Ms Clare Dunham
Profession: Paramedic
Registration Number: PA51208
Hearing Type: Final Hearing
Date and Time of hearing: 10:00 15/07/2024
End:
17:00 02/08/2024
Location:
Virtual via Videoconference
Panel: Conduct and Competence Committee
Outcome: Conditions of Practice
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Allegation
Allegation (as amended at the hearing following decision on No Case To Answer)
As a registered paramedic (PA51208) your fitness to practise is impaired by reason of misconduct. In that:
1. On 11 December 2020, you did not act in Service User 1’s best interests and/or adequately assess Service User 1 in that you:
a. did not carry out observations or assessments of Service User 1, specifically Service User 1’s blood pressure, pulse oximetry and/or heart rate;
b. did not record accurate observations or assessments of Service User 1, specifically Service User 1’s blood pressure, pulse oximetry and/or heart rate;
2. On 11 December 2020 you provided false information to an out of hours GP in that you reported that Service User 1’s observations were within normal ranges or words to that effect, when you had not taken observations.
3. On or around 11 December 2020 you sent a message via WhatsApp to your colleague who attended Service User 1 with you, specifically, “we gonna have to say we did obs” when you knew that this was not true as observations had not been taken.
4. Your conduct in relation to particulars 1b and/or 2 and/or 3 was dishonest.
5. The matters set out at 1,2, 3, and 4 above constitute misconduct
6. By reason of your misconduct your fitness to practise is impaired.
Finding
Preliminary Matters
Hearing partly in private
1. Ms Bernard-Stevenson made an application for any reference to the health of the Registrant or any witness to be heard in private. Mr Harries KC supported that application.
2. The Panel had regard to the HCPTS Practice Note On ‘Conducting Hearings in Private’ and accepted the advice of the Legal Assessor. The Panel granted the application on the grounds advanced by Ms Bernard-Stevenson.
Application for special measures
3. Ms Bernard-Stevenson made an application for special measures to be applied during the evidence of a witness for the HCPC, BB, on the grounds that he should be treated as a vulnerable witness. The special measure sought was that the Registrant should be directed to turn off her video when BB gave evidence.
4. Mr Harries KC opposed that application on the grounds that there was no evidence that BB was a vulnerable witness.
5. The Panel had regard to the HCPTS Practice Note on ‘Special Measures’ and accepted the advice of the Legal Assessor. The only evidence in support of the HCPC’s application was an email from BB to the HCPC with which he exhibited a medical certificate from his GP. The email did not contain any suggestion by BB that he felt intimidated, and the medical certificate did not suggest that he suffered from any of the other grounds identified as per the Practice Note that required Special Measures.
6. In the absence of any such evidence, the Panel was not satisfied that the grounds for special measures had been made out and therefore refused the application.
Application to introduce hearsay evidence
7. Ms Bernard-Stevenson made an application to adduce in evidence two letters dated 19 July 2022 and 17 October 2022 from the Registrant’s former solicitors to the Investigating Committee of the HCPC when it was considering whether or not the Registrant had a case to answer. The grounds advanced in support of that application were that the letters contained previous inconsistent statements on behalf of the Registrant in relation to the proposed allegation and were relevant to the issue of credibility. She submitted that the Panel should at least read the letters in question and then decide whether they should be admitted.
8. Mr Harries KC opposed that application. He stated that no advance notice of this application had been given and that the attempt to admit these letters was manifestly unfair to the Registrant and amounted to an attempted “ambush” by the HCPC. He submitted that the letters written by the Registrant’s solicitors to the Investigating Committee could not properly or fairly be treated as evidence against her at the substantive hearing and that their potential prejudicial effect would far outweigh any potential probative value.
9. The Panel was advised by the Legal Assessor that the letters which the HCPC wished to adduce in evidence would have been based on discussions between the Registrant and her former solicitors to which legal professional privilege would usually apply. The Registrant should not be required to explain what discussions took place between her and her former solicitors. Furthermore, material of such a nature put before the Investigating Committee would not usually be used as evidence before the Conduct and Competence Committee at a substantive hearing. Whilst the Panel could look at the material in order to decide whether to admit it in evidence, the Panel should be aware of the potential prejudice to the Registrant by the Panel having even seen the material.
10. In summary, the Panel was of the view that any probative value provided by the letters dated 19 July 2022 and 17 October 2022 from the Registrant’s former solicitors to the Investigating Committee was likely to be of limited value and potentially prejudicial. Fairness to the Registrant required that it should be excluded.
Background (as provided by the HCPC in their Case Summary)
11. The Registrant is a registered Paramedic. The Registrant has been employed in the role of Paramedic by East of England Ambulance Service NHS Trust (“the Trust”) since November 2020.
12. On 10 December 2020, the Registrant was scheduled to complete a 7 pm to 7 am shift with an Emergency Medical Technician known as BB which was due to start from Ely station. The Registrant and BB (‘the crew’) were assigned to DSA vehicle NAF554.
