Mr Gavin Wood

Preliminary Matters

Potential conflict of interest

1. At the start of the hearing, the Chair of the Panel raised an issue regarding a possible conflict of interest which had been brought to her attention prior to the hearing. This was that the Registrant Panellist had previously been a member of an Education Advisory Committee at the College of Paramedics and that he had met the expert witness, Dr Vince Clarke who also sat on the same Committee. The Registrant Panellist informed the hearing that his contact with Dr Clarke had been minimal and entirely professional in nature. He explained that he had probably sat with Dr Clarke in 3 or 4 meetings, and that he had left the committee in March 2020. The Registrant Panellist indicated that he did not consider that this previous limited and professional contact with Dr Clarke would interfere with his duty as a panel member in this hearing to carry out his role independently and impartially.
2. The Legal Assessor advised the Panel that it was ultimately a decision for them as to whether there was a conflict of interest which demonstrated either actual bias or any apparent bias such that the Registrant Panellist should recuse himself from hearing this case. The Panel is satisfied that there is no actual bias in this case. It is also satisfied that there is no reason why a reasonable observer would conclude that there was the appearance of bias for the following reasons:
(i) The relationship between the Registrant Panellist and Dr Clarke could be described as “fleeting” and was in a purely professional context of a committee where the discussions centred on matters of education; the Panel notes that there is a spectrum of acquaintances and considers that this level of acquaintance falls at the lower end of that spectrum.
(ii) Dr Clarke is not a witness as to fact but is being called as an independent expert witness to assist the Panel in reaching its decisions on facts;
(iii) As an expert, Dr Clarke’s profile will be fairly high within Paramedic circles: he is a leading light in the College of Paramedics, in particular in the field of education, and has published widely;
(iv) It would be difficult to find another Registrant Panellist who had no knowledge of the expert witness, particularly at short notice.

3. In all the circumstances, the Panel considers that there are no grounds on which the Registrant Panellist should recuse himself from sitting on this case.

Service

4. The Panel has seen an unredacted letter dated 28 October 2022 which was sent by email to the Registrant’s registered email address and to the email address of his partner. The Register shows that two email addresses are given for the Registrant, one of which is his own and the other is that of his partner. The Panel is aware that the Registrant has previously requested that all communications from the HCPC and HCPTS are sent to the email address of his partner.
5. The email letter gives notice of the date, time, and purpose of this hearing and that it will be conducted remotely. The Panel has seen an email of the same date from Microsoft Outlook confirming delivery to both the email addresses which appear on the Register for the Registrant. The Panel has also seen a statement from a Scheduling Officer of the HCPTS which confirms that the email was sent to the Registrant’s registered email address on 28 October 2022.
6. Accordingly, having seen these documents, the Panel is satisfied that proper notice of these proceedings has been served on the Registrant.

Proceeding in the absence of the Registrant

7. Ms Jones applied for the hearing to proceed in the absence of the Registrant, submitting that there was no compelling reason for the case to be adjourned.
8. Ms Jones submitted that it was in the public interest for the hearing to proceed in the Registrant’s absence and referred to the fact that the HCPC witnesses were available to give evidence. She submitted that the allegations in the case dated back to December 2018 and referred to the potentially detrimental effect that any adjournment would have on the witnesses’ memories of the alleged events.
9. Ms Jones submitted that the Registrant had voluntarily waived his right to attend. She informed the Panel that the Registrant has not been engaging with the proceedings. Ms Jones stated that the Registrant has provided no explanation for his non-attendance and has not sought an adjournment. She further submitted that an adjournment was unlikely to secure the Registrant’s attendance at a future date given his lack of engagement.
10. The Panel received and accepted legal advice before considering whether to proceed in the Registrant’s absence. The Panel has exercised particular care and caution in reaching its decision and has considered the various matters set out in the HCPTS Practice Note on “Proceeding in the Absence of the Registrant”. The Panel has balanced fairness to the Registrant with the wider public interest and has been mindful of the need to protect the public.
11. The Panel accepts that there will be some disadvantage to the Registrant by not being present and participating in the hearing but considers that this is outweighed by the public interest in proceedings being heard when scheduled, especially where there is the potential for any delay to affect the memories of witnesses. The Panel will be careful to consider all matters which are in the Registrant’s favour throughout the proceedings and to test the evidence by asking appropriate questions of the witnesses.
12. The Panel is satisfied that the Registrant has made a deliberate and settled decision not to attend the hearing or be represented at it. He has removed himself from the process and has indicated that he only wants to be contacted through a third person. The Panel has therefore concluded that the Registrant has voluntarily waived his right to be present.
13. The Panel has also considered whether an adjournment would result in the Registrant’s attendance on another date. It notes the Registrant has not asked for an adjournment. The Panel is satisfied that no useful purpose would be served by adjourning this hearing as it is unlikely that the Registrant would attend on a later date.
14. The Panel is satisfied that there is a clear public interest in this case, which is now some four years old, being concluded. The Panel considers that it is in the public interest for final hearings to proceed on the date on which they are listed to be heard.
15. The Panel is satisfied that it is in the interests of justice to proceed in the Registrant’s absence.

Application to amend the Allegation

16. Ms Jones applied to amend the Allegation in a number of respects. With regard to the original Particular 1b, Ms Jones offered no evidence. Particular 1 alleges that the Registrant did not follow the North East Ambulance Service NHS Foundation Trust guidance (“NEAS guidance”) and/or the Joint Royal Colleges Ambulance Liaison Committee Guidelines (JRCALC Guidelines) in a number of respects which are set out in sub-particulars. These included as the original 1b that the Registrant: “Did not check Service User A’s femoral pulse”. Ms Jones submitted that in light of the expert report of Dr Vince Clarke, the HCPC could no longer allege that in order to follow the guidance and/or Guidelines, the Registrant should have checked Service User A's femoral pulse.
17. Ms Jones applied to amend Particular 1 by adding a number of sub-paragraphs (now numbered 1c to 1i in the Amended Allegation above). Ms Jones explained that these proposed additional sub-particulars clarified a number of specific ways in which it is alleged that the Registrant did not follow the relevant NEAS guidance and/or the JRCALC Guidelines. This evidence had come to light after receipt of the expert report of Dr Clarke in February 2022 which was after the original Allegation had been referred to this Committee in December 2021.
18. Ms Jones also applied to amend Particular 2 by clarifying that the allegation was that the Registrant had not undertaken an electrocardiogram examination of Service User A at the time when he is alleged to have told Colleagues 2 and/or 1 that an electrocardiogram indicated that Service User A was asystolic.
19. Ms Jones applied to amend Particular 5 by removing the Registrant’s alleged motivation for the two matters set out in sub-particulars 5a and 5b so as to better reflect the evidence the HCPC intended to call. She also applied to correct the identities of the colleagues involved from Colleagues A and/or Colleague B to Colleagues 2 and/or Colleague 1.
20. In reaching its decision, the Panel has received and accepted legal advice. It has considered each of the proposed amendments separately.
21. In relation to the HCPC’s decision to offer no evidence on original Particular 1b by striking through that part of the allegation, the Panel agrees with Ms Jones’ submission that there is no evidence to suggest that the Registrant was required by the NEAS guidance or the JRCALC Guidelines to check Service User A’s femoral pulse. The Panel therefore agrees to Particular 1b being deleted from Particular 1. As a result, the Panel directs that all sub-paragraphs which follow will now be re-numbered accordingly.
22. In relation to the addition of Particulars 1c to 1i (in the new numbering), the Panel is satisfied that these sub-particulars clarify the various ways in which it is alleged that the Registrant did not follow the NEAS guidance and/or the JRCALC Guidance on 9 December 2018. The Registrant has been on notice of the proposed additions to Particular 1 since he was provided with a notice of amended allegation on 28 April 2022. He has not indicated any objections to them. The Panel has decided that none of these proposed additional sub-particulars causes any prejudice to the Registrant nor is it in any way unfair to him for them to be added to Particular 1.
23. In relation to Particular 2, the Panel has concluded that the proposed amendment better reflects the evidence that the HCPC intends to call. It is satisfied that no prejudice is caused to the Registrant by making the amendment and nor is it in any way unfair to him.
24. In relation to Particular 5, the Panel has decided that the proposed deletion of the Registrant’s motive in respect of sub-particulars 5a and 5b is appropriate. If the Panel were to find any part of Particular 5 proved, under Particular 7 it would then have to consider whether the Registrant’s conduct was dishonest. The Panel is satisfied that no prejudice is caused to the Registrant by making this amendment and nor is it in any way unfair to him.
25. The other proposed amendment to Particular 5b is not a matter of substance but merely corrects what is clearly an error in referring to Colleagues 1 and 2 as Colleagues A and B. Although the Registrant was not given notice of this in the letter of 28 April 2022, the Panel is satisfied that this proposed amendment does not cause any prejudice or unfairness to the Registrant.
26. Accordingly, all proposed amendments are approved.

Application to conduct part of the case in private

27. Ms Jones applied for those parts of the case where matters relating to the Registrant’s health were raised, to be heard in private in order to protect his private life.
28. In reaching its decision, the Panel has had in mind the HCPTS Practice Note on “Conducting Hearings in Private”. It has also received and accepted legal advice.
29. The Panel is aware that these proceedings should be heard in public unless there are exceptional circumstances which would dictate that either the whole or part of the hearing should be conducted in private. One exceptional circumstance which might arise is where matters arise concerning the personal life or health of a witness or registrant and, in order to protect their private life, the hearing should be conducted in private. The Panel has considered whether in this case there are any such exceptional circumstances.
30. The Panel notes that part of the Allegation relates to a health matter (Particular 8). It is satisfied that where matters relating to the Registrant’s health arise during the hearing, these should be heard in private so as to protect his private life. The rest of the hearing will be conducted in public.

Background

31. At the relevant time, the Registrant was employed as a Band 6 Paramedic by North East Ambulance Service NHS Foundation Trust (“the Trust”). The Registrant was first employed by the Trust in 1983 and began practising as a Paramedic in 1997.

32. On 9 December 2018, the Registrant attended an emergency incident where a young female (Service User A) had been found by members of the public hanging from a tree. At this time the Registrant was a lone worker as a Rapid Response Vehicle (“RRV”) paramedic from Bishop Auckland Ambulance Station. The Registrant attended the scene and was the first Trust paramedic to arrive. Two police officers were already at the scene and providing cardiopulmonary resuscitation (“CPR”) to Service User A. Colleague 2, a Community Paramedic employed by the Trust was the next paramedic to arrive on the scene.
33. On the arrival of Colleague 2 the Registrant stated that he had declared Service User A was deceased at the scene on grounds that he had found her to be asystolic with fixed and dilated pupils. Colleague 1, a Band 6 Paramedic and Colleague 3, a Clinical Care Assistant were in a dual crewed ambulance which was dispatched to the scene. On arrival, they were advised by Colleague 2 that the Registrant had declared Service User A as deceased at the scene.
34. Colleague 1 and Colleague 3 submitted a North East Ambulance Service 07 incident report (“NEAS07”) regarding the Registrant’s conduct and treatment of Service User A and, as a result, the Trust instigated an internal investigation. The investigating officer was AP, a registered Paramedic who was at the time the Clinical Operations Manager for the Stockton Cluster where the Registrant was a member.
35. On 30 May 2019, the HCPC received a referral dated 28 May 2019 from Parent A in relation to the conduct of the Registrant on 9 December 2018. The referral related to the Registrant’s treatment of their daughter, Service User A.
36. On 1 December 2021, a panel of the Investigating Committee decided that there was a case for the Registrant to answer and referred the Allegation to this Committee. The Registrant was notified of this decision on 8 December 2021.

