Debbie Porter

Preliminary Matters

Service
1. The Panel noted from the service documents contained in the hearing bundle that the Registrant was served with notice of today’s hearing by email dated 18 May 2023. An email of the same date confirmed delivery of the notice. In accordance with Rule 6(2) of the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 (the Rules), the Registrant was entitled to 28 days’ notice of this hearing. In fact, the Registrant only had 26 days’ notice of the hearing and therefore service is irregular. However, by an email dated 7 June 2023 to the HCPC the Registrant stated: “This is to confirm once again that I will not be attending the hearing”. In these circumstances, the Panel concluded that the Registrant had waived the irregularity in service and wished the hearing to proceed, notwithstanding the irregularity in service of the notice.
2. The Panel took into account the HCPTS Practice Note on “Proceeding in the Absence of the Registrant” and accepted the advice of the Legal Assessor. The Panel was mindful that today’s hearing is a mandatory review of a substantive order which should be heard expeditiously and must take place before the order expires on 12 July 2023. The Panel was satisfied that the Registrant had voluntarily absented herself from today’s hearing and that an adjournment to another date would be very unlikely to secure her presence. The Registrant had not applied for an adjournment and had made it clear that she had no intention of attending this review hearing. The Panel considered that no useful purpose would be served by an adjournment. The Panel determined that it was in the public interest and fair to the Registrant to proceed with the hearing today in her absence.

Background
3. The Registrant has been registered with the HCPC as a paramedic since 28 September 2011. At the relevant time she was employed as a Band 6 Paramedic by SouthWestern Ambulance Services NHS Foundation Trust (the Trust) covering Bristol, North Somerset and South Gloucestershire. Her role included responding to all types of emergencies and providing urgent care to patients.

4. On 20 August 2018 at 14.19 hours the Registrant attended a 999 call with Colleague 1, an ECA. The Registrant was the lead clinician on the scene. They attended to Patient A, a 31-year-old male, who, according to the call log, had been “shaking since 2am …. was dizzy and faint”; he had presented with a twelve-hour history of diarrhoea and vomiting, was not completely alert and had “messed himself’”. The Registrant assessed Patient A and deemed it appropriate to leave him at home. She advised the patient to self-administer Imodium, to maintain fluid intake and to call the GPs the following day if symptoms persisted. Patient A and his wife were advised to call 999 if the symptomsworsened. Having given this advice, the Registrant discharged Patient A.

5. The Trust received a further 999 call at 16.01 hours from Patient A’s wife. She stated that Patient A had started to feel worse at 15.35 hours and had collapsed to the floor at 15.40 hours. When the second ambulance crew arrived, they found that Patient A was unconscious and apnoeic and they diagnosed that he was in cardiac arrest. Emergency resuscitation measures were performed but, sadly, Patient A died, as confirmed at 16.21 hours. The Police and the Coroner were informed as this was an unexpected, but not suspicious, death. A Coroner’s Inquest was held into the death of Patient A from 2 to 5 December 2019.

6. The trust both conducted separate and parallel internal investigations into the concerns around the initial call out to Patient A, following which the Registrant was placed on restricted practice on 21 August 2018. This was lifted on 22 August 2018 after statements had been taken and after the Trust had made a decision about the Registrant’s ongoing practice. However, after the Coroner’s involvement into the death of Patient A, the Trust decided to place the Registrant back on restricted practice and change her status to that of an Emergency Clinical Assistant on 21 September 2018. After the investigation meeting of 5 October 2018, the Trust decided to suspend the Registrant from all duties until the outcome of the disciplinary process.

7. The Registrant’s disciplinary hearing took place on 7 January 2019. The allegation was of gross misconduct, in that the Registrant had failed to deliver appropriate patient care and had falsified readings in respect of a patient that she had discharged on scene. The decision letter of the disciplinary hearing was sent to the Registrant on 16 January 2019.

8. On 14 May 2019, the Registrant self-referred to the HCPC. She stated that she had undergone a phased return to work from 17 January 2019 when her suspension was lifted by the Trust, and, by 14 May 2019, had resumed all her Paramedic duties.

9. The coroner commissioned a report from a Consultant Cardiologist at the Liverpool Heart and Chest Hospital NHS Foundation on the care and treatment that Patient A received from the Paramedics on the first occasion, referring to the involvement of the Registrant and Colleague 1 in Patient A’s care on 20 August 2018. The report dated 2 October 2019 concluded as follows:

“…there appeared to have been several serious errors in Patient A’s management.
• Patient A’s symptoms do not appear to have been taken seriously, and there was an alleged comment that he may have been exaggerating his symptoms.
• There is variance and some disagreement in the accounts given by Person B and the Paramedic.
• There was a lack of appreciation as to how ill Patient A was.
• Signs were missed or ignored
• The initial observation were overwritten in order to put the observations in a better light. In addition, there was failure to document the clinical rationale for such a significant alteration in the observations.
• ECG – was deemed to be unnecessary.
• Hospitalisation was also deemed to be unnecessary in spite of grave warning signs.
• Patient A received no real treatment. He was advised to take Paracetamol, sips of water and lmodium. What he required was administration of oxygen and hospitalisation.
• The golden hour was lost. In my opinion Patient A was let down by the initial Ambulance Team which led to his death.”