13. At approximately 4.46 am the crew were assigned to Service User 1. This call out was assigned as CAD 2356.
14. At approximately 4.58 am, the Registrant and BB attended Service User 1’s home address based in West Suffolk following a call from Service User 1’s doctor (GP). Service User 1’s doctor had recommended that Service User 1 should be conveyed to hospital.
15. The Registrant, in her role as a Paramedic, was the senior clinician in attendance.
16. Upon the crew’s arrival, they attended upon Service User 1, who informed them that she had been experiencing constipation and had not had a bowel movement for 16 days. Service User 1 further advised that earlier that day district nurses had attempted a manual evacuation which had been unsuccessful and that, as a result of this, her GP had decided that she should attend an Accident and Emergency Department for further treatment. However, Service User 1 expressed an unwillingness to attend hospital owing to concerns regarding potentially contracting COVID 19.
17. Following this initial conversation with Service User 1, the Registrant contacted 111 and spoke to an out of hours nurse. During this call, the Registrant advised the out of hours nurse that “all of the patient’s observations are within normal ranges”. However, according to BB, neither he nor the Registrant had assessed the patient and therefore no such observations had been recorded. In addition to this, upon the crew’s departure from Service User 1’s home, it is alleged that the Registrant recorded “textbook perfect” observations for the Service User and this record was alleged to be a fabrication.
18. The call out was recorded as completed on the Trust system by 6.18 am.
19. Following the incident, BB submitted a DATIX WEB183088 (incident report). As a result of this, a member of the management team at the Trust asked the Registrant and BB to write a statement about the incident. Whilst BB was writing this witness statement, he received a WhatsApp message from the Registrant stating “we gonna have to say we did obs”.
20. As a result of the submission of the incident report, an internal investigation was conducted which culminated in disciplinary hearings and appeal meetings. At the conclusion of this process, the Registrant retained her role at the Trust.
The Evidence
21. The Panel was provided by the HCPC with a hearing bundle which included:
• A Signed witness statement from BB for the HCPC dated 4 April 2023 and his previous statements to the Trust;
• A signed witness statement dated 20 February 2023 from OB for the HCPC. He was the investigating officer appointed by the Trust. In addition to his witness statement, he included his local investigating report summary dated 28 January 2021 and witness statements of BB and the Registrant together with other relevant documents;
• A signed witness statement dated 21 March 2023 from SM for the HCPC. He was employed as a Human Resources business partner by the Trust. He gave formal evidence to the effect that the disciplinary hearings and appeal meetings relating to the Registrant took place in compliance with HR policies.
22. The Panel was provided with a bundle of documents on behalf of the Registrant which included her witness statement for this hearing dated 9 July 2024.
23. The Panel heard oral evidence from each of the above witnesses, including the Registrant.
The evidence of BB
24. BB adopted his witness statement and gave additional evidence as set out below.
25. In December 2022 he was employed by the Trust as an Emergency Medical Technician (“EMT”). He had just completed his qualification but did not end his apprenticeship with the Trust until January 2021. He was at the time part of a dual staffed ambulance working with the Registrant, who was a qualified Paramedic.
26. He said that he knew the Registrant “reasonably well” and had a good working relationship with her. Furthermore, they had also met socially on occasion.
27. On attending Service User 1 on 11 December 2020 the Registrant was the attending clinician. He could not recall what, if any, medical equipment, he or the Registrant took out of the ambulance initially on attending to the Service User.
28. Shortly after starting to take Service User 1’s medical history, BB returned to the ambulance to collect a device known as the Toughbook, a laptop which contained a form known as Electronic Patient Care Record (“EPCR”) on which patient details would be recorded.
29. On returning to the property, BB started to complete patient demographics, the Service User’s medical history and medications, which details were provided to him by the patient’s daughter, who was on the scene. He started to complete the history of the presenting complaint with the details elicited by the Registrant from the Service User.
30. He stated that the Registrant, as the primary clinician, was responsible for completing the “observations”, i.e. the physiological findings of the patient, such as blood pressure, respiratory rate, pulse, GCS, temperature and blood glucose levels.
31. He stated that he did not believe that these observations were completed by the Registrant because he did not recall the Corpuls being used, that being the equipment required to obtain such information.
32. He stated that he heard the Registrant speak by telephone to a clinician via the 111 service. He overheard the Registrant say that all the Service User’s observations were within normal ranges. He stated that, to his knowledge, observations had not been recorded at that point. He said, “I was surprised and did not quite know what to do”. When asked why he had not brought this up with the Registrant he stated that, “I believed that it was something that Ms Dunham would react badly to, as I know that she has not taken feedback or input from others during her assessments particularly well”.
33. He stated that the 111 clinician had agreed with the Registrant that the patient could be treated with a phosphate enema and was happy for the patient to remain at home.
34. He stated that a newly qualified Paramedic, such as the Registrant, could discharge the patient via a senior clinician which, in this instance, could be classed as the 111 clinician.
35. He stated that they then returned to the ambulance. He sat in front whilst the Registrant remained in the back of the ambulance completing the EPCR. He stated that he did not see what information she had completed until after he had reported the incident, when the EPCR was accessed by the duty manager. He did not remember the observations recorded on the EPCR having been being taken of the Service User.