Decision on Facts

Evidence

37. The HCPC provided the Panel with a bundle of documents for the hearing which totalled 728 pages of which some 620 pages were exhibits in the case. The HCPC also called 3 witnesses and expert evidence from Dr Vince Clarke. In relation to one witness, the HCPC made a hearsay application. The Panel also relied on a production statement from OA, a legal assistant at Kingsley Napley LLP producing various of the exhibits in the HCPC bundle. These exhibits include:
a) The Trust’s internal investigation documentation.
b) NEAS07 documentation regarding the 9 December 2018 incident.
c) Electronic patient care records (“ePCR”) for Service User A from the Registrant, Colleague 2, and Colleagues 1 and 3.
d) The recognition of live extinct (ROLE) form completed by the Registrant on 9 December 2018 and the 2016 JRCALC ROLE guidelines.
e) The Inquest findings and the report of the expert appointed for the Inquest, Dr Kirby.
f) Witness statements from a number of people who were not called or specifically relied upon by the HCPC at the fact-finding stage of the proceedings, other than as background information. These exhibits included statements from Service User A’s parents and from the two members of the public who had first found Service User A.
g) Documents relating to the Zoll defibrillator used by the Registrant on 9 December 2018 including a detailed case history (July 2016 to March 2019), a Zoll Basic Summary, a Zoll Rhythm Summary together with photographs of a Zoll defibrillator and information on its use.
h) Various Trust policies including its Social Media Policy.

38. The Panel notes that the documentary evidence includes some hearsay statements. The Panel also notes that much of this hearsay evidence sets out what is in effect background information about the case and so it does not directly relate to the matters which the Panel has to consider in this hearing. The Panel has received and accepted legal advice on hearsay evidence. Where the hearsay evidence relates to the facts alleged against the Registrant, the Panel has considered in relation to each statement whether it would be fair to admit it in evidence. Where it has admitted such evidence, the Panel has only then considered what weight to attach to it.
39. The Panel has borne in mind throughout that the burden of proving the Allegation is on the HCPC and that to do so, there must be sufficient evidence to satisfy the civil standard of proof. The Panel has considered each of the particulars and sub-particulars of the Allegation separately.
40. The Panel proposes to set out the salient features of the evidence it has heard from the witnesses.

AP

41. AP is a registered Paramedic and is employed by the Trust as an Emergency Preparedness, Resilience and Response Training Manager. AP has been in this role since March 2021. Prior to that AP was employed by the Trust as a Clinical Operations Manager for Stockton Cluster – South Division. In this role, AP had management responsibility for five Clinical Care Managers together with 110 clinical staff at the Cluster level. Part of AP’s role was to conduct formal investigations and prepare statements for reviews and disciplinary hearings. AP was the Registrant’s Line Manager from early 2017 and although he had not worked with the Registrant, he was aware of him through being based at the same ambulance station. As the Registrant’s Line Manager, AP told the Panel that he was not aware of any previous concerns of a clinical or disciplinary nature.
42. AP told the Panel that he had established a timeline of events on 9 December 2018 as the starting point for his investigation. An emergency call was made by a member of the public to the Trust which was reported as a Category 1 incident regarding a patient hanging from a tree at a location in Shildon. Taking information from the Control Log, electronic patient care records of the Registrant, Colleagues 2, 1 and 3, and from the Registrant’s Zoll defibrillator machine, the timeline includes the following entries:
- that the emergency call was logged at 19:19
- that it was recorded that “CPR” was in progress at 19:21
- that the Registrant was assigned to the call at 19:22
- that the Registrant was mobile at 19:23
- that Colleague 2 was assigned at 19:23
- that Colleague 1 and Colleague 3 were assigned at 19:24
- that Colleague 1 and Colleague 3 were mobile at 19:24
- that Colleague 2 was mobile at 19:25
- that Colleague 2 was notified by Control that the ambulance crew was 20 minutes away (travelling from Barnard Castle)
- that the Registrant was logged as arriving at the scene at 19:28
- that the Registrant told Control that he could see blue lights ahead at 19:29
- that Colleague 2 arrived at the scene at 19:31
- that the Registrant stood HEMS down at 19:32
- that the Registrant’s Zoll defibrillator basic summary start time 19:33:18
- that the Registrant’s Zoll defibrillator passed the Self Test at 19:33:26
- that the Registrant’s Zoll defibrillator only showed activity between 19:36:05 to 19:36:21 (16 seconds) and documents “ECG multi-lead out of fault; Alarm Heart rate (low); Respiration impedance lead fault. Last event (elapsed time 3:08)”
- that Colleague 1 and Colleague 3 arrived at the scene at 19:38
- that the Registrant logs onto Colleague 1 and Colleague 3’s electronic patient care record at 19:42:01
- that Colleague 2 logs onto Colleague 1 and Colleague 3’s electronic patient care record at 19:42:07
- that Colleague 1 and Colleague 3 conducted a 30 second electrocardiogram examination of Service User A at 19:44:33 to 19:45:03 which showed Service User A to be asystole
- that Colleague 2 cleared the scene at 19:50
- that the Registrant cleared the scene at 19:51
- that Colleague 1 and Colleague 3 cleared the scene at 23:40.

43. AP told Panel that the Zoll defibrillator used by the Registrant on 9 December 2018 had been retrieved by a Trust Clinical Care Manager (Stockton Cluster) in the days following the incident so that information could be obtained from it for the investigation. AP told the Panel that the time on the Zoll machine was checked for accuracy and found to be accurate. The Zoll Basic Summary which AP retrieved from the Registrant’s Zoll defibrillator had shown that no interventions had been undertaken by the Registrant. AP said he had obtained the Zoll Rhythm Summary from the same machine so that he could see what information the Registrant had been looking at when he made the decision to declare recognition of life extinct (“ROLE”).
44. AP also told the Panel that having reviewed the ROLE form completed and signed by the Registrant and his rationale for not moving from Basic Life Support to Advanced Life Support, he had then obtained and reviewed a copy of the JRCALC Guidelines to assess the Registrant’s actions against the standards and to determine if the ROLE form was completed correctly and the rationale was correct. AP said that the Registrant had marked Group A and Group B as the reasons for why he had declared ROLE. AP explained that Group A and Group B set out circumstances where there may be no need to initiate cardiopulmonary resuscitation (“CPR”) or CPR can be discontinued once the relevant facts are established. Group A was where there are conditions unequivocally associated with death and where the JRCALC Guidelines say that resuscitation should not be attempted. Group B is used where there would be no realistic chance that CPR would be successful, and a number of conditions are all present.

Colleague 1

45. Colleague 1 is a Band 6 Paramedic employed by the Trust. Colleague 1 has been in that role since 2009. She works as a front-line paramedic as part of a dual crew ambulance and was based at Barnard Castle Ambulance Station at the relevant time.
46. Colleague 1 told the Panel that she had not worked with the Registrant prior to the incident on 9 December 2018 when she met him for the first time. On that day, Colleague 1 said that she had responded to an emergency call to attend a report of a hanging in the Shildon area. Colleague 1 said that she was despatched as back up to the RRV paramedic who was already at the scene. The other member of the ambulance crew was Colleague 3 who was a Clinical Care Assistant employed by the Trust at that time.
47. Colleague 1 made a witness statement to the Trust on 10 December 2018. She made a further statement dated 23 August 2019 as part of an independent investigation into the incident conducted by RB. Colleague 1 adopted both statements as her evidence in the hearing. Colleague 1 told the Panel that she was deployed at 19:24 to an emergency call to attend a hanging in the Shildon area. She said that the ambulance arrived at the scene at 19:38 hours. Colleague 1 said that she had taken the timings from the electronic patient care record which takes the time from the Terafix computer which is a computer console in the ambulance. This automatically records the time of arrival when the ambulance is within 200 meters of the location.
48. Colleague 1 said that as she and Colleague 3 arrived, Colleague 2 was walking up a footpath towards them and Colleague 2 had told them that the Registrant had already pronounced Service User A deceased at the scene. Shortly after this the Registrant had joined them and had asked if she and Colleague 3 would mind completing the paperwork as he was due to go off shift. Colleague 1 told the Panel that she had indicated that they were happy to complete the ePCR but that the Registrant would have to complete the ROLE documentation as he had made that decision. Colleague 1 said she had also told the Registrant that they would need a Rhythm strip. Colleague 1 said that the Registrant had said that he had not got one because his printer was not working.
49. Colleague 1 told the Panel that her first impression she got from the Registrant was that it was the end of his shift and he wanted to go home.
50. Colleague 1 told the Panel that it was only after she had gone with Colleague 3 to obtain a 30 second rhythm strip reading from Service User A that she had become concerned that the Registrant had not followed the Trust’s advanced life support protocol or the NEAS ROLE guidance which includes the use of the defibrillator and/or drug therapy and airway management.

Colleague 2

51. Colleague 2 is currently employed at the University of Sunderland as a lecturer and teaches on the Paramedic Science degree programme. In December 2018, Colleague 2 was employed the Trust and working as a lone Community Paramedic. Colleague 2 said that whilst she knew of the Registrant prior to 9 December 2018 she could not recall if they had worked together. Colleague 2 said that she had made statements about the incident to the Trust on 10 December 2018 and on 14 September 2019 to an independent investigation into the incident.
52. Colleague 2 told the Panel that she was deployed to an emergency call to attend a C1 cardiac arrest. She said that she was mobile in her vehicle at 19:25 hours and arrived at the scene at 19:31 hours. Colleague 2 said that the time of arrival is taken from the Terafix computer which links to GPS (Global Positioning System) and is activated when she presses the button on arrival at the scene. Whilst on route to the scene, Colleague 2 said she was aware from Ambulance Control that the HEMS (Helicopter Emergency Medical Service) team was on its way and a dual crewed ambulance was about 20 minutes away. Colleague 2 said that when she arrived, the Registrant and police officers were already at the scene. She said that the Registrant was on the phone standing down the HEMS team, and that when he had finished his call, he had told her that he had “called” the incident as the patient (Service User A) was asystolic and had fixed and dilated pupils. Colleague 2 said that there was no CPR going on when she arrived on the scene.
53. Colleague 2 said that she had then gone to see Service User A, who she found lying supine on the ground, fully clothed except for her abdomen which was exposed. Colleague 2 said that she did not examine Service User A as from what the Registrant had told her she assumed that he had done so. Colleague 2 offered to get the ROLE form and ePCR. However, when she got to the Registrant’s RRV it was locked so she got the ePCR from her vehicle. Colleague 2 said that the Registrant had asked her what time her shift finished as he should have finished his shift at 19:30 and had already run over the end of his shift. Colleague 2 said that as she was due to finish her shift at 20:00 so the Registrant had said he would complete the ePCR and gave her the keys to get it from his RRV. It was whilst she was doing this that the ambulance arrived with Colleagues 1 and 3.
54. Colleague 2 said that when the Registrant had come to them, he had said that his printer was not working and therefore Colleague 1 and Colleague 3 had taken their defibrillator to monitor Service User A and print out a rhythm strip. Colleague 2 said that the Registrant had said that he had completed the ROLE form as far as he could and that there was a lot of information that was unknown, and he had asked Colleague 1 and Colleague 3 if they would mind completing the ePCR as they were on night shift.

Police Officer 1 – application to adduce hearsay evidence and for that application to be heard in private

55. Ms Jones indicated that she would apply for the evidence of Police Officer 1 to be admitted as hearsay evidence. She informed the Panel that the basis of her application involved the private life of Police Officer 1, namely matters relating to his health, and submitted that it would not be possible to make the hearsay application without reference to health matters as these were inextricably intertwined. Ms Jones submitted that the application should be heard entirely in private so as to safeguard Police Officer 1’s private life.
56. The Panel has received and accepted legal advice. Prior to the application, the Panel had been provided with a further 5-page witness statement from OA, a legal assistant at Kingsley Napley LLP, together with an exhibit bundle of 16 pages which set out the efforts made by the HCPC to secure the attendance of Police Officer 1 and the situation with regard to Police Officer 2 who the HCPC does not intend to call as a witness.
57. Having seen the additional evidence which sets out the basis of the application and refers to the health of Police Officer 1, the Panel is satisfied that the entire hearsay application should be heard in private. It accepts that it would be difficult for Ms Jones to make her application without reference to matters relating to the witness’s health. Accordingly, the Panel has decided that it will hear the hearsay application in private. It will announce its decision with as much of its reasoning as possible in public session.

