 30 days of supervised practice;

– ten days of supervised practice, ten days of private study, and ten days of formal study; or

– 15 days of private study, and 15 days of formal study.

This is not a full list of possible combinations.”

113. In the Registrant’s case this period would be 60 days, but the same principles apply. ‘Supervised practice’ means practising under the supervision of a registered professional. To complete a period of supervised practice, a Registrant will need to identify a supervisor, who must have been on the relevant part of the HCPC Register for at least the previous three years; and not be subject to any fitness to practise proceedings or sanctions (such as a caution or conditions of practice).

114. The Panel did consider whether these requirements alone would be sufficient to ensure public safety, whilst providing the Registrant with the necessary level of support. However, since it would be open to her to do 30 days of private study and 30 days of formal study and therefore no days of supervision, the Panel was not so satisfied. That said, the Panel was confident that with some specific conditions in place based on the return to practice provisions, the public would be protected and the Registrant would receive the support she needs.

115. The Panel considered a Suspension Order would be both disproportionate and unduly punitive in a case where the errors are remediable, could be readily addressed by a Conditions of Practice Order and related to a lack of competence rather than misconduct. The Panel considered that, in all the circumstances, it would not be in the public interest to suspend a Paramedic who clearly has much to offer the profession and who was, to some extent, let down by the system when the breakdown of her preceptorship was not acted upon promptly by the Trust.

116. 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 complete the return to practice requirements in accordance with the conditions placed by this Panel on her Registration and to demonstrate to a review Panel that she is safe to practise without restrictions on her registration.

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, Jasmine Fletcher (now Jasmine McLellan-Jewell), must comply with the following conditions of practice:

1. When updating your knowledge and skills as part of the HCPC’s return to practice requirements you must complete at least 30 days of supervised practice. The remaining days can be made up of any combination of formal study, private study and/or supervision.

2. Your supervised practice must be with a Practice Placement Educator registered with the HCPC.

3. Your Practice Placement Educator must be provided with a copy of this determination so that they are aware of the issues that have previously arisen with your practice and which need particular attention.

4. You must provide the HCPC with a report from your Practice Placement Educator when you have successfully completed all aspects of the return to practice requirements, in accordance with these conditions, confirming this to be the case.

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

6. You must promptly inform the HCPC of any disciplinary proceedings taken against you by your employer, when employed as a Paramedic.

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

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

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

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

Interim Order

Application

Mr Bridges made an application for an Interim Conditions of Practice Order in the same terms as the substantive order on the grounds that such an Order was necessary to protect the public and was otherwise in the public interest. This was to cover the 28 day appeal process and any appeal in the event that one was made. Mr Hockton, on behalf of the Registrant, said it was a matter for the Panel, but he did not oppose the application.

Decision

The Panel heard and accepted the advice of the Legal Assessor. 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. The Order is in the same terms as the substantive Order and is necessary in light of the risks to the public identified above. The Panel considered 18 months was appropriate and proportionate taking into account the likely length of any appeal in the event that one is made.
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.

History of Hearings for Jasmine Fletcher