36. He said that the reason why he decided to speak to the duty manager at the beginning of his next shift was because he felt uneasy about the job and needed to speak to someone with regard to follow-up and safety netting of the patient. He was subsequently asked by the duty manager to complete a DATIX incident report.
37. The DATIX report dated 14 December 2020 stated “We attended at patient today who did not want to attend A&E. My crew mate spoke to an OOH clinician and informed them that all obs were within normal ranges when no obs had been taken”.
38. BB confirmed the above information in his statement to the Trust dated 15 December 2020 to the Trust.
39. In a further undated statement BB explained he had gathered information from the patient’s daughter to confirm the Service User’s details. He had also completed drug history and past medical history from the patient and recorded the prescription given to him by the patient’s daughter and had entered this into the comments section of the EPCR. He stated “I did not complete the assessment, impression, treatment or care plan sections of the EPCR, leaving this for my crew mate who made those assessments and decisions…. I did not take any observations of the patient, nor did I witness any being taken, therefore I did not complete this section of the paperwork”. He went on to say “Whilst attempting to sleep the following day, in preparation for my final night shift, I had time to reflect on this job. This reflection lead me to speak to the LOM the next night and subsequently to the completion of DATIX …. Following this reflection I realise that I should have stepped in and challenged the assessment made or even taken a full set of observations myself, however at the time I felt that this was something that I could not do, for which I apologise. I have learnt that this is something that I must to do ensure the safety, respect and dignity of my patients if I should ever find myself in a similar situation again”. [Sic]
40. BB was cross-examined by Mr Harries KC. He agreed that in his statement dated 4 April 2023 he had said “I cannot recall what equipment, if any, was taken inside the patient’s home. However, equipment is usually taken inside on arrival so it’s likely that Ms Dunham did bring equipment inside”. On further questioning, he could not remember whether the Registrant had taken in the Corpuls machine or not.
41. He was firm in his evidence that he had not made any core assessments of the patient and had not completed the assessment section in the EPCR.
42. He agreed with Mr Harries KC that the patient had not consented to be taken to hospital and could not be taken there against her will. He agreed that she had capacity to make that decision.
43. Mr Harries KC referred BB to his note recorded in the ambulance on the Computer Aided Dispatch device (CAD) after leaving the patient’s home in which he had recorded “Obs Normal” he said that he had written “to reflect what happened on the scene and what was said”.
44. He was asked about the timing recorded on the EPCR and stated that although times were auto-generated, they could be changed retrospectively when competing the entries on the EPCR.
45. Following BB’s evidence, the panel heard evidence from OB and SM, neither of whom gave direct evidence relating to the particulars of Allegation.
Decision on No Case to Answer
46. At the close of the HCPC’s case, Mr Harries KC made a submission of no case to answer in relation to Particulars 1(a), 1(c) and 1(d) of the Allegation. On behalf of the HCPC, Ms Bernard-Stevenson conceded that that there was no case to answer in respect of Particulars 1(a) and 1(d) but challenged the submission in respect of Particular 1(c).
47. The Panel heard detailed submissions from Mr Harries KC in respect of each of the above particulars. Ms Bernard-Stevenson provided detailed written and oral submissions in respect of Particular 1(c) only.
48. The Panel had regard to the HCPTS Practice Note on ‘Submissions of No Case to Answer’ and accepted the advice of the Legal Assessor.
49. The Panel upheld the submissions of no case to answer in respect of Particulars 1(a), 1(c) and 1(d) for the following reasons.
50. The relevant particulars allege that:
1. On 11 December 2020, you did not act in Service User 1’s best interests and /or adequately assess Service User 1 in that you:
a. did not convey Service User 1 to hospital as had been requested by Service User 1’s GP;
b. xxxx;
c. did not take adequate medical equipment to the scene in that you did not take monitoring equipment, namely the Corplus machine;
d. did not, as required as a Newly Qualified Paramedic, seek approval from a senior clinician prior to discharging Service User 1 at home.
51. Each of the Particulars - 1(a), 1(c) and 1(d) - is alleged to be an instance of the Registrant not acting in Service User 1’s best interests and/or not adequately assessing her.
52. The only witness relied on by the HCPC as giving direct evidence in support of each of these particulars was BB.
53. With regard to Particular 1(a) the undisputed evidence was the Registrant and BB attended on Service User 1 following a request by her GP that she should be conveyed to hospital. On arrival at Service User 1’s home, the Registrant and BB spoke to Service User 1, carried out a “primary survey” and encouraged her to be conveyed to hospital as requested by her GP. Service User 1, however, refused to be taken to hospital. Both the Registrant and BB were satisfied that Service User 1 had capacity to refuse her consent to be conveyed to hospital.
