Francis Mwangi

Preliminary Matters
Amendment of the Allegation.
1. The HCPC applied to amend the Allegation by withdrawing Particular 4 in its entirety. This would mean that the Allegation would change in the following way, with strike through indicating removed wording:

As a registered Paramedic (PA39810) your fitness to practise is impaired by reason of your misconduct. In that:

1. On 17 January 2020, you did not conduct an abdominal assessment of the Service User when you should have done so.

2. On 17 January 2020, you falsely recorded that you had conducted an abdominal assessment of the Service User.

3. On 17 January 2020, you did not offer and/or provide analgesia medication despite recording the Service User’s pain score as 8.

4. On 17 January 2020, you did not convey the Service User to the emergency department.

5. On 17 January 2020, you did not communicate professionally with the Service User and/or present with a professional attitude towards the Service User. In that:

a) On arrival you advised the Service User there was nothing you could do because the Service User was pacing around.

b) You were dismissive of the Service User’s presenting symptoms.

6. Your conduct in relation to particular 2 was dishonest.

7. The matters set out in particulars 1 to 6 constitute misconduct.

8. By reason of your misconduct your fitness to practise is impaired.

2. The HCPC had served details of the proposed amendment in advance. It stated that the written evidence of Person B and Person C clarified that the decision to take a patient to an Emergency Department (ED) was difficult. Person B’s statement explained there was no absolute guidance.

3. In these circumstances, the HCPC submitted that there was no longer a realistic prospect that Particular 4 could amount to misconduct and it applied to withdraw that Allegation. It submitted that it was not in the public interest to pursue this and referred the Panel to the case of PSA v NMC and X [2018] EWHC 70 (Admin). The Panel heard advice from the Legal Assessor, who summarised the cases of PSA v NMC and X [2018] EWHC 70 (Admin) and Ruscillo v CHRE and GMC (2004) EWCA Civ 1356 and PSA NMC and Jozi (2014) EWHC 764 (Admin).

4. The Panel was mindful of its role to ensure cases were not under-charged. It was aware of its duty to ensure that the case was properly presented and that relevant evidence was placed before it, due to the function of regulatory proceedings in ensuring protection of the public.

5. The Panel had regard to the HCPTS Practice Note, ‘Discontinuance of Proceedings’ dated August 2023.

6. The Panel did not consider that this was a case in which the HCPC should have sought more evidence to pursue Particular 4. The decision to request that the particular was withdrawn had come after the HCPC had obtained all of the written evidence. Essentially, the HCPC now accepted that the Registrant had exercised his professional discretion in his decision not to convey Service User A (SU A) to hospital in the absence of absolute guidelines. The Panel agreed with the HCPC’s analysis of the evidence on this aspect of the case, and agreed to withdraw Particular 4.

7. The Allegation was therefore amended and now was as follows:

1. On 17 January 2020, you did not conduct an abdominal assessment of the Service User when you should have done so.

2. On 17 January 2020, you falsely recorded that you had conducted an abdominal assessment of the Service User.

3. On 17 January 2020, you did not offer and/or provide analgesia medication despite recording the Service User’s pain score as 8.

4. On 17 January 2020, you did not communicate professionally with the Service User and/or present with a professional attitude towards the Service User. In that:

a) On arrival you advised the Service User there was nothing you could do because the Service User was pacing around.

b) You were dismissive of the Service User’s presenting symptoms.

5. Your conduct in relation to particular 2 was dishonest.

6. The matters set out in particulars 1 to 5 constitute misconduct.

7. By reason of your misconduct your fitness to practise is impaired.

Proceedings in Private.
8. The HCPC applied for any part of the hearing that related to the Registrant’s health to be heard in private. The Panel had received written information provided by the Registrant prior to the hearing, which related to both health matters and family matters.

9. The Panel had regard to the HCPTS Practice Note, ‘Conducting Hearings in Private’ and heard advice from the Legal Assessor. It determined that any part of the proceedings relating to the health or private life of the Registrant should be heard in private in order to protect the Registrant’s privacy.

Redaction of Information.
10. The Panel had been provided with information from both the HCPC and the Registrant that there had been ‘previous complaints’ made about the Registrant (although not to the HCPC). This vague and unspecified suggestion had not been redacted from the bundle.

11. The HCPC indicated that they wanted the hearing to go ahead, and that the Panel should have no regard to any information that was not properly before it. The Registrant confirmed he wanted the hearing to proceed as he had waited a long time. The Panel heard advice from the Legal Assessor.

12. The Panel was confident that it could disregard the unspecified information within the bundle and that it would only proceed on the information properly before it in relation to the Allegation. The Panel found that it did not need to recuse itself and that the hearing could proceed. As the Panel had already seen and read the documentation, it was not necessary for a redacted bundle to be served at this stage.

Questioning of Witnesses.
13. The Registrant was unrepresented. He confirmed that he felt comfortable questioning Person C and SU A, but did not feel comfortable questioning Person B. This was because Person B was his senior, and the Registrant described himself as someone who was very respectful of authority. It was agreed that the Registrant would submit questions for Person B to the Hearings Officer, who would in turn provide them to the Legal Assessor. The Legal Assessor agreed to ask these questions on the Registrant’s behalf.