Hearsay application

58. Ms Jones submitted that it was fair and just to admit Police Officer 1’s witness statement as hearsay evidence as it was important explanatory evidence. The witness had attended the scene and could assist the Panel on key aspects of the case. Police Officer 1’s evidence was not the sole and decisive evidence of some of the particulars in the Allegation and that it was reliable evidence as the officer had made his statements in the course of his employment. Ms Jones submitted that the HCPC had taken all reasonable steps to secure his attendance. Ms Jones also confirmed to the Panel that notice of the application together with the documents in support of it, had been sent on 9 January 2023 to the Registrant’s requested email addresses and there had been no response from him.
59. The Panel has received and accepted legal advice. The Panel has seen documentary evidence of the steps taken on behalf of the HCPC to secure the attendance of Police Officer 1. It accepts that it was as late as 5 and 6 January 2023 when it first became clear that the officer was not going to be able to attend. Although there is no medical report confirming that the officer is medically unfit to attend, the Panel accepts that a senior officer who has managerial responsibility for Police Officer 1 has been in touch with him and is fully aware of the situation. The Panel does not think that there is any reason to doubt that Police Officer 1 is medically unfit to attend as a witness.
60. The Panel also notes that it was originally the intention of the HCPC to call both Police Officer 1 and Police Officer 2 and that steps were taken to secure a witness statement from Police Officer 2 back in 2021 when the case was being prepared for final hearing. This proved difficult and, in the end, it appears these steps simply petered out. The Panel does not consider that it would be possible at this very late stage for the HCPC to attempt to locate Police Officer 2, obtain a witness statement from him and secure his attendance at this hearing.
61. The Panel is aware that if Police Officer 1’s evidence is admitted as hearsay evidence, this would, in circumstances where the Registrant was present, deprive him of the opportunity to cross examine the witness. This consideration does not arise in this case as the Registrant has voluntarily absented himself from the hearing.
62. The Panel accepts that there is a good reason for the non-attendance of Police Officer 1. In relation to Particular 1a the officer’s evidence is the sole evidence available and the Panel accepts that Particular 1a is part of a serious allegation which has the potential to adversely impact the Registrant’s career. The Panel is also mindful of its obligations to protect the public, serve the public interest and uphold professional standards.
63. The Panel notes that in the statements the Registrant gave to the Trust on 10 December 2018 and on 15 December 2018, the Registrant does not disagree with Police Officer 1’s evidence that he advised the officer to cease CPR. Where the Registrant’s account of events differs from Police Officer 1, there is evidence from other witnesses who have been called.
64. The Panel also notes that the Registrant was given notice of the application on the first day of the hearing and that it appears he has chosen not to oppose it.
65. In the circumstances, the Panel has decided that it is fair to admit Police Officer 1’s statement as hearsay evidence. In due course, when it has heard all the evidence in the case, the Panel will decide what weight to give to the evidence.

Police Officer 1 – hearsay evidence

66. Police Officer 1 is a police constable employed by Durham Constabulary stationed at Shildon Police office where he is deployed as part of the Shildon Neighbourhood Police team. Police Officer 1 said that on 9 December 2018 he was on patrol duty with Police Officer 2 when they attended a report of a female hanging from a tree which had been reported by a member of the public.
67. The Panel will refer to the detail of Police Officer 1’s evidence when it sets out its findings in relation to Particular 1 below.

Expert Evidence from Dr Vince Clarke, BSc (Hons), PGCE, MA, EdD, FHEA, MC Para.

67. Dr Vince Clarke was called as an expert witness. Dr Clarke is a Principal Lecturer in Paramedic Science employed by the University of Hertfordshire where he is the Programme Lead for the BSc Paramedic Science programme. Previously, Dr Clarke was employed by the London Ambulance Service NHS Trust as a Principal Paramedic Tutor. He is the College of Paramedics’ Trustee for Education and sits on the Board of the College of Paramedics.
68. Dr Clarke told the Panel that on attending a patient who appears to be in cardiac arrest, a paramedic should be reasonably expected to follow the guidelines set out by the Joint Royal Colleges’ Ambulance Liaison Committee (JRCALC) and that the JRCALC Guidelines for 2016 were those current at the time of the incident. Dr Clarke said that the guidelines were informed by those produced by the Resuscitation Council UK and can be considered to be the reasonable standard for registered paramedics. He also said that local variations to procedures may be in place, as may local variations in the requirements for documentation and reporting. Dr Clarke appended the relevant JRCALC Guidelines relating to basic life support, advanced life support, airway and breathing management and recognition of life extinct to his report.
69. Regarding Service User A, Dr Clarke said that she had been identified by the attending police officers (Police Officers 1 and 2) as being unresponsive and he referred to the suggestion that one of the police officers had felt a pulse in Service User A’s wrist (radial pulse). Dr Clarke noted that the police officers had commenced basic life support which was appropriate and followed the adult basic life support guidance in relation to patients who are not breathing or not breathing normally. Although Service User A was 17 years old at the time, it was Dr Clarke’s opinion that the appropriate basic life support guideline to follow was the JRCALC Basic Life Support (Adult) guidance as the paediatric guidance applies to prepubescent children. These guidelines have a table which clearly sets out the expected actions of the attending ambulance crew. Dr Clarke said that the actions should be followed regardless of the decisions of those already on the scene. The ambulance clinician should undertake their own assessment.
70. The Panel will refer to Dr Clarke’s expert opinion when it is setting out its findings in respect of Particular 1.
71. Dr Clarke said that the Registrant had made no appropriate clinical decisions in relation to Service User A. None of his decisions appeared to have had any basis in clinical need. The Registrant appeared to have made a single decision which was not to commence any clinical assessment or CPR. Dr Clarke considers that the rationale presented by the Registrant in interview i.e., that Service User A’s presentation was “incompatible with life”, was wholly erroneous and not based on any assessment of Service User A. Dr Clarke recognised that the Registrant’s experience may have biased his view of the likely outcome of the case with resuscitation efforts more likely than not proving fruitless, but this was not a clinical decision.

Half time submission – Particular 3

72. At the conclusion of the HCPC’s case, the Legal Assessor raised an issue regarding the sufficiency of the evidence in relation to Particular 3 of the Allegation. Ms Jones did not make any submissions to suggest that there was sufficient evidence of Particular 3 and accepted that both Colleague 1 and Colleague 2 when asked in their evidence about the matter, had each said that they could not recall the Registrant stating to them that he had checked Service User A’s femoral pulse.
73. The Panel received and accepted legal advice as to how to approach the sufficiency of evidence at the close of the HCPC’s case. It has considered the HCPTS Practice Note on “Half-Time” submissions. The Panel has reviewed the oral evidence of Colleagues 1 and 2 and considered their witness statements. The Panel is satisfied that there is no evidence before it that the Registrant ever stated to either Colleague 1 or Colleague 2 that he had checked Service User A’s femoral pulse. Accordingly, the Panel is satisfied that the HCPC has failed to discharge the burden of adducing any evidence of Particular 3. The Panel has decided that it should stop the case at this point and enter a finding that Particular 3 is not proved.

Decision on the facts

Particular 1

74. The Panel has approached this Particular by considering the JRCALC Guidelines and what these say about the steps a paramedic should take when treating a patient such as Service User A who appears to be in cardiac arrest as a result of hanging. The Panel has considered whether the NEAS guidance differs in any material way from the JRCALC Guidelines. The Panel has also considered whether the JRCALC Guidelines are mandatory or whether a paramedic may depart from them.
75. The Panel accepts the evidence of Dr Clarke that the JRCALC Guidelines are produced periodically (usually every three years) and that supplements are also issued. Dr Clarke referred to there being a disclaimer at the beginning of the Guidelines which makes it clear that they are guidelines and are not mandatory. Dr Clarke said that this was because there may be local variations and procedures in place as to the procedures to be adopted and in relation to the requirements for documentation and reporting. He also said that they were guidelines rather than mandatory procedures as they applied to a range of care professionals not all of whom would be able to carry out all the procedures. As Dr Clarke did not refer to any local variations and procedures within the Trust, the Panel is satisfied it is more likely than not that the local NEAS guidance is essentially the same as the national JRCALC Guidelines. Dr Clarke also said that so far as declaring ROLE was concerned this was what he called a “procedural tick box exercise” for the good reason that even as an experienced paramedic you cannot always tell if someone is dead just by looking at them.
76. Dr Clarke was also asked by the Panel if there was any scope for intuitive decision making based on experience. He said that there was in certain areas but in a case where the patient has collapsed and is unresponsive, intuition has to be led by evidence.
77. Dr Clarke told the Panel that on attending a patient who appears to be in cardiac arrest, a paramedic should be reasonably expected to follow the JRCALC Guidelines issued in 2016. Dr Clarke explained that the Guidelines were informed by those produced by the Resuscitation Council UK and can be considered to be the reasonable standard for registered paramedics.
78. Dr Clarke told the Panel that in the normal course of events, it was his opinion that a reasonable paramedic attending Service User A should have cleared and secured the airway, applied AED, ventilated with supplemental oxygen, gained intravenous access, administered adrenaline “as per the JRCALC Guidelines” and continued resuscitation efforts for a minimum of twenty minutes. He also said that the potential risk of not undertaking these assessments/interventions is that the Registrant cannot make an informed clinical decision as to whether or not to continue with resuscitation efforts. The subsequent risk is that a potentially viable resuscitation attempt was not taken. Dr Clarke’s conclusion was that the Registrant’s failure to follow basic life support, advanced life support and ROLE guidelines was, on a balance of probabilities, less likely to have had a material outcome on the survivability of Service User A.
79. Dr Clarke’s opinion was that the Registrant had failed to follow local (i.e., NEAS guidance) and national (i.e., JRCALC Guidelines) in attending Service User A.