10. The Coroner’s inquest took place from 2 – 5 December 2019. He found that on 20 August 2018 ‘the Deceased, who was suffering with serious undiagnosed ischaemic heart disease, developed gastroenteritis’. ‘The medical cause of death was given as 1(a) Cardiac failure; 1(b) Ischaemic heart disease; 1(c) Coronary artery atheroma; II Gastroenteritis’. At the conclusion of the Inquest, the Coroner recorded that Patient A’s death was one of ‘natural causes contributed to by neglect’.

11. On 13 December 2019, the coroner wrote to the HCPC raising serious concerns with regard to the Registrant’s fitness to practise.

The Substantive Hearing
12. The Registrant did not attend the Substantive Hearing nor was she represented.

13. The panel concluded that the facts found proved amounted to serious misconduct. It found that the Registrant’s clinical performance and record keeping fell seriously below the standards expected of a registered Paramedic. It found that the Registrant had failed to uphold her professional standards in several fundamental areas and had breached fundamental tenets of the profession. It found that the Registrant, by her actions and omissions, put the health, safety and wellbeing of a vulnerable patient at risk of harm and in so doing she had undermined the trust and confidence that the public was entitled to have in her as a registered Paramedic at the front-line of patient care. In so doing she had brought her profession into disrepute. The panel considered that the Registrant’s acts and omissions also betrayed the trust and confidence of her Paramedic colleagues.

14. The panel concluded that the Registrant’s failings identified were remediable, as they occurred around a single call-out to a patient and concerned sub-standard clinical practice and record keeping that, in principle, could be addressed so as to prevent recurrence in the future.

15. The panel, however, found that the Registrant had not remediated her failings and that in her reflections on the incident she had not fully recognised the seriousness of the errors she made on 20 August 2018, their consequences and how she would address those now to prevent recurrence in the future.

16. The panel noted that the Registrant had stated in her 31 March 2021 response to the Allegation that she had left the profession in October 2020.

17. The Registrant had not provided the panel with an updated account of any additional remediation she may have completed. The panel concluded that the Registrant’s insight into these events was not complete and lacked specific reference as to how she would prevent a recurrence of these events in the future. Without a complete picture of the level of the Registrant’s recent remediation, the panel was unable to conclude that she would be a safe and effective practitioner. Thus, in the panel’s judgement, the risk of repetition of these events remained. The panel therefore found the Registrant’s fitness to practise to be impaired having regard to the personal component of impairment.

18. The panel also found a reasonable and an informed member of the public would expect some restriction to be placed on the Registrant’s registration, having regard to the seriousness of the incident and the risk of repetition. Accordingly, the panel found the Registrant’s fitness to practise to be impaired having regard to the public component.

19. With regard to sanction, the panel noted the following mitigating and aggravating factors:
“Mitigating factors”:
• This was a one-off incident in a career lasting seven years;
• The Registrant consistently acknowledged most of her failings from an early stage;
• The Registrant expressed remorse, regret and an apology to Patient A’s family in her reflective pieces;
• The Registrant demonstrated some insight into her failings from an early time;
• The Registrant had undergone remediation by way of training and supervision organised by the Trust and had returned to unrestricted practice at the Trust by 2019;
• In her short time at the Trust in unrestricted practice during 2019, the Registrant had no further issues raised about her practice; and
• The Registrant produced positive references and testimonials reflecting that she was a trusted and valued professional.

Aggravating factors:
• The case was extremely serious, as it involved the Registrant’s failure to professionally adapt her practice to a patient, who was presenting with symptoms consistent with a serious underlying condition;
• By intransigently setting herself on a track that prevented her from undertaking a greater amount of routine and basic clinical tests on the patient, such as seeking further clarification from the patient’s wife and lacking sufficient professional curiosity with regard to the patient’s condition, the Registrant failed to capture a more informed overview.”

20. The panel decided that, as the Registrant was no longer working and had left her Paramedic position in December 2020, no workable conditions of practice could be formulated.

21. In the panel’s judgement, as the Registrant ceased to practise and expressed the intention not to return to the profession, there could be no confidence that she was genuinely committed to resolving the concerns regarding her fitness to practise. The panel considered that there might be a situation in the future when the Registrant might change her mind and be willing to undertake what would be required of her by way of remediation. Given this possibility, the panel decided that the appropriate and proportionate order was a Suspension Order for 12 months. It stated that a reviewing panel was likely to be assisted by the following: -
• That the Registrant might wish to consider appearing in person before the review panel;
• That the registrant might wish to send an updated and relevant reflective piece;
• That the Registrant might wish to provide updated and relevant CPD documentation;
• That the Registrant might wish to provide any updated references and testimonials from any employer, or other, all of whom should know the details of this case.

First review: 10 June 2022
22. The Registrant did not attend the first review hearing nor was she represented.