Background
14. The Registrant is a Paramedic, employed by South West Ambulance Service NHS Foundation Trust (the Trust).

15. On 21 January 2020, the Trust received a complaint from a third party about the Registrant’s treatment of SU A. Person B spoke to SU A on 6 February 2020 and during that call became aware that the Registrant had not undertaken a physical examination of SU A’s abdomen, but the notes completed indicated that an abdominal assessment had been undertaken.

16. A Consideration of Scope of Practice (COSOP) meeting was arranged for 16 February 2020 and the matter was investigated. After a COSOP review meeting on 11 April 2020, all restrictions imposed by the Trust on the Registrant were removed.

17. The Registrant referred himself to the HCPC on 29 April 2020. The referral relates to the single incident outlined above.

18. The HCPC investigated the matter relating to this incident. It was said that when the Registrant initially arrived at SU A’s address, he commented that he was unable to assist SU A as she was pacing around. It was also alleged that the Registrant was dismissive of her symptoms.

19. The concerns raised by SU A included that the Registrant did not offer pain medication, despite the fact that she had indicated she was in severe pain. The Registrant arranged for SU A to attend an out of hours’ clinic with a General Practitioner (GP).

20. During the Registrant’s contact with SU A, it was alleged that the Registrant did not conduct an abdominal assessment of SU A, when he should have done. Whilst no physical abdominal assessment was carried out, the Registrant recorded that an abdominal assessment had been completed in SU A’s records. It was the HCPC’s case that this was dishonest as the Registrant intended to create a false impression that this assessment had been completed when it had not.

Witness Evidence.
21. Three witnesses gave evidence under affirmation on behalf of the HCPC. Each confirmed their written statement.

Person C
22. Person C indicated that she was now a qualified paramedic, but at the time of the visit to SU A was a student paramedic working as an Emergency Care Assistant (ECA). This was a non-clinical role, supporting the paramedics.

23. Person C stated that she could not remember words used by the Registrant specifically. In her oral evidence she explained that the Registrant initially asked why they were there, and everything was normal ‘as per most jobs.’ Person C had no recollection of a dog on the premises.

24. In her oral evidence, Person C explained that SU A had taken Paracetamol and the next available option for pain relief would have been Entonox. This was not viable. The ‘next one up’ would have been morphine. Person C explained that she could not specifically remember discussing pain relief with SU A herself.

25. When asked to clarify issues about the abdominal assessment, she described ‘guarding’ as a patient covering their abdomen with their hands by not letting you come near it. She described rebound tenderness as being used for specific problems, for example if appendicitis is suspected, so this was specific to a certain type of problem. Person C described the pulsatile mass question as a specific question in relation to a very specific problem.

26. Person C clarified that it is possible to answer some of the questions without touching the patient, as you can ask the patient some of these questions, and ask how their stomach feels. She confirmed that rebound tenderness would require a physical examination to answer.

27. In response to Panel questions, Person C confirmed that paramedics would not do an examination of someone’s rectum. The Registrant had stated this, and she ‘felt like it didn’t need to be said.’ She did not think the Registrant had been curt and short immediately on arrival. When questioned she clarified that the Registrant may not have been curt and short within the first seconds of arrival but could have been within the first couple of minutes of arrival. Person C described how SU A’s personal data would be obtained through a search of NHS systems and that the Registrant had completed the record.

28. Person C confirmed it would have been appropriate to consider what the patient would normally do in that situation regarding pain management. Even with hindsight, she would not change this view.

29. Person C confirmed she had not considered involuntary guarding and that she had not received training around completing the forms for the abdominal assessment from the Trust as a paramedic. As an ECA at the time of the visit to SU A, this did not form part of her role. Person C had received training at university as to how to complete an abdominal assessment, for example by listening with a stethoscope, having a feel of the abdomen for rebound tenderness if appendicitis was suspected and looking for discolouration. The training was on completing a physical abdominal assessment, not on completing the forms.

30. Person C confirmed that she stood by her original statement but could not remember certain things more specifically due to the passage of time. She thought it would have been a worthwhile conversation to have with the out of hours’ doctor as to whether pain relief could have been offered. She stated that the doctor would know best rather than the paramedics.

31. The Registrant asked Person C if they had worked together for the best part of year, and Person C confirmed this was the case. They only worked together when on relief, which Person C thought was every 8 weeks or so. She did not remember the Registrant verbalising a fear of dogs. She did not consider the Registrant to be a dishonest person from her knowledge of him, and she did not know SU A.

Service User A
32. SU A gave evidence. She clarified that she had been pacing and unable to sit down when the paramedics arrived. SU A confirmed that she had an extensive medical history and thought that the Registrant became fixated on the amount of urine she had passed that day, even though she said the pain was different from a Urinary Tract Infection (UTI). SU A stated that the Registrant was dismissive as to what she had to say and the feel and feedback she was getting from him was that she wasn’t being taken seriously.