Particular 1a was found proved

80. The Panel has accepted the hearsay evidence of Police Officer 1 who made a written witness statement on the same day (9 December 2018) and later made a supplementary statement dated 2 May 2019. The officer produced both these statements in the statement he gave to the HCPC for this hearing and confirmed that they accurately reflected what had happened on 9 December 2018.
81. Police Officer 1 stated it had been at about 19:15 when he and Police Officer 2 who were in an unmarked police car, had heard on the car radio that there was a suspected hanging incident not far from where they were. Police Officer 1 said they had driven straight to the location and that very shortly after their arrival he and a member of the public had assisted Police Officer 2 to cut Service User A down from the tree. Police Officer 1 said Service User A was then laid on the ground, and he had untied the ligature from her neck. The ligature was a dressing gown belt. Police Officer 1 said he had started chest compressions, in other words, cardiopulmonary resuscitation (CPR), while Police Officer 2 had tried to find a pulse before starting mouth to mouth resuscitation using a face mask. The chest compressions had been continued for about 10 minutes before the Registrant arrived. Police Officer 1 describes Service User A as being warm to the touch but unresponsive throughout.
82. The Panel is satisfied, on the evidence of both Police Officer 1 and Colleague 2, that the Registrant was the first paramedic to attend the scene. Colleague 2 told the Panel the Registrant was there when she arrived. The Panel notes that the Registrant accepts, in both his written statement and in his interview as part of the Trust’s internal investigation, that he answered a call to attend the incident and was the first paramedic to arrive at the scene. The Panel has seen the Registrant’s ePCR for Service User A which logs his arrival at 19:28.
83. The Panel accepts the evidence of Police Officer 1 that when the Registrant arrived, he had checked Service User A for vital signs by checking her pupils. Police Officer 1 believes the Registrant may have also tried to find a pulse. According to Police Officer 1, the Registrant had then told him to stop chest compressions and pronounced Service User A to be dead, stating words to the effect “You can stop now, she’s gone”. Police Officer 1 then acted on this advice and stopped chest compressions.
84. The Panel is satisfied that both police officers were with Service User A carrying out basic life support when the Registrant arrived. The Panel is also satisfied it is more likely than not that both police officers were present, and both would have heard the Registrant when he advised the officers to cease CPR. The Panel therefore finds that it is more likely than not that the Registrant gave advice to Police Officer 1 and to Police Officer 2 to cease CPR.
85. The Panel has reviewed the Registrant’s statement dated 10 December 2018 and has reviewed the Control Log. It is clear from the Control Log that the Registrant was aware before he arrived at the scene that Service User A had been cut down from the tree and that CPR had commenced. There is an entry in the Control Log timed at 19:26 which shows that prior to his arrival at the scene the Registrant had sought an update and had been told “[redacted] found hanging, cut down, CPR in progress”. According to the Registrant’s account to the Trust, he had arrived at 19:28 and he had taken from the RRV his defibrillator, first responder bag and the paramedic bag. The Registrant said that on arrival he had seen the police officers were doing CPR on Service User A and that they had a face shield over her. He had noted there was vomit in her nostrils, her mouth and in her hair. He said he had concluded that her airway was obstructed with vomit. The Registrant said he had asked the police officers how long she had been there, but that they did not know but had said she was still warm. The Registrant said he had checked this and had found that she was warm centrally but cold peripherally. He said he had noticed there was a deep ligature mark on her neck and saw that she had been hanging from a dressing gown cord. The Registrant said he had checked for a carotid and femoral pulse but had found neither. He said he then checked Service User A’s pupils with a pen torch and found them to be fixed and dilated. The Registrant said he had seen that Service User A was asystole on the monitor. He said he had then made a decision that further resuscitation was futile based on the fact that Service User A had a compromised airway, had fixed and dilated pupils, was asystole on the monitor and had been hanging.
86. In questions put to him on 15 December 2018 by AP as part of the internal fact-finding investigation, the Registrant added he had ascertained from the police officers that CPR had been going on for 5 to 10 minutes before he arrived and that one of the officers thought he had felt a radial pulse prior to Service User A being cut down. The Registrant stated that in confirming asystole there had been “a complete flat line without disturbance”. It was at this stage that he had decided that the injuries were incompatible with life and that this decision had been shaped by extensive experience of similar traumatic calls over his 26-year career. The Registrant said that he had declared ROLE within 5 minutes of his arrival.
87. The Panel has considered whether in giving that advice, the Registrant did not follow the JRCALC Guidelines which are referred to by Dr Clarke and appended to his expert report. According to Dr Clarke, the JRCALC Basic Life Support (Adult) Guidelines clearly set out the expected actions of the attending ambulance crew. Dr Clarke told the Panel that the JRCALC Guidelines for ROLE set out criteria for not undertaking/cessation of CPR. The first set of criteria is set out as Group A in the NEAS ROLE form which lists conditions unequivocally associated with death where resuscitation should not be attempted. The Panel notes that the Registrant ticked the Group A box on the ROLE form. It accepts Dr Clarke’s evidence that none of the listed conditions applied in Service User A’s case.
88. The Panel notes that the Registrant has also ticked the Group B box on the ROLE form. The second set of criteria which is set out as Group B in the NEAS ROLE form lists conditions where resuscitation can be discontinued. Dr Clarke said that resuscitation can be stopped when there is no realistic chance that CPR would be successful. The JRCALC Guidelines qualify this by requiring that all of the following factors must exist together:
• 15 minutes since the onset of cardiac arrest
• No bystander CPR prior to the arrival of the ambulance
• The absence of the exclusion criteria (i.e., drowning, hypothermia, poisoning/overdoes or pregnancy)
• Asystole for greater than 30 seconds on the ECG monitor screen
• CPR should only be paused for a 30 second asystole check if all the other criteria are met.

89. According to Dr Clarke, the Registrant ceased all resuscitation efforts without due consideration of the above criteria. CPR had been carried out by the police officers and the Registrant was aware of this having been told by the Control prior to his arrival. He would have seen the officers continuing to do CPR when he arrived at the scene. It is Dr Clarke’s opinion that CPR should have been continued while Service User A’s airway was cleared and secured, and the defibrillator attached. He said it would have been reasonable to pause the CPR while the rhythm was being checked on the monitor, but this should have been done to inform advance life support efforts and not to invoke ROLE.
90. The Panel is satisfied that it is more likely than not that in advising Police Officer 1 and Police Officer 2 to cease CPR, the Registrant did not follow the NEAS guidance or the JRCALC Guidelines.
91. The Panel therefore finds Particular 1a proved.

Particular 1b was found proved

92. The Panel accepts the evidence of Dr Clarke that the application of a defibrillator to Service User A presenting in cardiac arrest would have necessitated exposing her bare chest in order to apply the self-adhesive pads. There is no evidence from either police officer or from Colleague 2 or Colleague 1 that any of Service User A’s upper clothing had been removed or cut off at any time.
93. The Panel accepts the evidence of Police Officer 1 that he did not see the Registrant retrieve his defibrillator from his kit bag or use a defibrillator on Service User A prior to declaring ROLE. The Panel accepts Police Officer 1’s evidence that he remained with Service User A for some time after he had been advised to cease CPR. The Panel has concluded that had the Registrant used the defibrillator on Service User A, Police Officer 1 would have seen him do so. It would have taken the Registrant time to access Service User A’s bare chest and apply the pads in addition to the defibrillator being monitored for 30 seconds to obtain a 30 second rhythm strip. The Panel accepts that it was night-time, and the scene would have been dark, but it does not think it likely that Police Officer 1 would have failed to notice the Registrant use the defibrillator machine.
94. The Panel notes that the Registrant said in his statement dated 10 December 2018 that Service User A was asystole on the monitor prior to his declaring ROLE. The Panel also notes that in further questions put to him by AP on 15 December 2018, the Registrant said he had confirmed asystole with the monitor which had shown “a complete flat line without disturbance”.
95. The Panel is satisfied that there is no printout from the Registrant’s defibrillator which indicates that he undertook a 30 second ECG of Service User A prior to declaring ROLE. Even if the time on the ROLE form of 19:28 is inaccurate, which it is likely to be if the Registrant only arrived at the scene at 19:28, and if, as he told AP on 15 December 2018, he had declared ROLE within 5 minutes of his arrival, the Zoll defibrillator does not show any ECG which lasted for 30 seconds in relation to Service User A. The only data retrieved from the Registrant’s defibrillator for 9 December 2018 is a 16 second ECG strip which does not show that Service User A was asystole. The Panel accepts the evidence of Dr Clarke that the 16 second rhythm strip does not show that Service User A was asystole and that it is more likely than not that what is shown is artefact. The Panel notes that Colleague 1, Colleague 2 and AP each confirmed that the 16 second rhythm strip did not show that Service User A was asystole. The Panel has concluded that the 16-second rhythm strip was, in any event, not consistent with the Registrant’s description of “a complete flat line without disturbance”. The Panel is satisfied on this evidence that it is more likely than not that the defibrillator was never attached to Service User A. The Panel is therefore satisfied that it is more likely than not that the Registrant did not undertake a 30 second ECG of Service User A prior to declaring ROLE.
96. The Panel then considered whether by not undertaking a 30 second ECG of Service User A prior to declaring ROLE, the Registrant did not follow the JRCALC Guidelines which are referred to by Dr Clarke and appended to his expert report. Dr Clarke said there was no evidence to suggest that the Registrant obtained a 30 second rhythm strip at any point which was a breach of the JRCALC ROLE Guidelines in the context of cessation of resuscitation attempts. Its purpose is to confirm clinical findings. It was Dr Clarke’s opinions that this was a secondary breach of the Guidelines with the failure to commence basic and advanced life support being of greater import.
97. The Panel is satisfied that it is more likely than not that in not undertaking a 30 second electrocardiogram examination of Service User A prior to declaring ROLE, the Registrant did not follow the NEAS guidance or the JRCALC Guidelines.
98. The Panel therefore finds Particular 1b proved.

Particular 1c was found proved

99. The Panel accepts the evidence of Police Officer 1 that he was with Service User A at all times when the Registrant was with her. The Panel has concluded that if the Registrant had carried out any CPR on Service User A, Police Officer 1 would have seen it. The Panel accepts Police Officer 1’s evidence that the Registrant did not commence CPR on Service User A at any time. The Panel notes that the Registrant in his statements does not suggest that he commenced CPR on Service User A. The Panel therefore finds that it is more likely than not that the Registrant did not commence CPR.
100. The Panel then considered whether by not commencing CPR, the Registrant did not follow the JRCALC Guidelines which are referred to by Dr Clarke and appended to his expert report. Dr Clarke said that in his opinion it would be clinically appropriate to cease resuscitation attempts following a period of advanced life support being undertaken. The JRCALC Guidelines for 2016 identity that resuscitation can be ceased if the patient is in asystole despite 20 minutes of advanced life support resuscitation which would include commencing CPR.
101. The Panel has concluded it is more likely than not that when the Registrant did not commence CPR, he did not follow the NEAS guidance or JRCALC Guidelines.
102. The Panel therefore finds Particular 1c proved.

Particular 1d was found proved

103. The Panel has considered with care the Registrant’s suggestion that he did assess Service User A’s airway. He told the Trust during its internal investigation that he had noted there was vomit in Service User A’s nostrils, her mouth and in her hair. He said he had concluded that her airway was obstructed with vomit. The Registrant did not suggest that he had made any attempt to clear Service User A’s airway.
104. The Panel accepts the evidence of Police Officer 1 that he did not see the Registrant do more than check Service User A’s pupils. He did not see the Registrant carry out an assessment of Service User A’s airway or take any steps to clear the obstruction.
105. The Panel takes the view that the Registrant carried out only a cursory visual assessment of Service User A’s airways. The Panel accepts the evidence of Dr Clarke that securing the airway is key in cases of cardiac arrest. In addition to a visual examination, a proper assessment would involve clearing any obstruction using suction or postural drainage for fluids or by way of a finger sweep or Magill forceps for solids. Dr Clarke explained that if the airway cannot be cleared and maintained using those methods, further interventions should take place using a stepwise approach. Dr Clarke said that vomit in the upper airway can be effectively managed using manual techniques and suction. In his experience, in the absence of suction, postural drainage and finger sweeps give an effective means of clearing the airway. Any obstruction needs to be cleared and the airway opened as part of basic life support so that it can progress to advanced life support. The Panel is satisfied that an assessment of a patient’s airway requires more than a visual examination.
106. The Panel notes Dr Clarke’s opinion that although the JRCALC Guidelines indicate that an automated external defibrillator (AED) should be applied to the patient as soon as it arrives, in this case the first priority should have been to secure an obviously obstructed airway, closely followed by the application of an AED or a manual defibrillator. Dr Clarke said the presence of the police officers undertaking basic life support facilitates a lone paramedic in the Registrant’s position in securing the airway and then applying the defibrillator.
107. The Panel has concluded that in not assessing Service User A’s airway, the Registrant did not follow the NEAS guidance or JRCALC Guidelines. The Panel therefore finds Particular 1d proved.