54. Particular 1(a) is qualified by the stem of Particular 1 which stated, “you did not act in Service User 1’s best interests and /or adequately assess Service User 1”. In not conveying Service User 1 to hospital, the Registrant had no option but to accept Service User 1’s refusal to go hospital. They arranged for a prescription for a phosphate enema, updated the GP and provided worsening advice to Service User 1 and her daughter. Therefore, in the Panel’s judgement, the Registrant’s non-conveyance of Service User 1 to hospital was not probative of her failing to act in Service User 1’s best interests and/or adequately assessing her, nor was it capable of constituting misconduct. For all these reasons, the Panel found no case to answer in relation to Particular 1(a).
55. With regard to Particular 1(c), BB gave differing accounts at different times as to whether or not the Registrant took the Corplus machine to the scene. In his local statement dated 15 December 2020 to the Trust as part of their investigation, BB stated that the Corpuls remained on the ambulance. At the appeal meeting on 14 June 2021 when BB was asked whether the equipment was available in Service User 1’s property he modified his position by stating “not to my knowledge no”. However, in his signed statement for the HCPC dated 4 April 2023, he stated “I do not recall what equipment, if any, was taken inside the patient’s home. However, equipment is usually taken in on arrival, so it is likely that Ms Dunham did bring equipment inside”. Further, when cross-examined by Mr Harries KC, BB said that “I can’t recall either way whether the Corpuls was still in the ambulance or not” and it was “possible” that the Registrant had taken the Corplus machine into the property. He also said during his cross-examination that he could not remember seeing it when he returned to the ambulance to collect the laptop to complete the EPCR. In addition, BB said that he “assumed” that he would have taken the Corplus machine from the ambulance if he had seen it.
56. Ms Bernard-Stevenson made the point that BB’s statement dated 15 December was made within four days of the incident, when his memory of events was likely to be clearer than when he made a statement in April 2023, some 2 ½ years later. On the other hand, that statement was not made under affirmation nor was there any evidence that it had been subject to any questioning. When giving his evidence on affirmation, and subject to cross-examination, BB did not stand by his earlier account.
57. The only evidence in support of Particular 1(c) was that of BB, which was inconsistent. In these circumstances, the Panel was of the view that the evidence could not be relied upon to be able to find Particular 1(c) proved and accordingly upheld the submission of no case to answer.
58. With regard to Particular 1(d), BB gave evidence that the Registrant called 111 and had a follow-up telephone call with an out-of-hours nurse before discharging Service User 1 at home. This was in accordance with the Trust’s ‘Safe Non-Conveyance and Discharge Policy’ which provided that “If on assessment of an HCP referral, the patient refuses admission, this must be discussed with the referring clinician or an out of hours provider following assessment of the patient’s capacity to refuse”. On the evidence, the Registrant followed this guidance. The Panel concluded that there was no evidence in support of Particular 1(d) and therefore upheld the submission of no case to answer.
Application to amend the Allegation
59. Following the Panel’s decision on the half-time submission, Ms Bernard-Stevenson made an application to amend the Allegation as set out above. No objection was taken by Mr Harries KC. The Panel was satisfied that the proposed amendment did not materially alter the case against the Registrant. Accordingly, the Panel granted the application to amend.
The Registrant’s evidence
60. The Registrant confirmed and adopted the evidence contained in her witness statement dated 9 July 2024.
61. She confirmed that she and BB had, prior to the incident, a good working relationship and were good friends outside work.
62. She stated that, on arrival at Service User 1’s home, they had taken the medical equipment, including the Corpuls machine into the property. She stated that the Corpuls is a machine that is used to take observations including ECG, heart rate, pulse oximetry and blood pressure. At the time, the battery on the Toughbook was faulty and needed extra charging time and was left in the ambulance on arrival.
63. She stated that Service User 1 was adamant that she did not want to go to hospital and clearly had the capacity to refuse. BB then went back to the ambulance to collect the Toughbook. On his return, she left him to complete the observations and went downstairs to speak to the Service User’s daughter. She used her mobile phone to call 111 for a clinician to call her back. As she was making her call, she made her way back upstairs. She remembered that BB was sitting on the floor with the Toughbook in his lap and that she had had to step over him.
64. After five or ten minutes chatting with the patient, the clinician from 111 called back. The Registrant had her phone in one hand and took the Toughbook from BB in the other. It was displaying the EPCR. She said that she was scanning through the information on the EPCR including observations which had, to the best of her knowledge, been entered accurately by BB, while she was talking to the patient’s daughter. She explained to the nurse that the patient refused to go to hospital. When asked by the nurse if the observations were within normal ranges, she confirmed that they were. The nurse prescribed a phosphate enema and the Registrant made a note on the 111 system for the District Nurse to follow up the next morning.
65. The Registrant said that she and BB then returned to the ambulance where she signed off the EPCR including the observations. She also completed the impressions section on the EPCR.
66. On 15 December 2020 she was again working with BB when she received a message from Central Control that they had been “booked out of service” and were ordered to return to Cambridge Station immediately. At the Station she met CK, Leading Operations Manager, with BB. She was told that a very serious complaint had been made against her via a DATIX entry. She handed the Registrant a copy of Service User 1’s EPCR and said that the Registrant had made up a set of observations. She said that it was a very serious allegation and that the Registrant would lose her job.