33. SU A confirmed that she had explained that the pain she was experiencing was around 8 out of 10. She stated she is in pain every day due to her medical condition and would not normally call out for help. The fact that on this occasion she was unable to get her pain under control was serious and specific for her.

34. SU A gave evidence that there was a discussion about morphine, but her partner was out, and she believed it was the Registrant who said the paramedics were not able to give her morphine as she was on her own.

35. In response to questioning, SU A gave evidence that she had not received a formal diagnosis or follow up after her hospital admission, as she had been informed that this treatment was too complex due to her previous surgery. She also clarified that in respect of her pre-existing medical conditions, she had no paperwork provided to her to show healthcare professionals and she was not asked to show paperwork to the ambulance crew.

36. SU A clarified that at a GP appointment the same day, she did have an abdominal examination, and was provided with a diamorphine injection and anti-sickness injection, which were effective. The next day she arranged a morning appointment with her own GP, who made further enquiries then arranged for her admission to a surgical assessment unit at hospital.

37. SU A indicated that she did not recall that there was shared decision making with the ambulance crew. She clarified that the Registrant had not conducted any physical examination other than to check her blood pressure. She said that when not given pain relief she accepted the decision of the Paramedic. There was not much opportunity to discuss this again once her partner had arrived home, as at that point the appointment with the out of hours GP had been made and the Paramedics left.

38. The evidence given by SU A clarified that she was left feeling as if she had been a burden and that she was wasting people’s time by calling an ambulance. Since then, she has been reluctant to call an ambulance and instead, on one occasion, has self-presented to an ED.

39. SU A explained that it was the behaviour and treatment she received that made her feel this way. In her role as a police officer, she sees paramedics quite a lot and also is aware how stretched the ambulance service and NHS are. She would not have made the complaint herself, as she is not that sort of person and she did not see the point in it, the experience had left a ‘bad taste’ in her mouth and that was it.

40. SU A confirmed that there was a dog in the house when the paramedics arrived, but it was shut away in the kitchen behind a wooden door. When SU A called 111 the call handler could hear the dog and asked that it was shut away into another room. SU A confirmed that the dog was scratching at the door and barking, but that it was not visible to the paramedics. SU A did not recall any conversation about the dog. She said that at no point did the Registrant mention his fear of dogs. The dog could not have peeked through the door, because the door was wooden and closed.

41. SU A pointed out that the handover to the GP had been that she might have a UTI and that she had told the paramedics the pain was not like this, she thought the Registrant was dismissive in nature and that she had been ignored. SU A described the ‘female paramedic’ as more amenable and approachable. She felt the Registrant had not behaved in a compassionate way towards her.

42. SU A gave evidence the Registrant did not ask any inappropriate questions. She was of the view that his questioning about her medical history was appropriate otherwise she would have challenged this. She had not met Person C before.

43. SU A explained that she had gone upstairs at one point to use the bathroom, as this was the quickest route to a bathroom in the house. She did not remember the Registrant saying that a doctor could offer stronger or more analgesia than the paramedics could. She was not asked to lie down and did not remember the Registrant saying the paramedics were unable to assist her when she was pacing. SU A explained that she would have stopped pacing to have her blood pressure checked. She said she was not asked to stop pacing for further physical examinations, and clarified she had a ‘very lengthy conversation’ with the Registrant.

Person B
44. Person B gave evidence that at the time of his original investigation, he was in a team of 14 operations officers. He was new in the role at this point, and it was only his second or third investigation.

45. Person B confirmed he knew the Registrant personally as they had worked together as paramedics. He confirmed that the comment in his written statement about decisive choices was a compliment regarding the Registrant’s clinical ability in situations where a lack of decisiveness can be a problem. Person B also later confirmed that he had seen the Registrant display courage.

46. It was established that the Registrant would have been responsible for the clinical pathway of patients when teamed with an ECA, although the Trust encouraged collaborative thinking. There was a discussion around the linear score system for pain, and Person B confirmed that 8/10 would be very serious or severe pain. He said pain scoring was a very subjective matter, but that was a significant level for the patient recording it.

47. Person B gave his view that four answers in respect of the abdominal assessment could not be answered without a physical assessment. These were whether the abdomen was soft or rigid, whether there was rebound tenderness and whether there was a pulsatile mass. He didn’t think it would be clinically appropriate to ask a patient to self-report, but it would only be appropriate to put hands on a patient’s abdomen with their consent.

48. Person B explained that the oral morphine would have made the patient more comfortable and explained that the abdomen was a complex area. If a paramedic was not taking a patient to hospital, the paramedic should have contact with a more experienced clinician. He confirmed that the Registrant had done this.

49. Person B gave further information about the Trust guidelines for administering pain relief and that these were available to paramedics. He confirmed that the Trust guidelines were that if a patient was alone they should not be administered oral morphine without being taken to ‘definitive care’ to be supervised. It was a requirement that if alone at home then the patient should have a competent adult to look after them. His understanding was that SU A’s partner was present at the end of the assessment, but Person B stated ‘that may have been a misunderstanding on my part.’