Particular 1e was found proved

108. The Panel accepts the evidence of Police Officer 1 that he did not see the Registrant do anything other than check Service User A’s pupils before declaring ROLE. The Panel is satisfied that as the Police Officer remained with Service User A for some time, he would have seen had the Registrant ventilated Service User A with a bag-valve-mask with supplemental oxygen. The Panel also accepts the evidence of Colleague 1 and that of Colleague 2 that there was no evidence that the Registrant had tried any advanced life support measures. The Panel concludes from this that Colleague 1 saw no evidence that the Registrant had ventilated Service User A’s lungs by using a bag-valve-mask with supplemental oxygen. The Panel accepts the evidence of Dr Clarke that where a patient’s airway is obstructed it is not possible to progress from basic life support to advanced life support. The Panel notes that the Registrant does not suggest in his statements to AP that he did ventilate Service User A’s lungs as set out in Particular 1e.
109. The Panel accepts the evidence of Dr Clarke that the Registrant should have ventilated the patient’s lungs using a bag-valve-mask with supplemental oxygen attached after assessing and clearing Service User A’s airway while the police officer continued with CPR.
110. The Panel has concluded it is more likely than not that the Registrant did not ventilate Service User A’s lungs by using a bag-valve-mask with supplemental oxygen.
111. The Panel then considered whether by not ventilating Service User A’s lungs in this way, the Registrant did not follow the JRCALC Guidelines which are referred to by Dr Clarke and appended to his expert report. According to Dr Clarke, one of the steps a reasonable paramedic attending Service User A should have taken is to ventilate her with supplemental oxygen.
112. The Panel has concluded that in not ventilating Service User A’s lungs with supplemental oxygen, the Registrant did not follow the NEAS guidance or JRCALC Guidelines. The Panel therefore finds Particular 1e proved.

Particular 1f was found proved

113. The Panel accepts the evidence of Police Officer 1 that he did not see the Registrant use the defibrillator on Service User A prior to advising him to cease CPR. The Panel also accepts the evidence of Colleague 2 and Colleague 1 that when they saw Service User A she was still fully clothed. Colleague 2 also said that Service User A’s abdomen was exposed. Neither witness saw evidence that Service User A’s upper clothing had been either removed or cut from her which it would have to have been to apply the self-adhesive pads to her bare chest.
114. The Registrant did suggest to AP that he had applied the defibrillator to Service User A and had observed on the monitor that she was asystole. He did not give any detail as to how he had done this or whether he had used the defibrillator leads attached with dots to Service User A’s wrists and ankles, or the self-adhesive pads attached to her chest. The Panel notes there is no evidence from any witness present at the scene that they had seen either dots or pads on Service User A’s body, nor had the Registrant been seen to remove these and return them to his kit bag at any time.
115. The Panel prefers the evidence of Police Officer 1, Colleague 2 and Colleague 1. Their respective accounts are mutually supportive, and the Panel considers that the Registrant’s version is not supported by the evidence obtained from the Zoll machine. The Zoll Rhythm Summary shows that the Registrant turned the defibrillator on at 19:33:18 and the Panel is satisfied it is more likely than not that 16 second rhythm strip shows artefact and not a “rhythm” obtained from Service User A. The Panel was of the view that in any event the 16 second rhythm strip does not show what the Registrant described as “a complete flat line without disturbance”. The Panel has decided it is more likely than not that the Registrant did not apply an AED to Service User A.
116. The Panel then considered whether by not applying an AED to Service User A, the Registrant did not follow the JRCALC Guidelines which are referred to by Dr Clarke and appended to his expert report.
117. The Panel accepts the evidence of Dr Clarke that the Registrant should have applied an AED to Service User A following assessing and clearing her airway and ventilating her lungs by using a bag-valve-mask with supplemental oxygen. According to Dr Clarke, it was more likely than not that Service User A would present in a non-shockable rhythm. He explained that if the Registrant had applied an AED to Service User A this would have necessitated exposing Service User A’s chest in order to apply self-adhesive pads to her bare chest. Dr Clarke explained that the purpose of attaching an AED to a patient is to identify whether there are “shockable” rhythms and it would enable the clinician to determine if there was likely to be any cardiac output, i.e., a sinus rhythm, which may be compatible with a pulse. Dr Clarke stated that in cases of cardiac arrest due to hanging, the more likely presenting cardiac rhythm is pulseless electrical activity (PEA) due to cerebral hypoxia brought about by the strangulation. In such cases, Dr Clarke said that the reasonable paramedic would be expected to consider hypoxia as being a potentially reversible cause for the cardiac arrest. It would be expected that the hypoxia could be rectified by way of clearing and maintaining the patient’s airway, carrying out ventilations with supplemental oxygen and continuing cardiac chest compressions.
118. The Panel has concluded that in not applying an AED to Service User A, the Registrant did not follow the NEAS guidance or JRCALC Guidelines. The Panel therefore finds Particular 1f proved.

Particular 1g was found proved

119. The Panel accepts the evidence of the Police Officer 1 that he did not see the Registrant do anything other than check Service User A’s pupils. According to Police Officer 1, he had stayed with Service User A after he had been advised by the Registrant to cease CPR and after the Registrant had declared her to be deceased. The Panel has concluded from this that had the Registrant attempted to gain or gained intravenous access to Service User A this would have been seen by Police Officer 1.
120. The Panel has seen from the Zoll Basic Summary that there is no record of this intervention. The Panel notes that the Registrant does not suggest that he did either attempt or gain intravenous access to Service User A.
121. The Panel is satisfied it is more likely than not that the Registrant did not attempt to gain intravenous access and did not gain such access.
122. The Panel then considered whether by not attempting to gain intravenous access or not gaining such access, the Registrant did not follow the JRCALC Guidelines which are referred to by Dr Clarke and appended to his expert report.
123. The Panel accepts the expert evidence of Dr Clarke that where basic life support and/or defibrillation does not restore cardiac output, the next level of intervention would be Advanced Life Support (Adult) (“ALS”). Advanced life support is a natural progression from basic life support with the addition of intravenous drug administration and consideration given to the potentially reversible causes of cardiac arrest.
124. The Panel is satisfied that in not either attempting to gain intravenous access and in not gaining intravenous access report, the Registrant did not follow the NEAS guidance or JRCALC Guidelines. The Panel therefore finds Particular 1g proved.

Particular 1h was found proved.

125. The Panel accepts the evidence of the Police Officer 1 that he did not see the Registrant do anything other than check Service User A’s pupils. According to Police Officer 1, he had stayed with Service User A after he had been advised by the Registrant to cease CPR and after the Registrant had declared her to be deceased. The Panel considers that if the Registrant had administered adrenaline to Service User A, Police Officer 1 would have seen this.
126. The Panel has seen from the Zoll Basic Summary that there is no record of this intervention. The Panel also notes that the Registrant does not suggest that he did administer adrenaline to Service User A.
127. The Panel also accepts the evidence of Dr Clarke that a reasonable intervention would have been to administer adrenaline. It considers that in order to administer adrenaline the Registrant would have had to gain intravenous access. The Panel has already found he did not.
128. The Panel is therefore satisfied it is more likely than not that the Registrant did not administer adrenaline to Service User A.
129. The Panel then considered whether by not administering adrenaline, the Registrant did not follow the NEAS guidance or the JRCALC Guidelines which are referred to by Dr Clarke and appended to his expert report. The Panel accepts the evidence of Dr Clarke that the next step a reasonable paramedic attending Service User 1 would take, after clearing and securing her airways, applying an AED to her, ventilating her with supplemental oxygen, and if they had successfully gained intravenous access, would be to administer adrenaline in accordance with the JRCALC Guidelines.
130. The Panel is satisfied it is more likely than not that in not administering adrenaline to Service User A, the Registrant did not follow the NEAS guidance or JRCALC Guidelines.
131. The Panel therefore finds Particular 1h proved.

Particular 1i was found proved

132. The Panel notes that the Registrant does not suggest that he undertook any resuscitation efforts on Service User A, let alone for a minimum period of 20 minutes. The Panel considers that had he done so not only would Police Officer 1 have seen which resuscitation efforts the Registrant had taken, but that Colleague 2, Colleague 1 and Colleague 3 would also have been present at the scene to observe these as well. The Panel can see from the timeline produced by AP that the Registrant arrived at the scene at 19:28 and cleared the scene at 19:51, a period of 23 minutes during which time he had also spoken to his paramedic colleagues and had time to stand down the HEMS team.
133. The Panel notes that the Registrant does not suggest that he did continue with resuscitation efforts for a minimum period of 20 minutes. According to AP, he had spoken to the Registrant on 20 December 2018 and that a Clinical Care Manager had been present. During this second meeting, the Registrant did not say that he would have done anything differently but, as the JRCALC Guidelines were put to him, the Registrant had acknowledged that he should have done 20 minutes resuscitation efforts. The Panel has no reason to doubt that there was a meeting with the Registrant on 20 December 2018 but notes that AP does not refer to this in his witness statement provided to the HCPC or in his Investigation Report.
134. The Panel is satisfied it is more likely than not that the Registrant did not continue resuscitation efforts for a minimum period of 20 minutes.
135. The Panel then considered whether by not continuing resuscitation efforts for a minimum period of 20 minutes, the Registrant did not follow the NEAS guidance or the JRCALC Guidelines which are referred to by Dr Clarke and appended to his expert report.
136. The Panel accepts the expert evidence of Dr Clarke that it would be reasonably expected practice to consider recognition of life extinct (ROLE) on scene following a sustained period of advanced life support which would include continuing with resuscitation efforts for a minimum period of 20 minutes.
137. The Panel has seen the JRCALC Guidelines and heard evidence regarding these from Dr Clarke. Dr Clarke told the Panel that the 2016 JRCALC Guidelines identify that resuscitation can be ceased if the patient is in asystole despite 20 minutes of advanced life support resuscitation (ALS) and that in the case of Service User A, ALS means the use of advanced airway adjuncts and drug therapy.
138. The Panel has concluded it is more likely than not that by not continuing resuscitation efforts for a minimum period of 20 minutes, the Registrant did not follow the NEAS guidance or JRCALC Guidelines. The Panel therefore finds Particular 1i proved.

Particular 2 was found proved

139. The Panel accepts the evidence of Colleague 2 who arrived at the scene at 19:31, that the Registrant had told her when explaining why he had declared recognition of life extinct, that Service User A was asystolic. The Panel also accepts the evidence of Colleague 1 who arrived at the scene at 19:38 that the Registrant had also said this to her. The Panel considers that in telling his colleagues that Service User A was asystolic, the Registrant was, by necessary implication, stating he had an electrocardiogram which had indicated Service User A was asystolic. The Panel considers that the Registrant would know that his colleagues would understand this to be the case. The Panel also accepts the evidence of Dr Clarke that an electrocardiogram examination is the only way with a patient such as Service User A to show that she was asystolic.
140. The Panel has already found that the Registrant did not undertake a 30 second electrocardiogram examination of Service User A (Particular 1b) and that he did not apply an AED to her (Particular 1f). The Panel has also accepted the evidence of Dr Clarke that the 16 second rhythm strip from the Registrant’s Zoll defibrillator timed at 19:36 does not show an asystole rhythm and that the reading was unlikely to have been obtained from Service User A. The Panel is therefore satisfied it is more likely than not that at the time the Registrant made the statement to Colleague 2 and Colleague 1, he had not undertaken an electrocardiogram examination.
141. Accordingly, the Panel finds Particular 2 proved.