67. She and BB were instructed to make statements about what they remembered happening at Service User 1’s home and were told to go to separate rooms where they made their statements.
68. She admitted sending BB a WhatsApp message which read “You ok We gonna have to say we did obs”. She said that her intention was to reassure BB that “we just need to confirm that we had conducted observations which I believed we had”.
Decision on Facts
69. In deciding whose account of the incident it preferred, the Panel noted carefully the previous statements of both witnesses. The Panel was mindful that in principle and as advised by the Legal Assessor, those statements made nearest to the events in question were likely to be more reliable than the memories of witnesses and their witness statements made years after the incident.
70. From the time of completing the DATIX report on 14 December 2020 onwards, BB had been entirely consistent in stating that he did not take the observations of Service User 1 and did not record any such observations on the EPCR. He was also consistent in his statements that he did not see the Registrant take any observations and was surprised and concerned that the Registrant had informed the nurse on 111 that Service User ‘s observations were normal or words to that effect. The only material inconsistency in his evidence was that, whereas in his statement dated 15 December 2020 he was clear that the Corpuls machine had remained in the ambulance, by the time he made his witness statement dated 4 April 2023, and in is evidence before the Panel, he could no longer remember whether it had remained in the ambulance or had been taken to the Service User’s property.
71. By contrast, the Registrant made a number of inconsistent statements:
• In her first statement dated 15 December 2020, the Registrant stated “I am not sure as to why it has been said obs were falsified as why would I want to falsify these….. observations taken blood pressure, pulse, BM, SATS. ECG not undertaken as not cardiac problem”.
• In a second statement dated 15 December 2020 the Registrant stated "I have been thinking and trying to pull apart this job and what I can remember and after thinking I am doubting myself. Therefore would like to add that I just don’t know if I carried out all of the observations mentioned, however I cannot see why I would write down and documented them if I hadn’t. It was a very long night shift and was take off the night before I was very tired and emotional when we were given the job. Maybe was confused due to tiredness. If this is the case, I did not mean any harm to be caused to anybody and I have not intentionally falsified documents to any gain”.
• CK recorded that on 15 December 2020 “I reassured her that we could prove that observations were taken using the Corpuls had been carried out, as we could obtain the data from the Corpuls, and this would assist her case. The Registrant then stated that she was so tired on shift that she was not sure that she had taken the observations, and that she was confused and over thinking things. She stated that maybe she did not and that she actually documented clinical observations of the previous patient into this patients EPCR”.
72. The Panel noted that the Registrant appeared to have changed her position after being informed by CK that details could be obtained from the Corpuls to confirm use including date and time.
73. In addition, the Panel noted that the Registrant’s evidence before the Panel and her previous statements had omitted to make any reference to the Corpuls having been used either by herself or BB to take observations, although it was undisputed evidence that use of the Corpuls was required to carry out assessments of the Service User’s blood pressure, pulse oximetry and heart rate.
74. Furthermore, the Panel also noted that the Registrant had not at any stage in her evidence stated that she had seen BB carry out these assessments.
75. In addition, when considering the credibility of the Registrant and BB respectively and whose account of events was most likely, the Panel noted in particular the following matters:
• It was agreed by both the Registrant and BB that they had a good relationship in and outside of work prior to this incident;
• The Panel did not accept that it was credible to suggest that BB had a motive for maliciously fabricating allegations against the Registrant;
• By reporting this incident to the Duty Manager BB was implicating himself in poor practice by admitting that he was a member of a crew that had left an elderly patient without carrying out observations;
• By making an allegation against a crew mate he put himself in a very difficult position.
76. Taking all these matters into account, where the Registrant’s evidence differed from that of BB, the Panel preferred the evidence of BB.
77. The Panel heard and accepted the advice of the Legal Assessor and were mindful that the burden of proof in relation to the facts is on the HCPC and the standard of proof is on the balance of probabilities.
Particular 1a - Proved
On 11 December 2020, you did not act in Service User 1’s best interests and/or adequately assess Service User 1 in that you:
a.did not carry out observations or assessments of Service User 1, specifically Service User 1’s blood pressure, pulse oximetry and/or heart rate;
78. The Registrant acknowledged that she had not carried out any observations or assessments of Service User 1, specifically blood pressure, pulse oximetry or heart rate. The Panel did not accept her explanation that she believed that BB had carried out such observations and assessments. The Panel was satisfied that, in not carrying out such observations or assessments, and not believing them to have been carried out, the Registrant did not act in Service User 1’s best interests or adequately assess her. Accordingly, Particular 1a is proved.
Particular 1b – Proved
On 11 December 2020, you did not act in Service User 1’s best interests and/or adequately assess Service User 1 in that you:
b. did not record accurate observations or assessments of Service User 1, specifically Service User 1’s blood pressure, pulse oximetry and/or heart rate;
79. The Panel believed BB’s evidence that he had not recorded the observations and assessments of Service User 1 in the EPCR. It followed that, contrary to the Registrant’s denials, she had recorded these observations and assessments, which had not in fact been carried out. She thereby did not act in Service User 1’s best interests, Accordingly, Particular 1b is proved.