50. In Person B’s view, there was a risk to the patient in the Registrant not carrying out a physical examination of the abdomen. An ectopic pregnancy, for example, could be life-threatening in a female patient of child-bearing age.

51. In response to Panel questions, Person B confirmed that the abdominal section on the form was completed only when entered by the practitioner, the default answers were blank.

52. Person B confirmed that specific guidance was not provided by the Trust as to the meaning of ‘guarding’ to his knowledge. There was no specific training around medicine protocols although practitioners would be aware of the existence of these and they were available at the time on the Trust’s intranet. The Registrant was authorised to prescribe analgesic medication and it was standard practice for paramedics within the Trust to carry oral morphine.

53. It could have been reasonable for the Registrant to reconsider morphine once SU A’s partner had arrived on the scene. He acknowledged that this was with the ‘benefit of hindsight after the fact and that often once a practitioner started down a course a detail changes, but the practitioner does not necessarily re-approach from the beginning because they have already started down a specific course, which was possible and an understandable scenario.’

54. Person B clarified that a pain score is for a patient to report. He said there are conflicting opinions about what to record in a patient record and often the emphasis was on ‘doing things as quickly as we reasonably can to make ourselves available for the next patient.’ He explained less experienced clinicians tend to write more, but more experienced clinicians often write less. He took the stance that it was reasonable to expect some notice given to those conditions that could have been variable, for example pregnancy.

55. Person B clarified what his exhibited handwritten notes meant, and that going out to the ambulance with a patient would be reasonable if there was something distracting a paramedic and impacting on the ability to do the job. He confirmed that, within his witness statement, he meant ‘substantiated concerns’ rather than ‘substantive concerns’ when referring to the concerns expressed by SU A in her complaint, and this was why part of the complaint was upheld.

56. When asked about a handwritten note that paperwork would be more robust if a complaint was suspected, Person B went into some detail about situations when this was likely, for example when a patient lacked capacity to consent to treatment and treatment was provided in that patient’s best interests. He said that there was a baseline standard of acceptable and accurate recording, and that the Registrant had been able to recognise this point.

57. Person B said the abdominal assessment was a fundamental concern. He reiterated that Paramedics are generalists not specialists and are expected to deal with all manner of healthcare needs, it was therefore probable that during a Paramedic’s career a mistake would be made. A Paramedic would be expected to reflect and learn from the mistake made.

58. Person B explained that his main concern was that the Registrant had misled and falsified patient records. This was because the Registrant had completed forms which stated that the abdominal assessment had been completed when it had not been. He stated that his opinion was that it was impossible to fill that section in accurately without a physical examination, but if someone was saying they thought this was achievable it felt reasonable to give them the opportunity to learn and reflect, with a set of expectations going forwards.

59. Person B stated that at the time of his investigation, he did ultimately feel that the failure to undertake an abdominal assessment physically and then record that an abdominal assessment had been completed was dishonest. During the investigation he was mindful of other factors, such as the Registrant’s fear of dogs, and at that time was inexperienced in the role so sought guidance from his seniors. He clarified that the normal approach was to identify the issue then refer to learning and development for support, but that he had also gone through a series of fundamental expectations about honesty and integrity in a professional conversation with the Registrant.

60. The Trust did not refer the matter to the HCPC because the Trust policy was not to do this when the Registrant had already self-referred, and there was a conversation with the Registrant about this. Person B confirmed that if the record had clearly stated the abdominal assessment was completed by only asking questions and with no physical examination, he would not have had a concern about honesty and integrity then.

61. In response to questions, Person B confirmed that there was no entry on the patient record for SU A about the decision around analgesia. There is a part of the form under ‘drug intervention’ which would allow a clinician to enter this. Person B said that best practice or the accepted standard of practice would be that if a clinician is not doing something that they should reasonably be doing then he would expect that to be documented.

62. Person B explained that training was given in the completion of Electronic Patient Care Record (EPCR) when the system was rolled out, which was approximately in 2017. This was a significant change in the Trust’s practice, as before this a single sheet of A3 paper was the patient care record. The new system came with a training package as it was a drastic change from the way that the Trust had worked previously.

63. Person B also explained that all clinicians would have one review shift per year with the learning and development team, which would include discussion around Trust expectations as to proper and accurate completion of patient care records. It was a fairly well accepted cultural understanding within the organisation that if you do something clinically you write it down, and if you don’t do something you are expected to do, you write it down.

64. Person B gave evidence that it was common practice for a ‘dip’ test of the clinician’s patient’s health care records to be done if a clinical concern was identified about a clinician. This was to look at a sample of the patient records completed by the clinician, usually over the last three months, to establish if this was a wider problem. It could also be used to try and support clinicians to correct the problem and to ensure that any input given had the desired effect.

65. In respect of the Registrant, Person B was clear that this was an isolated episode, or a one-off.

66. A question was asked about human factors, and what the response of the Trust had been to the Registrant’s reflective piece describing his experience of racial abuse and discrimination. Person B explained there may have been a conversation about this with the learning and development team, but he recalled that this was not considered to be a significant factor and did not believe any other actions had been taken in relation to it.