Particular 4 was not proved

142. The Panel has already found proved in Particular 1b that the Registrant did not undertake a 30 second electrocardiogram examination of Service User A prior to declaring recognition of life extinct.
143. The Panel has considered whether there is any evidence from Colleague 2 and/or Colleague 1 that the Registrant ever said to either of them that he had undertaken a 30 second electrocardiogram examination of Service User A prior to declaring ROLE. Neither witness has said any more than that they were told that Service User A was asystolic. The Panel accepts that the Registrant said to each of the witnesses that Service User A was asystolic. The Panel notes that in respect of Particular 2, it has concluded that by this statement the Registrant implied that he had undertaken an electrocardiogram examination using the Zoll defibrillator.
144. Although the Panel accepts the evidence of Dr Clarke that it is not possible to pronounce someone as asystolic without use of a defibrillator, it is possible to establish that a patient is asystolic in less than 30 seconds. The Panel has therefore concluded that it would not be proper to draw the inference from the Registrant’s statement that Service User A was asystolic, that his electrocardiogram examination had lasted 30 seconds prior to declaring ROLE. The Panel therefore does not consider it is more likely than not that the Registrant said to either Colleague 2 or Colleague 1 that he had undertaken a 30 second electrocardiogram examination.
145. Accordingly, the Panel has concluded on the evidence before it, that the HCPC has failed to discharge the burden of proving this allegation and finds Particular 4 not proved.

Particular 5a was found not proved

146. The Panel accepts the evidence of AP that as part of his internal investigation he had reviewed the data relating to the Zoll defibrillator used by the Registrant on 9 December 2018. The Panel has seen the Zoll Basic Summary and the Zoll Rhythm Summary produced from the machine as part of AP’s internal investigation. The Zoll Basic Summary is timed at 19:33:18 and shows that there were no observations or interventions recorded. The Zoll Rhythm Summary shows that the machine was turned on at 19:33:18 and the only activity is between 19:36:05 and 19:36:21 and shows a 16 second rhythm strip. The Panel has concluded that this rhythm strip does not show Service User A was asystole and does not show a “complete flat line without disturbance” as alleged by the Registrant when he was interviewed by AP on 15 December 2018. The Panel accepts AP’s evidence that there was no defibrillator data saved to the Cloud.
147. The Panel has seen the three ePCR’s: from the Registrant, Colleague 2 and Colleagues 1 and 3. The Panel can see from those electronic records that there is no data from the Registrant’s Zoll defibrillator saved to them.
148. Although the Panel is satisfied that the Registrant did not save any data from the Zoll defibrillator to either the Cloud or the ePCRs, in view of its findings in Particular 1b and 1f (namely that the Registrant did not undertake a 30 second electrocardiogram examination of Service User A and that he did not apply an AED to her), the Panel has concluded it is more likely than not that there was no defibrillator data for the Registrant to save either to the Cloud or to the ePCR.
149. Accordingly, the Panel has concluded on the evidence before it, that the HCPC has failed to discharge the burden of proving this allegation and finds Particular 5a not proved.

Particular 5b was found not proved

150. The Panel accepts the evidence of both Colleague 1 and Colleague 2 that the Registrant stated to them that the Zoll defibrillator was unable to print. However, the Panel is not satisfied that there is evidence which shows that the Zoll defibrillator was able to print at that time. The Panel heard evidence from AP that the machine was retrieved by a Clinical Care Manager in the days following the incident so that data could be retrieved from it. From this the Panel infers that the Zoll defibrillator was not taken out of service and continued to be used.
151. The Panel has also seen evidence a number of exhibits relating to Zoll defibrillators including how the machine works, a detailed history of the Zoll defibrillator used by the Registrant from July 2016 to March 2019 and photographs of labels to put on faulty machines. However, there has been no evidence from a witness to explain what sort of issues might arise with regard to the printers on Zoll machines or how common these are.
152. The Panel accepts that as a result of a NEAS07 incident report being lodged in relation to this incident PB, the Clinical Operations Manager (Bishop Cluster) met with the Registrant on 10 December 2018 to obtain a statement from him. The Panel has seen notes of that meeting and from the Registrant’s subsequent statement of the same date. The Registrant did not mention at that time that there had been a fault with the Zoll defibrillator printer. It would appear that the first mention of this was when the Registrant was interviewed by AP on 15 December 2018. The Panel accepts the evidence of AP that the Registrant had told him then the printer did not print the 30 second strip. The Registrant also told him that there had been no printing problem when he had turned the machine on and had carried out a self-test in the morning of 9 December 2018. The Registrant also said that he did not think that he had used the Zoll defibrillator printing function on the shift before attending Service User A.
153. However, the Panel is not satisfied, on a balance of probabilities, that the evidence shows the printer was still in working order when the Registrant attended Service User A. In these circumstances, the Panel is not satisfied it is more likely than not that when the Registrant told Colleagues 1 and 2 the Zoll defibrillator was unable to print, that this was not the case.
154. Accordingly, the Panel has concluded on the evidence before it, that the HCPC has failed to discharge the burden of proving this allegation and finds Particular 5b not proved.

Particular 6

155. The Panel notes that the only evidence produced by the HCPC in relation to Particular 6 is (i) the Trust’s Social Media Policy and (ii) screenshots taken by the parents of Service User A of what purports to be pages from the Registrant’s Facebook account. The screen shots are contained within a letter of complaint by Service User A’s parents to the Trust dated 5 June 2019. The Panel has concluded that it is only the screenshots which are relevant to the matters which it has to decide in Particular 6. The Panel has therefore concentrated on the screenshots themselves.
156. The Panel has considered the Trust’s Social Media Policy document which indicates that it was effective from 15 January 2016 and was due to be reviewed in 2019. The Introduction to the Social Media Policy states:
“The content of social media posts can have a significant impact on organisational, professional and individual reputations”.
157. Paragraph 2 of the Policy makes clear that it covers Facebook as well as other social media networking sites and that it applies to “use of social media for business purposes as well as personal use that may affect our business in any way”. The onus is on the Trust staff to use social media appropriately. Examples of inappropriate use are set out in a general way and include using social media “to bully or harass an individual, defame the Trust, breach confidentiality or cause reputational damage”, any one of which would result in disciplinary proceedings.

Particular 6a was found not proved

158. The Panel has seen a screenshot of what appears to be a Facebook profile page relating to the Registrant. The Panel considers that it is a proper inference to draw from the fact that this page refers to the Registrant by name and to his being a Paramedic with the North East Ambulance Service, that the screenshots it has seen are taken from the Registrant’s Facebook account. The Panel has also seen a screenshot dated 23 December 2018 which shows in a large red box the words “Time to Check Oo”. On the next screenshot for the same date, someone whose identity has been redacted has asked “Time to check what x” and the response which is in the Registrant’s name states, “Check out of life x”.
159. Although there is no evidence as to who was making the posts on the Registrant’s Facebook account at the relevant time, the Panel has decided that it is reasonable for it to infer that it was the Registrant himself. The Panel notes that the Registrant was not questioned about these posts by AP as part of the Trust’s internal investigation. However, it has concluded it is more likely than not that the Registrant made this post.
160. The Panel then considered whether in making the post, the Registrant was in breach of the Trust’s Social Media Policy. The Panel considers that it is regrettable that the Registrant was posting personal information so widely. The Panel has heard no evidence as to how Facebook works, how posts are made and how e.g., security settings are managed. It seems clear that Service User A’s parents were able to view his Facebook account in order to take screenshots and so it is a reasonable inference that no privacy settings were in place at the relevant time.
161. However, this post is personal to the Registrant. It does not show any evidence that he is bullying or harassing anyone, he is not defaming the Trust, breaching confidentiality, or causing reputational damage to the Trust. In these circumstances, the Panel has concluded it is not more likely than not that in making this post the Registrant breached the Trust’s Social Media Policy.
162. Accordingly, the Panel has concluded on the evidence before it, that the HCPC has failed to discharge the burden of proving this allegation and finds Particular 6a not proved.

Particular 6b was found not proved

163. The Panel has seen undated screenshots of what appears to be the Registrant’s Facebook “Replies” page. It is unclear when the posts shown were made and the names of those who have made the posts, other than the Registrant, have been redacted. The allegation relates to one of the Registrant’s responses in a “conversation” involving others. This conversation begins with someone asking the Registrant if he has any plans for the next day, to which reply under the Registrant’s name is “I HOPE not to be here!!!!!” When asked where he is going to be, the response under the Registrant’s name is “The other side if I can find the strength”. There then follows a number of posts which indicate concern as to whether there is anyone with the Registrant and confirmation that it appeared someone was with him, and he was “ok”.
164. The Panel has already found it is more likely than not that the screenshots come from the Registrant’s Facebook account. It has therefore concluded it is more likely than not that the Registrant made the post alleged in Particular 6b. It is clearly shown under his name, and it is clear that the names of other people who took part in the conversation have been redacted.
165. The Panel then considered whether this post by the Registrant breaches the Trust’s Social Media Policy. The Panel has decided the post does not show any evidence that the Registrant is bullying or harassing anyone, he is not defaming the Trust, breaching confidentiality, or causing reputational damage to the Trust. In these circumstances, the Panel has concluded it is not more likely than not that in making this post the Registrant breached the Trust’s Social Media Policy.
166. Accordingly, the Panel has concluded on the evidence before it, that the HCPC has failed to discharge the burden of proving this allegation and finds Particular 6b not proved.

Particular 6c was found not proved

167. The Panel has seen a screenshot which it is has concluded is more likely than not to have been posted by the Registrant in his Facebook account which shows an image of a wooden figure hanging from a ligature around its neck. It is clear from the comment above the image that the post is about male suicide as this read “It’s okay not to be okay lads!” and below the image are statistics relating to male suicide. This post appears on a page in the Registrant’s Facebook account entitled “Posts”. The Panel has concluded it is more likely than not that the Registrant has posted it on that page as it seems it was originally posted on 27 April by someone using the name “Bare Knuckle Gypsies”.
168. The Panel then considered whether this post by the Registrant breaches the Trust’s Social Media Policy. The Panel has decided the post does not show any evidence that the Registrant is bullying or harassing anyone, he is not defaming the Trust, breaching confidentiality, or causing reputational damage to the Trust. In these circumstances, the Panel has concluded it is not more likely than not that in making this post the Registrant breached the Trust’s Social Media Policy.
169. Accordingly, the Panel has concluded on the evidence before it, that the HCPC has failed to discharge the burden of proving this allegation and finds Particular 6c not proved.

Particular 6d was found not proved

170. The Panel has seen screenshots from what appears to be the Registrant’s Facebook “replies” page. There is a conversation between the Registrant and either one or more people whose names have been redacted. The conversation starts with someone asking the Registrant what has happened, and it is clear from the thread of the conversation that this is in the context of his work as a paramedic. The Registrant responds by suggesting that this person reads the Northern Echo, Shildon Coroners. Someone (it may be the same person) responds to this and then the Registrant posts the following “Thank you for all the kind words !! But ones reputation can be ruined in a press release”. The Panel is satisfied it is more likely than not that the Registrant made this post. It arises in the context of a newspaper report which he infers is about him and it references the Shildon Coroners. The Panel has not seen the article to which the post appears to refer but infers that it is a reference to the inquest for Service User A.
171. The Panel then considered whether this post by the Registrant breaches the Trust’s Social Media Policy. The Panel has decided the post does not show any evidence that the Registrant is bullying or harassing anyone, he is not defaming the Trust, or causing reputational damage to the Trust. The Panel has considered with care whether the post breaches confidentiality in relation to the Registrant’s involvement with regard to Service User A. The Panel has concluded that it does not. The Registrant has referred only to a newspaper which was publicly available. In these circumstances, the Panel has concluded it is not more likely than not that in making this post the Registrant breached the Trust’s Social Media Policy.
172. Accordingly, the Panel has concluded on the evidence before it, that the HCPC has failed to discharge the burden of proving this allegation and finds Particular 6d not proved.