Particular 2 - Proved
On 11 December 2020 you provided false information to an out of hours GP in that you reported that Service User 1’s observations were within normal ranges or words to that effect, when you had not taken observations.
80. The Registrant acknowledged in her evidence that she had informed the out of hours clinician on 111 that Service User 1’s were “unremarkable”, which was, to all intents and purposes, the same as saying that they were within normal ranges. The Panel accepted BB’s evidence that, when providing this information, there had been no vital signs taken, or recorded on which the Registrant could have provided this information. The Panel did not accept the Registrant’s evidence that, when providing this information, she was relying on the vital signs recorded on the EPCR by BB. However, the Panel accepted that a primary survey was likely undertaken by the Registrant upon arrival at Service User 1’s side. The Panel also accepted that BB elicited a medical history from Service User 1 and her daughter. Having not taken the vital signs it was not clinically appropriate to report that observations were in normal ranges or words to that effect. It follows that Particular 2 is proved.
Particular 3 – Proved
On or around 11 December 2020 you sent a message via WhatsApp to your colleague who attended Service User 1 with you, specifically, “we gonna have to say we did obs” when you knew that this was not true as observations had not been taken.
81. The Panel was provided with a copy of the message referred to in Particular 3 which the Registrant admitted sending to BB when he was writing or about to write his statement at the behest of CK. The date of the message appears to have been 15 December 2020 but the Panel did not consider that the date of “On or around 11 December” to be a material difference. Having found as a fact that the Registrant knew that observations of Service User 1 had not been taken, she plainly knew that it would be untrue to say that they had been taken. Particular 3 is therefore proved.
Particular 4 – Proved
Your conduct in relation to particulars 1b and/or 2 and/or 3 was dishonest
82. Having found Particulars 1b, 2 and 3 proved, the Panel went on to determine whether in relation to those Particulars, or any of them, the Registrant was dishonest. The Panel applied the test in Ivey v Genting Casinos [2017] UKSC 67. The Panel was satisfied that the Registrant was well aware that, in relation to Particular 1b, the recorded observations of Service User 1 were a fabrication, that, in relation to Particular 2, she knowingly gave the out of hours clinician false information and that, in relation to Particular 3, her message to BB was intended to conceal the fact that observations had been falsely recorded. Ordinary, decent people would consider her conduct in respect of each of these Particulars to have been dishonest. Accordingly, Particular 4 is proved.
Decision on Grounds
83. The Panel went on to consider whether the facts found proved in Particulars 1a, 1b, 2, 3, and/or 4 of the Allegation amounted to misconduct as alleged in Particular 5.
84. The Panel had regard to the submissions of Ms Bernard-Stevenson and Mr Harries KC and accepted the advice of the Legal Assessor.
85. The Panel was mindful that this is a matter for the Panel’s professional judgment, there being no standard or burden of proof.
86. Misconduct was defined in Roylance v GMC (No 2) [2000] 1 A.C. 311 as:
“a word of general effect, involving some act or omission which falls short of what would be proper in the circumstances. The standard of propriety may often be found by reference to the rules and standards ordinarily required to be followed by a medical practitioner in the particular circumstances. The misconduct is qualified in two respects. First, it is qualified by the word ‘professional’ which links the conduct to the profession…... Secondly, the misconduct is qualified by the word ‘serious’. It is not any professional misconduct which will qualify. The professional misconduct must be serious …”
87. The Panel found the Registrant to have been in breach of the following standards of HCPC Standards of Conduct, Performance and Ethics (2016):
• Standard 2.5: You must work in partnership with colleagues, sharing skills, knowledge and experience, where appropriate, for the benefit of service users and carers.
• Standard 2.6: You must share relevant information, where appropriate, with colleagues involved in the care, treatment or other services provided to a service user.
• Standard 6.1: You must take all reasonable steps to reduce the risk of harm to service users … as far as possible.
• Standard 6.2: You must not do anything which could put the health or safety of a service user ….. at unacceptable risk.
• Standard 9.1: You must make sure that your conduct justifies the public’s trust in you and your profession.
• Standard 10.1: You must keep full, clear and accurate records for everyone you care for, treat, or provide services to.
88. The Registrant was in breach of standards 2.5 and 2.6 in respect of Particulars 1b and 2 by not working in partnership with BB for the benefit of Service User 1, by giving false information to the senior clinician on 111 and recording false information on the Service User’s EPCR.
89. The Registrant was in breach of standards 6.1 and 6.2 in respect of Particulars 1a, 1b and 2 by not taking observations of Service User 1, recording false information on the EPCR and providing false information to the senior clinician on 111.
90. The Registrant was in breach of standard 9.1 in respect of all the proven particulars, both individually and collectively.
91. The Registrant was additionally in breach of standard 10.1 in respect of Particular 1b in not keeping accurate records for Service User 1.
92. The Panel found that the Registrant’s practice fell seriously below the standards of conduct expected of her as a Paramedic in respect of each of the proven particulars and that, both individually and collectively, they amounted to misconduct.