67. The Legal Assessor put the questions to Person B on the Registrant’s behalf, for the reasons outlined above.

68. Person B was asked whether, in his previous experience of working with the Registrant, he would say the Registrant was an honest person. Person B confirmed that he had no prior experiences that would have led him to doubt that prior to this incident.

69. Person B also gave evidence that he thought he was able to investigate the initial complaint against the Registrant fairly, and that he considered himself to have a good awareness of bias. He acknowledged he was comparatively inexperienced at the time he investigated, but consulted with his own line manager to ensure that things were done in the right way.

70. The Registrant explained that he was speaking English as a second language and was more fluent in his first language, Swahili. The Panel reassured the Registrant that he could take time to decide on his approach to presenting his case and would not be rushed.

LD
71. The Registrant had asked his line manager, LD, to attend as a character witness. It was established that she was a character witness firstly in respect of the fact-finding stage, although she was not a witness of fact.

72. LD gave evidence that she is currently the operations officer for Wiltshire, which covers Swindon and Malmesbury. She has line managed the Registrant since January 2021. Prior to that, she knew the Registrant from the date that he qualified. LD described the Registrant as a laid-back character who took work in his stride and was proud of the work he does. He was reliable and always had the best interests of the patient when at work. LD confirmed that in her view, the Registrant had always been reliable in terms of patient care. She considered the Registrant to be an honest person.

73. LD confirmed she had worked with the Registrant on the front line, she did not have in-depth knowledge of the allegations other than what she has seen on the HCPC website. She was not working alongside the Registrant at the time or involved in the investigation. Person B was involved and had the information and so there was no reason for her to get involved.

74. LD explained she had attended incidents with the Registrant a handful of times, 5 if that. She had based her assessment of him on how he had been very open and honest with her about his social and personal circumstances. LD also explained that the Registrant had been calm and honest in his handovers. He did a lot of work on the rapid response vehicles and worked on a car on his own. In her experience, his handover regarding clinical presentation had always been an accurate description of that patient, alongside the paperwork presented at that time.

75. LD explained it was difficult to criticise another Paramedic when she was not in the room when a Paramedic had carried out an assessment. Her practice was to ask patients similar questions to those that the Paramedic handing over had asked. If it came to light that a patient said something had not been done when it had been recorded that it had, she would raise it with that Paramedic, and with another person if she thought that there had been any dishonesty. She confirmed that if a Paramedic had said that an assessment had been conducted, she would trust that it had been done.

The Registrant
76. The Registrant gave evidence under affirmation. He explained that the incident had a significant impact on his practice. He has now been a Registrant for just over 8 years.

77. The Registrant said that in respect of the first allegation, he had questioned by verbally interrogating SU A with reference to the abdominal assessment. He did not say there was nothing he could do for her. The words used were that he would be unable to assess her while she was pacing, the secondary part of the assessment. The primary part was collating vital signs and SU A went on to discuss her past medical history.

78. The Registrant said that there was what sounded like a vicious dog, barking and scratching at a door. This was distracting for him. There were tick boxes on the questionnaire which he was completing while looking at the patient. He was afraid that the dog would break free.

79. Despite this, the Registrant believed he had dealt with SU A to the best of his ability.

80. In respect of the second Particular, the Registrant said that he had not intended to lie or mislead on the paperwork, he was working through a ‘tick box.’ His recollection was that the pacing was relieving the pain from SU A. He was also considering on-going analgesia as opposed to the ‘here and now’. He said he should have put this on the paperwork. He spoke to the out of hours’ doctor, as he thought it was his role to liaise with out of hours’ professionals who are far more capable of prescribing on-going analgesia.

81. The Registrant gave evidence that it was not his intention to cause pain or agony to SU A, especially as she was scoring a pain threshold of 8 out of 10. He completely refuted that he said there was nothing he could do, he stated there was no way would he have said that to a patient. He remembered SU A saying she could not sit down and he conducted the other observations when she was standing after he learnt about the proctectomy. It was not in his character to be dismissive.

82. The Registrant described taking pride in being a Paramedic and described himself as a very compassionate person who did not discriminate or ‘give prejudice’. He was aware of biases, and a Gestalt bias might have been with the benefit of hindsight, of women being prone to UTIs as a differential diagnosis. He thought SU A was dismissive of what he was saying because he did not meet her expectation, although he was still unclear what her expectation was.

83. The Registrant explained that as a Paramedic, he believed he discharged his duties with a lot of pride and put the service users first. Following the incident, he had significantly changed his practice. It left him thinking about how he needed to allude to service users’ pets and how pets might impact on his practice. He has ‘come on in leaps and bounds’ and realised that a patient having a pet present ‘can work to my favour.’ He spent some time around pets to try and put his fear to one side.

84. The Registrant explained it was not the first time he had worked with Person C in the presence of pets. He believed the partner of SU A arrived home the first time he was leaving the house, following a discussion about long term disease. He did not think he treated SU A or her partner in a rude or disrespectful way. He speaks English as a second language, and it has previously been vocalised by others that he might come across as a bit abrupt or blunt. The response in English may not be the way he intended it to come across.