Particular 7 was found proved in relation to Particular 2

173. In view of its findings set out above, the allegation of dishonesty falls away in respect of Particulars 3, 4, 5a and 5b. The Panel has therefore considered dishonesty only in relation to Particular 2.
174. The Panel has had regard to the submissions of Ms Jones regarding dishonesty. It has received and accepted legal advice as to how it should approach the issue of dishonesty. The Panel has applied the test for dishonesty as set out in the case of Ivey v Genting Casinos [2017] UKSC 67 (at para 74) [the Ivey test]. In applying the Ivey test, the Panel first decided the Registrant’s knowledge or belief as to the factual circumstances of his conduct with regard to Particular 2. The Panel understands that the Registrant’s belief does not have to be a reasonable one, so long as it is genuinely held. The Panel has then considered whether, based on the factual circumstances as it has found the Registrant believed them to be, his conduct was dishonest by the (objective) standards of ordinary, decent people. The Panel understands there is no requirement that the Registrant must appreciate that what he has done is, by those standards, dishonest.
175. The Panel has considered the Registrant’s knowledge or belief as to the factual circumstances of his conduct with regard to Particular 2 i.e., at the time the Registrant stated to his colleagues that Service User A was asystolic when he had not undertaken an electrocardiogram examination to establish this. The Panel is satisfied that it is more likely than not that when the Registrant made this statement, he did so to justify his decision to declare ROLE, to stop his colleagues questioning his decision and to cover up the fact that he had not followed the JRCALC Guidelines in his treatment of Service User A. The Panel finds it is more likely than not that the Registrant knew when he made the statement that he had not attached the Zoll defibrillator to Service User A and therefore knew that he could not have found Service User A to be asystole. The Panel has concluded it is more likely than not that the Registrant knew he had based his decision to declare ROLE solely on his previous experience and after only a cursory visual examination of Service User A. The Panel has also concluded it is more likely than not that the Registrant knew at the time that he had not followed the JRCALC Guidelines and also knew that he should have done so.
176. The Panel notes that in their evidence both Colleague 2 and Colleague 1 refer to the Registrant telling them that his shift was due to end. According to Colleague 2, one of the first things he said to her was to ask when her shift ended and to indicate that his had already ended. A similar question was asked of Colleague 1. The Panel also notes that the Registrant asked Colleagues 1 and 3 if they would complete the paperwork as they were on night shift and his shift had ended. The Panel finds it is more likely than not that it was also part of the Registrant’s rationale for saying that Service User A was asystolic was that he knew his shift had already ended and he wanted to go home rather than become involved in a protracted resuscitation attempt using advanced life support measures which in his experience would be futile.
177. In these circumstances, and applying the Ivey test, the Panel has no hesitation in finding that the Registrant was dishonest when he stated to Colleague 2 and Colleague 1 that Service User A was asystolic, which implied that he had conducted an electrocardiogram examination to establish this, when he had not done so. The Panel is satisfied that an ordinary, decent person would judge the Registrant’s conduct to be dishonest and therefore finds Particular 7 proved as it relates to Particular 2.

Particular 8

178. As Particular 8 relates to a health matter it is not for this Panel of the Conduct and Competence Committee to make a finding of fact on this matter.

Decision on grounds

179. In reaching its decision on the statutory ground of misconduct, the Panel has taken account of Ms Jones’ submissions. The Panel has received and accepted legal advice.

Submissions

180. Ms Jones submitted that in the event the Allegation is found proved, it was clear that the Registrant’s conduct had fallen far below the standards required of a professional practitioner.

Decision

181. The Panel is satisfied that in relation to Particulars 1a to 1i, Particular 2 and Particular 7 (as it relates to Particular 2), the Registrant’s conduct fell far below the standards to be expected of a Paramedic and amounts to misconduct. The Panel concurs with Dr Clarke’s opinion that the actions of the Registrant fell significantly below the standard expected of the reasonable paramedic.
182. In relation to Particular 1a to 1i, the Panel has no doubt that the Registrant’s conduct in not following either basic life support procedures or advanced life support procedures, as set out in the JRCALC Guidelines, or the NEAS guidance (referred to above), represents a very serious departure from the standards expected of a Paramedic in the circumstances. As Dr Clarke told the Panel, the Guidelines can be considered to be the reasonable standard for registered paramedics. There is no suggestion in the evidence that the Registrant was unaware of the Guidelines and the Panel heard evidence from witnesses that the Trust provides annual advanced life support training for its paramedic staff.
183. In relation to Particular 2, and Particular 7 (as it relates to Particular 2), the Panel also has no doubt when the Registrant dishonestly stated to his colleagues that Service User A was asystolic without having undertaken an ECG to establish this, his conduct was a serious departure from the standards expected of a Paramedic. It is wholly wrong for a paramedic to lie to colleagues about the condition of a patient. The Panel has found that the reason the Registrant made this dishonest statement was to justify his decision to declare ROLE in an attempt to cover up the fact that he had not carried out the relevant examination to establish that Service User A was asystolic and had not followed the JRCALC Guidelines. The Panel has no hesitation in finding that this amounts to misconduct.
184. In reaching its decision on the statutory ground, the Panel has considered the impact of the Registrant’s conduct on Service User A’s family. It is clear the Registrant’s conduct has caused Service User A’s family very considerable distress. As members of the public, they could reasonably expect that the professionals who treated their daughter would follow the relevant local and national guidance in attempting to save her life even if, in the event, this was unsuccessful.
185. The Panel has also considered the impact of the Registrant’s conduct on his fellow colleagues who attended the incident. Colleague 1 told the Panel that she became concerned about the Registrant’s conduct only when she had spoken to the police officers to obtain information for the ePCR. Colleague 1 also said that Colleague 3 had been surprised to find Service User A was still warm to the touch when she had undertaken an electrocardiogram examination to obtain a 30 second rhythm strip at 19:44. This had been some time after the Registrant had declared ROLE and given it was a cold December evening. Colleague 1 said that she had been shocked by the Registrant’s conduct.

HCPC Standards of Conduct, Performance and Ethics (2016)

186. In reaching its decision on misconduct the Panel has also had in mind the HCPC Standards of Conduct, Performance and Ethics (2016) and has concluded that the following standards are engaged and have been breached:

Standard 8 Be open when things go wrong
Openness with service users and carers

8.1 You must be open and honest when something has gone wrong with the care, treatment or other services that you provide by:
- informing service users or, where appropriate, their carers that something has gone wrong;
- apologising;
- taking action to put things right if possible; and
- making sure that service users or, where appropriate, their carers receive a full and prompt explanation of what has happened and the likely effects.

187. The Panel takes the view that the Registrant was not completely open and honest to his colleagues at the scene when he tried to justify his decision to declare ROLE to them. This lack of candour appears to have carried through to when the Registrant later gave his account as part of the Trust’s internal investigation process.

Standard 9. Be honest and trustworthy
Personal and professional behaviour
9.1 You must make sure that your conduct justifies the public’s trust and confidence in you and your profession.

188. The Panel considers that the public expects Paramedics and other health professionals to be trustworthy in their personal and professional behaviour. The Registrant did not make sure that his conduct justified the public’s trust and confidence in him or in the Paramedic profession when he did not follow local and national guidelines or when he lied to his colleagues to cover up the fact that he had not followed these guidelines.

HCPC Standards of Proficiency for Paramedics (2014)

189. The Panel has also had in mind the Standards of Proficiency for Paramedics (2014). It considers that the following standards are engaged and have been breached:

Standard 2 be able to practice within the legal and ethical boundaries of their profession

2.1 understand the need to act in the best interests of service users at all times.
2.8 be able to recognise a professional duty of care.

190. The Panel considers that the Registrant failed in understanding the need to act in the best interests of Service User A when he did not progress from basic life support to advanced life support in accordance with the JRCALC Guidelines.
191. The Panel considers that the Registrant had a duty of care to Service User A and that he failed to recognise this in his treatment of her.

Standard 4 be able to practise as an autonomous professional, exercising their own professional judgment

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

192. The Panel considers that in not following the JRCALC Guidelines when treating Service User A, the Registrant demonstrated that he did not properly assess the situation he was presented with, nor did he make a reasoned decision when he advised Police Officer 1 to cease CPR or when he decided not to follow the JRCALC Guidelines. The Panel considers that the Registrant is not able to justify his decisions regarding his treatment of Service User A.
193. The Panel finds misconduct in this case.

Decision on Impairment

194. In reaching its decision on impairment, the Panel has had regard to the HCPTS Practice Note “Fitness to Practise Impairment”. The Panel has taken account of the submissions of Ms Jones. It has received and accepted legal advice. The Panel has borne in mind that the purpose of this hearing is not to punish the Registrant for past misdoings but to protect the public against the acts and omissions of those who are not fit to practise.

Submissions

195. Ms Jones submitted that the Registrant’s fitness to practise is impaired on both the personal and public components. She provided the Panel with a skeleton argument and made oral submissions.
196. On the personal component, Ms Jones submitted that while the misconduct in this case is capable of being remedied, there is no evidence that the Registrant has taken any remedial steps, such as attendance on courses or willingness to attend courses. Ms Jones told the Panel that the Registrant has not engaged with these proceedings and submitted that the misconduct is likely to be repeated. Ms Jones submitted that the Registrant’s misconduct was serious, and his lack of engagement indicated a lack of insight or willingness to change, or to receive training. She further submitted that there was no evidence that the Registrant has the potential to develop insight.
197. On the public component, Ms Jones submitted that public confidence in the Paramedic profession would be undermined if there is no finding of impairment in this case. She also submitted that there is a need to uphold standards of behaviour and conduct in the profession.

Decision

198. In reaching its decision, the Panel has considered the two different aspects of the misconduct in this case: (i) its findings of misconduct in Particular 1 which concern the Registrant’s clinical practice, and (ii) its findings of misconduct in Particular 7 as it relates to Particular 2, which concerns the Registrant’s dishonesty.

Personal component

199. The Panel is satisfied that although the misconduct in respect of Registrant’s clinical practice is very serious, it is clearly capable of being remedied. The steps that should have been taken by a reasonable paramedic attending a service user in circumstances similar to those on 9 December 2018, are set out in the JRCALC Guidelines. The Panel has seen no evidence that the Registrant has taken any steps to remedy his misconduct. There is no evidence as to the Registrant’s current employment or circumstances, or his plans for the future. All the Panel knows is that the Registrant is no longer employed by the Trust. The Panel considers, in view of the fact that the Registrant has had a career of over 26 years without there being any concerns as to his practice, that the Registrant should be able to remedy his misconduct. The Panel considers that in order to show remediation, the Registrant would need to evidence, as a starting point, that he has reacquainted himself with, and understands the importance of following, the relevant JRCALC Guidelines covering basic life support and advanced life support.
200. The Panel has seen no evidence that the Registrant has developed proper insight into his misconduct. AP in his evidence stated that when the Registrant was further interviewed on 20 December 2018 and taken through the relevant JRCALC Guidelines, he said that he should have carried out 20 minutes of resuscitation efforts. The Panel considers that, at most, this shows only limited insight and reflection into the misconduct. The Panel notes that there is no evidence that since then the Registrant has gone on to develop his insight or properly reflected on his actions on 9 December 2018.
201. With regard to the dishonest misconduct, the Panel accepts and acknowledges that while it is more difficult for a registrant to demonstrate remediation where there are findings of dishonesty, it is not impossible to do so. The Panel has seen no evidence that the Registrant has taken any steps to remedy his dishonest misconduct.
202. With regard to insight into the impact of both aspects of his misconduct on Service User A’s family, his colleagues and on his profession, the Panel has concluded that the Registrant has shown no insight. There is no evidence that the Registrant has recognised that by his actions he has damaged public confidence in his profession.
203. The Panel has considered the extent to which the Registrant’s misconduct has caused harm. With regard to Service User A, the Panel considers the Registrant’s misconduct (as found in Particular 1) was a missed opportunity, which no matter how slight her chances of survival may have been, caused her harm. The Panel has concluded that as the Registrant’s misconduct has not been remedied, there remains a risk that he may, in the future, cause harm to other service users.
204. The Panel has considered the likelihood that the Registrant will repeat his misconduct. It is satisfied that because of the Registrant’s very limited insight, and because there is no evidence that he has taken any steps to remedy his misconduct, it cannot rule out that the Registrant may repeat his misconduct in the future.
205. The Panel therefore finds that the Registrant’s fitness to practise is impaired on the personal component.