Decision on Impairment
93. The Panel carefully considered the submissions by Ms Bernard-Stevenson and Mr Harries KC. The Panel had regard to the HCPTS Practice Note on ‘Fitness to Practise Impairment’ and accepted the advice of the Legal Assessor.
94. In determining whether the Registrant’s fitness to practise is impaired, the Panel took into account both the personal and public components of impairment of fitness to practise. The personal component relates to the Registrant’s own practice as a Paramedic, including any evidence of insight and remorse and efforts towards remediation. The public component includes the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession and the Regulator.
95. With regard to the personal component, the Panel had regard to the fact that the Registrant had continued to practise as a Paramedic for the last 3 ½ years since the date of the incident without any concerns being raised about her practice. She provided the Panel with an impressive portfolio of courses in Continuing Professional Development which she had undertaken. The testimonials submitted on her behalf by service users and colleagues praised her dedication, hard work, integrity and exemplary standard of the care. The Registrant’s current line manager stated that she was proud to have the Registrant as a member of her team. In the light of this information, the Panel was satisfied that the Registrant had remediated any concerns about her clinical practice. The Panel also considered that the risk of repetition of her misconduct was very low.
96. The Panel, however, was concerned that the Registrant’s reflective statement, written for the purpose of these proceedings, avoided any acceptance of personal responsibility and sought to deflect blame onto colleagues. Absent was any reflection on the essential need for transparency, integrity and honesty in all her dealings with service users and colleagues. The Panel noted Mr Harries KC submissions that the Registrant accepted the Panel’s findings and was devastated by them and the negative impact which the findings of dishonesty had on her reputation and that of the profession. However, the Panel was not satisfied that the Registrant’s remorse extended beyond her being found guilty of misconduct or that she had yet reflected on, or acquired insight into the need for, integrity, honesty and transparency in all her dealings with service users and colleagues. To that extent, the Panel found the Registrant’s fitness to practise remains impaired with regard to personal component.
97. With regard to the public component of impairment, the Panel considered that the Registrant’s misconduct had posed a risk of significant harm to Service User 1 but that similar misconduct was unlikely to be repeated in the future. A finding of current impairment was therefore not necessary to protect the public. The Panel, however, was mindful of the need to maintain public confidence in the profession and to declare and uphold proper standards of conduct and behaviour on the part of registrants. The Panel considered that the Registrant’s misconduct in discharging an elderly service user without carrying out essential observations and assessments and her dishonesty in provided false information to the senior clinician on 111, fabricating patient records and seeking to implicate her junior colleague in a cover-up, represented serious departures from the standards to be expected of a member of her profession. In the Panel’s judgement, public confidence in the profession and in the HCPC as its Regulator would be undermined if there were no finding of impairment.
98. Accordingly, the Panel found the Registrant’s fitness to practise to be impaired having regard to both the personal and public components.
Decision on Sanction
99. The Panel took into account the submissions of Ms Bernard-Stevenson on behalf of the HCPC and Mr Harries KC on behalf of the Registrant.
100. The Panel was guided by the HCPC’s Sanctions Policy and accepted the advice of the Legal Assessor. The Panel was mindful that the purpose of a sanction is not to punish the Registrant but to protect the public and the wider public interest in upholding proper standards, safeguarding the reputation of the profession and maintaining public confidence in the profession and the HCPC as its Regulator. The Panel applied the principle of proportionality, balancing the interests of the Registrant with those of the public, and considered the available sanctions in ascending order.
101. The Panel considered that the following aggravating features were present in this case:
• There was a potentially serious risk of harm to Service User 1 in vital observations not being taken and unverified information about her condition being recorded in the EPCR;
• Entering false information into the Service User’s EPCR had potentially serious consequences for the health and well-being of Service User 1, together with reputational damage for her crew mate and the Trust;
• The Registrant compounded these concerns by maintaining her concealment and lack of candour.
102. The Panel found the following mitigating factors:
• At the time of the incident, the Registrant had only been qualified as a Paramedic for one month;
• The incident took place during the COVID 19 pandemic, when the Registrant had been working long hours under intense pressure, making extraordinary decisions under challenging conditions not seen outside of the pandemic with limited external support during the preceptorship period of her clinical practice;
• This was an isolated incident of misconduct and the Registrant’s practice and performance as a Paramedic for the subsequent period of 3 ½ years has been exemplary, as confirmed by testimonials from professional colleagues, including her line manager, and service users;
• The Registrant has prior to the start of the proceedings, presented the Panel with a bundle comprising of a comprehensive CPD portfolio and a number of reflections pertaining to high-pressured call outs in which she had been the leading/sole Paramedic in attendance. In addition to this, the Registrant has since provided the Panel with a forward-thinking development plan attempting to address the Panel’s current concerns;
• The Panel also considered the Registrant’s personal circumstances, which potentially had a negative impact on her judgement at the time of the incident.
103. The Panel was impressed by the continuing support offered to the Registrant by her colleagues, her line manager and the Trust. It is apparent that the Registrant appears to be highly regarded as a Paramedic by service users, colleagues and her employer.