85. In response to questions from the HCPC representative, the Registrant confirmed that it was him who completed the questions about the abdominal assessment and he completed the free text. He believed his colleague spoke first to SU A as he may have been hesitant to come in. He recalled asking questions about the proctectomy as he had not come across it prior to that. Both the Registrant and Person C asked questions. He acknowledged that he had not conducted a physical examination and had not felt SU A’s abdomen. He acknowledged that in the light of SU A’s symptoms, he should have done a physical assessment.

86. The Registrant said he did not deliberately fail to complete the physical assessment. He’d completed the primary survey and the abdominal assessment was in one tab and he had finished the primary survey. It was a subconscious decision, not a conscious decision.

87. The Registrant said that he did state that he was afraid of the dog. He strongly believes he would have said this, as he doesn’t like the sound of a dog barking and would have checked SU A had put it away.

88. The Registrant acknowledged it was a very valid point that he could have moved the patient into the ambulance. He had arranged the GP appointment. He described a situation in the NHS of ‘hospitals flooding’ and that the message of the day was to consider an alternative pathway. He explained that he always considered ‘can I use an alternative pathway’. SU A’s partner would have taken her to the GP, he recalled SU A’s partner had been spoken to and was on her way, so if she was to pass out, an adult would be with her. This was a contributing factor for the alternative pathway, as well as the plan for ongoing analgesia.

89. The Registrant accepted that some of the boxes required a physical assessment to complete. He agreed the question of ‘rebound tenderness’ required a physical assessment and that this was a false record. This was not his intention when completing the box. He accepted that the record he made was not right.

90. The Registrant confirmed that he did not provide pain relief, if he had, it would have been recorded. SU A had already had some analgesia. The record showed 1 gram of Paracetamol, orally. The plan was for the out of hours GP to provide ongoing pain relief.

91. The Registrant confirmed he did not recall saying there was nothing he could do. He may have said unable to assess but at no point did he say, ‘I can’t help you.’ He does not remember whether he requested the Registrant to stop pacing so he could examine her. He disputed that he dismissed SU A’s concerns. She dismissed his concerns about the dog scratching the door which was ajar and he thought the dog might come through the door. With hindsight, the Registrant acknowledged that the situation could have been avoided if he had continued to have the conversation with SU A in the ambulance.

92. In response to questions from the Panel, the Registrant confirmed that it was him who completed the questions about the abdominal assessment on the patient record. He clarified that he does not recall saying that there was nothing he could do, and that at no point did he say that he could not help SU A. If he said anything, it was that he couldn’t assess SU A while she was pacing. He did not ask SU A to stop pacing so he could examine her, or at least he did not remember having the conversation with her. He described the meaning of abdominal assessment as ‘everything that entails about the abdominal, the functions, the physical, how the system, function inside the abdomen – quite comprehensive.’

93. The Registrant confirmed that the worsening advice given was always that if further intervention is required 999 can be called.

94. The Registrant reiterated that he completed the paperwork as part of the job ‘more of an autopilot tick box’ for example ‘are they guarding, ‘no’ tick the box and come off it’. The other tabs were specific to, for example urinary, the colour of the patient – then going on to other subsystems for example the nervous systems or the cardiovascular system. He explained he had only ticked the box for the abdominal assessment as ‘in my head I knew it needed to be completed, holding a pen, tap and carried on tapping.’

95. The Registrant described the differentials that he considered included bowel blockage and UTI, and that women are more prone to UTIs than men. SU A had Paracetamol an hour or so before, and he had made her an urgent out of hours’ appointment. The therapeutic value of paracetamol had not quite been achieved to the maximum. The Registrant thought this was a good outcome for the patient, as it was avoiding an ED admission. He had written on the paperwork that there was an ‘extensive conversation’ with the GP but could not recall exactly what was said due to the time elapsed. He recalled the GP had said they can do urinalysis in out of hours.

96. The Registrant described feeling reassured about the Trust embracing body worn cameras, as this can have a significant effect on the way some-one responds to him. He has also embraced lowering his tone, letting the patient speak more, wait rather than asking, and asking more open questions, rather than closed or leading questions.

97. The Registrant disputed that he was dismissive of SU A and said this was not in his character – it was possibly the subject of misinterpretation. He gave examples as to how this might have occurred.

98. When asked about the door being ajar, the Registrant acknowledged that he could not quite remember if the door was ajar or closed but did remember it felt like a significant threat, with the door handle moving. He clearly remembered the barking and scratching and the threat of the dog coming through the door. At no point did moving SU to the ambulance
cross his mind, with hindsight this would have been ‘an absolute win win case.’

99. The Registrant described that the patient remained standing for her blood pressure to be taken. He does not think he considered giving a painkiller to help with a physical examination – he stated that if he gave analgesia, it would not have worked straight away. The most immediate analgesia would have been Entonox, which SU A could not have. He did not remember SU A stating that she experienced pain silently but did remember her saying that pacing relieves the pain. He was concerned about her level of pain. If he had planned to take SU A to hospital, the only option was morphine, but he did not want to take away the prospect of stronger analgesia being provided by the out of hours GP.