23. The Registrant provided no evidence that she had followed the recommendations of the substantive panel. The panel noted that the Registrant was not currently working as a Paramedic. In the absence of any evidence of reflection or remediation, the panel concluded that the Registrant’s fitness to practise remained impaired in respect of both personal and public components of impairment.

24. Given that the Registrant had opted to leave the Paramedic profession, the panel considered that a Conditions of Practice Order was neither relevant nor appropriate.

25. The Panel next considered a Suspension Order. It noted that the panel at the substantive hearing found the Registrant’s failings to be remediable.

26. As the Registrant stated that she had left the profession of Paramedic, the panel considered whether a Striking Off Order was appropriate.

27. In deciding to impose a Suspension Order, rather than a Striking Off Order, the panel stated as follows:
“This was a finely balanced decision because the Registrant is not engaging and has said she has left the profession of Paramedic. However, the Panel is mindful that it must impose the least restrictive option. The Panel has therefore determined that in the circumstances the Registrant should be allowed a further period of 12 months to re- engage in what will be a difficult journey to remediate her failings in the event that she wishes to resume her career as a Paramedic. It has made this decision knowing that the current Suspension Order will protect the public. The Registrant should be aware that if she fails to engage the next panel is likely to consider a Striking Off Order. Any future reviewing panel is likely to be assisted by the following:
• Evidence of ongoing reflection and relevant learning following the incident;
• Evidence of current and relevant Continuous Professional Development;
• Updated reference and testimonials from any employer, or others, all of whom should know the details of this case
Further, the Panel wishes to emphasise that the attendance by the Registrant at any review is likely to be pivotal if the Registrant wishes to return to Paramedic practice.”

Today’s hearing
28. The Panel was provided by the HCPC with a hearing bundle which included the decisions of the panels at the substantive hearing and the first review hearing.

29. The Panel noted that in her email to the HCPC dated 8 June 2023 the Registrant stated: “I do not want to be part of the profession; therefore, I am hoping the striking off order will be considered as I want this whole process to end now. I have no wish or desire to return to Paramedic practice now or at any time in the future”.

30. Ms Khan on behalf of the HCPC submitted that, in the absence of any evidence of insight, reflection or remediation since the last review, and given that the Registrant had followed none of the recommendations of the last review panel, the Panel today must inevitably conclude that the Registrant’s fitness to practise remains impaired.

31. Ms Khan submitted that no useful purpose would be served by imposing a further period of suspension on the expiry of the current Suspension Order.

The Panel’s decision
32. The Panel took into account the HCPTS Practice Notes “Review of Article 30 Orders” and “Fitness to Practise Impairment” and accepted the advice of the Legal Assessor.

33. The Panel first considered whether the Registrant’s fitness to prectise is currently impaired by reason of her misconduct.

34. The Panel took into account the decision of the High Court in Abrahaem v GMC where it was stated that in practical terms there is a “persuasive burden” on the Registrant to demonstrate at a review hearing that she has fully acknowledged the deficiencies which led to the original findings and has addressed his impairment sufficiently “through insight, application, education, supervision or other achievement”.

35. The Panel found that the Registrant had failed to take any steps to discharge this burden by addressing the fitness to practise concerns identified at the substantive hearing or by following the recommendations of either the substantive order panel or the panel at the first review.

36. In these circumstances, the Panel could not be satisfied that the Registrant had addressed any of the concerns relating to her fitness to practise. It followed that the Registrant had not discharged the persuasive burden referred to above. The Panel considered that the Registrant would not be safe to practise without restriction. The Panel therefore found that her fitness to practise remains impaired having regard to both the “personal” and “public” components of impairment.

37. With regard to sanction, the Panel took into account the HCPC’s Indicative Sanctions Policy. The Panel gave appropriate weight to the wider public interest, which includes the reputation of the profession and public confidence in the regulatory process. The Panel applied the principle of proportionality and considered the available sanctions in ascending order of seriousness.

38. The Panel considered that the concerns about the Registrant’s fitness to practise were too serious for the imposition of a Caution Order.

39. The Panel considered that a Conditions of Practice Order would not be appropriate because conditions would not adequately protect the public unless they were so restrictive as to amount to suspension in all but name. In any event, a Conditions of Practice Order was not relevant given the Registrant’s expressed intention not to return to practise as a Paramedic.

40. The Panel considered whether to impose a further period of suspension. However, in circumstances where the Registrant had been continuously suspended for a period of 2 years since the substantive hearing and had failed to address the failures in her practice, the Panel considered that no useful purpose would be served by a further period of suspension.

41. The Panel noted that the Indicative Sanctions Policy states that “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 process, in particular where the registrant:
• Lacks insight;
• Where a registrant has been suspended for two years continuously, fails to address a lack of competence; or
• Is unwilling to resolve matters.”

42. In the Panel’s judgement, the indicative criteria referred to above apply in this case and the appropriate and proportionate sanction is a Striking Off Order.

ORDER: The Registrar is directed to remove the name of Miss Debbie Porter from the register on expiry of the current Suspension Order.

The Order imposed today will apply from 12 July 2023.

History of Hearings for Debbie Porter