Public component

206. In relation to the public component, the Panel has considered carefully whether given the nature, circumstances, and gravity of the misconduct, public confidence in the profession and in its regulatory body would be significantly undermined if there is no finding of impairment in this case. The Panel has also considered whether it would be failing in its duty to declare and uphold proper standards of conduct and behaviour in that profession if it did not find impairment in this case.
207. The Panel has concluded that a reasonable and well-informed member of the public would be very shocked if there was no finding of impairment where those facts showed that in attending a young female who had been found hanging, the Registrant had not followed local and national guidelines regarding basic life support and advanced life support and had then lied to colleagues to cover this up. The Panel is satisfied that public confidence in the profession and in its regulator would be significantly undermined if there is no finding of impairment in this case. The Panel is also satisfied that it would be failing in its duty to uphold and declare proper standards of conduct and behaviour in the Paramedic profession if it did not find that the Registrant’s fitness to practise is impaired. It considers that if there is no finding of impairment, it would send out the wrong message, namely that misconduct of this nature, does not have any regulatory consequences.
208. The Panel has no doubt that the Registrant’s misconduct has brought the Paramedic profession into disrepute. The public is entitled to rely on registered professionals to conduct themselves appropriately when acting in the course of their profession. When they do not, this inevitably brings the profession into disrepute.
209. The Panel is also satisfied that in acting as he did, the Registrant breached a fundamental tenet of his profession, namely that a registered professional must make sure that their professional behaviour justifies the public’s trust and confidence in them and their profession.
210. The Panel takes the view that unless and until the Registrant demonstrates that he has remedied his misconduct, there is a risk that he will in future bring his profession into disrepute and breach a fundamental tenet of that profession.
211. The Panel is satisfied that the Registrant’s fitness to practise is impaired on the public component.
212. Accordingly, the Panel therefore finds, on both the personal and public component, that the Registrant’s fitness to practise is impaired and that the Allegation is well founded.

Decision on Sanction

213. In considering the appropriate and proportionate sanction the Panel was referred to, and has taken account of, the HCPC’s Sanctions Policy. The Panel has received and accepted legal advice. The Panel is aware that the purpose of any sanction it imposes is not to punish the Registrant, although it may have that effect, but it is to protect the public, to maintain confidence in the Paramedic profession and to uphold its standards of conduct and behaviour. The Panel has also had in mind that any sanction it imposes must be appropriate and proportionate bearing in mind the nature and circumstances of the misconduct involved.

Submissions

214. Ms Jones provided a skeleton argument regarding the imposition of a sanction. Although, as is the HCPC’s usual approach at the sanction stage, Ms Jones did not advance any particular sanction, she did submit that in light of the Panel’s findings, a Conditions of Practice Order would be inappropriate as there were no conditions which could be put in place which would maintain public confidence in the Paramedic profession.

Decision

215. The Panel has considered mitigating and aggravating factors. The Panel first looked at the mitigating factors. The only mitigating factor is that the Registrant has no previous findings of impairment recorded against him.
216. The Panel has considered whether there was anything in the documents regarding the Registrant’s health condition at the relevant time (9 December 2018) which might provide any mitigation in this case. The Panel notes that there is nothing to suggest that his health condition at that time caused him to act as the Panel has found that he did. The Panel has therefore concluded, on the information before it, that it cannot take the Registrant’s health condition into account as mitigation.
217. The Panel considers the following to be aggravating factors:
- the Registrant has only a limited level of insight into his misconduct and its impact on Service User A’s family, his colleagues, his profession and the wider public interest, and he has failed to express any remorse or apologise;
- the Registrant has not taken any steps towards remedying his misconduct;
- the ongoing risk of harm, or the potential for this to service users;
- while there was a single act of dishonesty by the Registrant, he maintained this lie during the Trust’s internal investigation.

218. The Panel has considered the available sanctions in ascending order of seriousness. It has decided that mediation or taking no action is inappropriate in this case given the serious nature of the concerns.
219. The Panel has also decided that imposing a Caution Order would not be appropriate or proportionate. The Panel has had in mind the HCPC’s Sanctions Policy paragraph 101 which states:

“101. 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."

220. The Panel considers that while the misconduct in this case might be “isolated” or even “limited”, it could not be described as “relatively minor in nature”. The Panel is not able to conclude that there is a low risk of repetition because the Registrant has not engaged with these proceedings and has shown only limited insight into the causes of his misconduct or its impact on Service User A’s family, his colleagues, his profession and the wider public. The Panel is satisfied that to ensure public confidence in the profession is not undermined, it must consider a more severe sanction.
221. The Panel then considered a Conditions of Practice Order and in particular the matters set out in paragraph 106 of the Sanctions Policy which states:
“A conditions of practice order is likely to be appropriate in cases where:
• the registrant has insight;
• the failure or deficiency is capable of being remedied;
• there are no persistent or general failures which would prevent the registrant from remediating;
• appropriate, proportionate, realistic and verifiable conditions can be formulated;
• the panel is confident the registrant will comply with the conditions;
• a reviewing panel will be able to determine whether or not those conditions have or are being met;
• the registrant does not pose a risk of harm by being in restricted practice”.

222.The Panel has also had in mind paragraphs 107, which states:
107 “Conditions will only be effective in cases where the registrant is genuinely committed to resolving the concerns raised and the panel is confident, they will do so. Therefore, conditions of practice are unlikely to be suitable in cases in which the registrant has failed to engage with the fitness to practise process or where there are serious and persistent failings”.

223. The Panel has concluded that as the Registrant has failed to engage with these proceedings, there is no evidence that he is genuinely committed to resolving the concerns raised.
224. The Panel has also considered paragraphs 108 and 109 which state:
108 “Conditions are also less likely to be appropriate in more serious cases, for example those involving dishonesty…”.
109 “There may be circumstances in which a panel considers it appropriate to impose a conditions of practice order in the above cases. However, it should only do so when it is satisfied that the registrant’s conduct was minor, out of character, capable of remediation and unlikely to be repeated.”

225. The Panel has found that the dishonest misconduct is capable of being remedied even if this may be difficult. The Panel has already referred to the fact that the Registrant has no previous disciplinary findings against him in a long career. However, the Panel does not consider that the Registrant’s dishonest misconduct was “minor”, and it cannot say that it is “unlikely to be repeated”. The Panel views the Registrant’s lies to his colleagues to cover up a poor clinical judgment to be a serious matter. The Panel has found that the Registrant has shown only limited insight into his misconduct and that therefore, there remains a real risk of repetition.
226. The Panel has also concluded that it is not possible to devise appropriate, proportionate, realistic, and verifiable conditions which would address the concerns regarding the Registrant’s behaviour in this case. The Registrant has not engaged with the regulatory process and so the Panel has no confidence that he would comply with a Conditions of Practice Order. The Panel also takes the view that given the nature and gravity of the misconduct, the imposition of a Conditions of Practice Order would undermine public confidence in the Paramedic profession and in the regulatory process.

227. The Panel next considered whether to impose a Suspension Order. It has had in mind the following guidance from the HCPC’s Sanctions Policy:
“121 A suspension order is likely to be appropriate where there are serious concerns which cannot be reasonably addressed by a conditions of practice order, but which do not require the registrant to be struck off the Register. These types of cases will typically exhibit the following factors:

• the concerns represent a serious breach of the Standards of conduct, performance and ethics;
• the registrant has insight;
• the issues are unlikely to be repeated;
• there is evidence to suggest the registrant is likely to be able to resolve or remedy their failings.”

228. The Panel has no hesitation is finding that the concerns in this case represent a serious breach of the Standards of Conduct, Performance and Ethics. It has considered very carefully whether the Registrant’s limited insight into his misconduct and the risk of repetition rules this sanction out. The Panel has already expressed its view that the concerns in this case are capable of being remedied. The Panel has considered whether there is evidence that this Registrant is capable of remedying his misconduct. The Panel has reached the conclusion that while the misconduct may be capable of being remedied, there is no evidence to suggest that the Registrant would use the opportunity to remedy his misconduct. In addition, the Panel has no up-to-date information as to the Registrant’s current state of health and so it is not in a position to find that he is likely to be able to resolve or remedy his failings.
229. In these circumstances, the Panel has concluded that a Suspension Order is not the appropriate and proportionate sanction in this case.
230. The Panel has therefore concluded that the only appropriate and proportionate sanction is an order striking the Registrant off the Register. The Panel has considered the Sanctions Policy where, in paragraphs 130, it is stated that such a sanction is one of “last resort for serious, persistent, deliberate or reckless acts involving e.g., dishonesty”.
231. The Panel considers that the Registrant made a deliberate decision not to follow the JRCALC Guidelines for basic life support and advanced life support and then to declare ROLE which he based on his own experience alone. He then chose to lie about it. The Panel also considers these decisions to be serious ones.
232. The Panel has also had in mind paragraph 131 which states:
“A striking off order is likely to be appropriate where the nature and gravity of the concerns are such that any lesser sanction would be insufficient to protect the public, public confidence in the profession, and public confidence in the regulatory profession. In particular where the registrant:
• lacks insight
• continues to repeat the misconduct
• is unwilling to resolve matters."

233. The Panel is satisfied, based on the Registrant’s limited insight and the nature and gravity of the allegation, involving as it does clinical failings and dishonesty, that to ensure the public’s confidence in the Paramedic profession and in its regulatory process, and in order to uphold proper standards of conduct in the profession, it is appropriate and proportionate to order that the Registrant’s name be struck off the register.
234. In light of the sanction imposed and following the HCPC guidance in “Guidance on dual allegations”, the health allegation now falls away.

Order: That the Registrar is directed to strike the name of Mr Gavin Wood from the Register on the date that this order comes into effect.

Interim Order

Decision to proceed in absence

1. The Panel has considered whether it should proceed to hear this application in the absence of the Registrant. The Panel can see from the Notice of hearing dated 28 October 2022 that the Registrant has been given notice of it.
2. The Panel has decided that it is in the interests of justice to proceed in the Registrant’s absence for the reasons set out in its decision. It is satisfied that the Registrant was given proper notice that an application for an Interim Order would be made in certain circumstances. Those circumstances have arisen. The Panel has concluded that the Registrant has voluntarily waived his right to attend.

Application for an Interim Order

3. Ms Jones applied for an Interim Suspension Order to be imposed pending the Striking Off Order coming into effect or the outcome of any appeal in this case.

Decision

4. The Panel has received and accepted legal advice. It has referred to the HCPTS Practice Note “Interim orders”. The Panel has decided to make an Interim Suspension Order under Article 31(2) of the Health Professions Order 2001.
5. The Panel is satisfied that because of the serious nature of the misconduct, and its findings in relation to the Registrant’s lack of insight and the risk of repetition, that an Interim Suspension Order is necessary for the protection of members of the public. The Panel is also satisfied that it is otherwise in the public interest, as it would seriously damage public confidence the Paramedic profession and in this regulatory process if the Registrant was permitted to be in unrestricted practice before the Order comes into effect or any appeal is concluded. The Panel considers that a reasonable and well-informed member of the public would be very concerned if a registrant whose fitness to practise is impaired and who has been sanctioned by the imposition of a Strike off order was permitted to practise pending the outcome of any appeal which may take up to 18 months.
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 Mr Gavin Wood