100. The Registrant explained that pain is subjective and that verbal reassurance can have a therapeutic value to some forms of pain – he believes he offered that to SU A. He used the Abbey pain score to present a picture of how SU A was presenting to him, of ‘trying to write what I’m seeing, it helps to put on the record what I’m seeing.’

101. The Registrant described how when SU A gave evidence he felt she was magnifying how she described her pain to him previously. He could not remember if he considered pregnancy as a differential but agreed it was an important consideration. He confirmed that in hindsight, a composed environment would have assisted him to write up everything, and best practice or good practice is to have everything documented. It was three years ago, and it was a complex situation. The Registrant reiterated and clarified about his fear of dogs and explained that she (SU A) felt he was dismissive of her, in the same way that he felt she was dismissive about his concerns about the dog. He clarified issues relating to his private life in the context of this being proximate to the date of the alleged events.

102. The Registrant explained that sometimes he can be blunt, but he did not mean to be rude or impolite in the way he speaks or asks questions. He could not remember writing on the patient record that SU A was nauseated and clarified that some of the history of the presenting condition could have been completed by his colleague. He did not doubt that SU A was in severe pain. He described that when on a call, he would not necessarily realise the amount of time he had been there, and repeated that he had not intended to give a false impression on the completion of the patient record.

103. The HCPC Representative had prepared a list of written bullet points that would constitute her oral submissions, and this was provided to the Registrant. The Panel heard submissions from the HCPC first. The HCPC invited the Panel to disregard any hearsay evidence that had inadvertently been referred to by the witnesses and set out the HCPC’s case. The HCPC submissions confirmed the test for dishonesty as set out in Ivey v Genting Casinos (2018) 2 All ER 406 and invited the Panel to find dishonesty in Particular 5. The Registrant was then given further time to consider both the oral submissions and the written submissions. The Panel ensured that the Registrant was not under pressure and had sufficient time to do this. The HCPC submitted that the Panel should not put much weight, if any, on the evidence of LR as she was not a witness of fact and had only become the Registrant’s line manager after the date of the allegations.

104. The Registrant made submissions to the Panel, including reminding the Panel of her chronic condition, and that any other diagnosis would have been the subject of further investigation. His view was that the out of hours GP appointment was a deliberate effort to achieve the best for the patient in line with the Trust policy. In terms of dishonesty, he did not consider himself to be a dishonest person, this is not something he takes lightly in his practice and he would not have created a record deliberately to be misleading.

105. The hearing had initially been listed for 5 days, but during a conversation with the Hearing’s Officer, the Registrant explained he had mistakenly thought it was listed for 4 days and would not be available until the afternoon of the next day. A conversation took place between the Legal Assessor, the Representative for the HCPC and the Registrant. It was explained to the Registrant that the next stage of the proceedings was for the Panel to hear legal advice from the Legal Assessor, before making their decision. The Registrant wanted the matter to proceed and conclude, and in these circumstances consented to the proceedings continuing in his absence for the legal advice stage only. The Legal Assessor agreed to provide him with the written note of legal advice and explained the limitations of this.
Proceeding in Absence (Legal Advice only).

106. The HCPC applied for the hearing to proceed in the absence of the Registrant for this element of the proceedings only. The Panel heard and accepted the advice of the Legal Assessor and retired to consider its decision. The Panel determined to proceed in the Registrant’s absence for this aspect of the proceedings only, as the Registrant had voluntarily absented himself having taken a pragmatic approach. It was in his interests as well as the interests of the public for the proceedings to conclude as swiftly as practicable. His absence was for a limited part of the hearing, he had given evidence and there was no disadvantage to him. The Panel took the view that the Registrant had made a fully informed decision to waive his right to attend this part of the proceedings. It confirmed the intention was for the Registrant to be present at the time the decision was handed down.

Legal Advice.

107. The Panel heard advice from the Legal Assessor. This included standard advice as to the burden of proof, the approach to decision making and reference to the relevant HCPTS practice notes. The Legal Assessor provided specific legal advice about assessing evidence and witness believability, and summarised material from the cases of Byrne GMC (2022) EWHC 2237 (Admin), R (Dutta) v GMC (2020) EWHC and R v Khan (2021) EWHC 374 (Admin). Legal advice was provided as to how the Panel should approach assessing dishonesty, with reference to the test set out in Ivey v Genting Casinos (2018) 2 All ER 406 (Ivey). The Legal Assessor also set out principles from the case law, including from the cases of R v Barton and Booth (2020) EWCA Crim 575, Ali V SRA LTD (2021) EWHC 2709 (Admin), Lawrence v GMC [2015] EWHC 86 Admin., Ahmedsowidau v GMC (2021) EWHC 3466 (Admin) and Maxfield –Martin v SRA (2022) EWHC 307 (Admin).

108. Legal advice was provided as to the Registrant’s good character, and the guidance in the case of Sawati v GMC (2022) EWHC (283) Admin set out. The Legal Assessor drew the Panel’s attention to Section 9 of the Equality Act 2010 and provided further guidance to the Panel in relation to the evidence it had heard as to the Registrant’s first and second language.
Decision on Facts
Particular 1:
On 17 January 2020, you did not conduct an abdominal assessment of the Service User when you should have done so.
Admitted and found proved.