104. The Panel acknowledged that, notwithstanding the Registrant’s denial of the allegations, her response to the Panel’s findings of fact showed remorse, acceptance of responsibility, developing insight and a willingness and determination to develop her practice.
105. When considering the type of Sanction, given the seriousness of the proven allegations, it would not be appropriate for the Panel to take no further action.
106. The reason stated above also applies with regard to the imposition of a Caution Order. Furthermore, it would not satisfy the wider public interest in declaring and upholding proper standards of conduct on the part of registrants.
107. The Panel decided that its findings met the criteria listed in the Sanctions Policy for the imposition of a Conditions of Practice of Order, namely:
• the misconduct, although serious, was an isolated incident in the career of a newly qualified Paramedic working in exceptionally difficult and stressful conditions
• the Registrant’s practice as a Paramedic in the period of 3 ½ years since the relevant incident has been exemplary, as confirmed by testimonials from professional colleagues, including her current line manager, and service users
• the Registrant has, through this process, shown developing insight
• the risk of repetition is deemed by the Panel to be very low
• appropriate, proportionate, realistic and verifiable conditions can be formulated with colleagues who are willing to support her
• a reviewing panel will be able to determine whether the conditions have or are being met.
108. In the Panel’s judgement a Conditions of Practice Order for a period of 12 months is the appropriate and proportionate sanction. This should give the Registrant sufficient time to address all the outstanding concerns about her fitness to practise in a supportive setting whilst addressing the public interest.
109. In reviewing the Sanctions, the Panel carefully considered whether to impose a Suspension Order and determined that it would be disproportionate and punitive in all the circumstances. It would also be contrary to the public interest in preventing a committed and competent practitioner from returning as soon as possible to unrestricted practice.
Order
Order: The Registrar is directed to annotate the Register to show that for a period of 12 months, from the date this Order comes into effect, you, Ms Claire Dunham, are subject to the following Conditions of Practice:
1) You must place yourself and remain under the indirect supervision of a workplace supervisor, senior to you and registered with the HCPC, and supply details of your supervisor to the HCPC within one month of the date of this Order. You must attend upon that supervisor as required and follow their advice and recommendations.
2) You must work with your workplace supervisor to formulate a Personal Development Plan designed to address the following areas of your practice:
a) the importance of honesty, transparency and probity in the workplace;
b) the duty of candour;
c) managing challenges and conflicts in the workplace; and
d) working in partnership.
3) Within eight weeks of today’s date (2 August 2024) you must forward a copy of your Personal Development Plan to the HCPC.
4) You must meet with your workplace supervisor on a monthly basis to consider your progress towards achieving the aims set out in your Personal Development Plan.
5) You must allow your supervisor to provide information to the HCPC about your progress towards achieving the aims set out in your Personal Development Plan.
6) You must maintain an ongoing reflective piece that includes, but is not limited to, the following areas:
a) honesty, integrity and probity;
b) the duty of candour;
c) managing challenges and conflict in the workplace;
d) working in partnership.
You must provide a copy of your reflective piece to the HCPC one month prior to any substantive review.
7) You must inform the HCPC within seven days if you cease to be employed by your current employer.
8) You must inform the HCPC within seven days if you take up any other or further professional work.
9) You must inform the HCPC within seven days if you take up work requiring registration with a professional body outside the United Kingdom.
10) You must inform the HCPC within seven days of returning to practice in the United Kingdom.
11) You must inform the HCPC within seven days of becoming aware of:
A. any patient safety incident you are involved in;
B. any investigation started against you; and
C. any disciplinary proceedings taken against you.
12) You must inform the following parties that your registration is subject to these conditions:
A. any organisation or person employing or contracting with you to undertake professional work;
B. any agency you are registered with or apply to be registered with to undertake professional work (at the time of application);
C. any prospective employer for professional work (at the time of your application).
13) You must allow the HCPC to share, as necessary, details about your performance, compliance with, and/or progress under these conditions with:
A. any organisation or person employing or contracting with you to undertake professional work;
B. any agency you are registered with or apply to be registered with to undertake professional work (at the time of application);
C. any prospective employer for professional work (at the time of your application).
Notes
Interim Order
Interim Order Application
1. Ms Bernard-Stevenson on behalf of the HCPC made an application for an Interim Conditions of Practice Order in the same terms as the substantive Conditions of Practice Order, for a period of 18 months to cover the appeal period or until any appeal lodged has been determined.
2. On behalf of the Registrant, Mr Harries KC did not oppose that application.
Decision
3. The Panel accepted the advice of the Legal Assessor.
4. The Panel determined that it was in the public interest to impose an Interim Conditions of Practice Order for a period of 18 months in the same terms as the substantive order.
Interim Conditions of Practice Order: The Panel makes an Interim Conditions of Practice Order under Article 31(2) of the Health Professions Order 2001, the same being otherwise in the public interest.
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.
Hearing History
History of Hearings for Ms Clare Dunham
| Date | Panel | Hearing type | Outcomes / Status |
|---|---|---|---|
| 15/07/2024 | Conduct and Competence Committee | Final Hearing | Conditions of Practice |