109. The Panel accepted the evidence of the witnesses Person C, and Person B that an abdominal assessment involved a physical examination. This would involve touching the patient’s abdomen. The Registrant also conceded this point. The EPCR questions in respect of the abdominal assessment required answers to specific questions, for example whether there was rebound tenderness. The Registrant accepted in his oral evidence that a physical abdominal assessment should have been done.

110. The Panel found that the HCPC had discharged the burden of proof and that an abdominal assessment must include a physical examination. This particular of the Allegation was found proved.
Particular 2:
On 17 January 2020, you falsely recorded that you had conducted an abdominal assessment of the Service User.
Admitted and found proved.

111. The Registrant admitted this Particular at the outset, but the Panel still examined the evidence presented by the HCPC carefully. The Panel found that there had been no abdominal assessment. The documentary evidence of the EPCR confirmed that an abdominal assessment had been completed. Person C gave evidence that the Registrant had completed this part of the paperwork. The Registrant in his own evidence acknowledged that the abdominal assessment section of the EPCR had been completed by him. As an abdominal assessment had not been completed, the Panel found that the record that it had been so completed was false. The Panel therefore found this particular of the Allegation proved.
Particular 3:
On 17 January 2020, you did not offer and/or provide analgesia medication despite recording the Service User’s pain score as 8.
Admitted and found proved.

112. The Panel found that the ECPR that had been exhibited as part of the documentary evidence in this case was correct. It was contemporaneous written evidence as to what had been recorded at the date of the Allegation and confirmed that pain relief had not been offered or provided. SU A had also confirmed this in oral evidence and in her written statement. A pain score of 8 out of 10 was clearly recorded on the EPCR.

113. The Registrant confirmed in oral evidence that if analgesia had been provided to SU A it would have been recorded. He accepted that SU A’s pain score was accurately recorded. At this stage, the Panel were only considering whether analgesia had been offered or provided and not the reasons as to why it had not been. The Panel found this Particular proved.
Particular 4 (a)
On 17 January 2020, you did not communicate professionally with the Service User and/or present with a professional attitude towards the Service User. In that: On arrival you advised the Service User there was nothing you could do because the Service User was pacing around.
The Registrant maintained a neutral position in respect of this allegation.
Found not proved.

114. The Panel considered the written and oral evidence it had heard on this point. It accepted the position of all witnesses, including the Registrant, that communication between the Registrant and SU A was difficult. The Panel was mindful that the Registrant had undertaken a series of actions and other elements of patient care, for example taking SU A’s blood pressure and making a referral to the out of hours GP. It bore in mind that the allegation related to an incident that occurred several years ago, and that witnesses’ memories are fluid and malleable. The Registrant consistently maintained that what he had said was that he could not conduct an assessment whilst SU A was pacing rather than saying there was nothing he can do. Therefore, the Panel found that it was more likely than not that the Registrant did not say the words alleged in this Particular. The Panel found this allegation not proved.
Particular 4 (b)
On 17 January 2020, you did not communicate professionally with the Service User and/or present with a professional attitude towards the Service User. In that: You were dismissive of the Service User’s presenting symptoms.
Denied and found proved.

115. The Panel acknowledged that the Registrant had taken a note of SU A’s medical history, including her complex history of her chronic illness. It acknowledged that the Registrant had spent time talking with SU A and made a referral to the out of hours’ service.

116. The Panel found that the primary presenting symptom for SU A and the reason that she had telephoned 111 for medical assistance was that she was in severe pain. SU A gave oral evidence that, on this occasion, she was unable to get her pain under control, and that it was ‘serious and specific’ for her. Her written statement confirmed that the Registrant appeared not to acknowledge her view that the pain was distinct from a UTI pain she had suffered previously. The Panel accepted that SU A had informed the Registrant and Person C that the pain was even worse than the pain of her previous surgery.

117. The Panel also took account of the written and oral testimony from Person C, who had concluded at the time that the Registrant was not listening to the information SU A was giving about her symptoms.

118. The Panel paid careful attention to the wording of the Particular, in that it was worded to reflect the Registrant’s presenting attitude to SU A’s presenting symptoms at that time. It considered the meaning of the word ‘dismissive’ and acknowledged the focus given to a UTI above other considerations, including the oral information given to the Registrant by SU A about this being a different type of pain from pain that she had previously experienced. Taking all of the evidence it had read and heard into account, the Panel concluded that the HCPC had made out the burden of proof for this Particular. The Panel found this Allegation proved.
Particular 5: Your conduct in relation to Particular 2 was dishonest.
Denied and found not proved.

119. The Panel started from the position that it was accepted by the Registrant that he had created a false record of SU A’s abdominal assessment. This accorded with the evidence it had read and heard, and the findings it had made so far.

120. The Panel had regard to the HCPTS practice note ‘Making decisions on a Registrant’s state of mind’ dated November 2022 and the legal advice it had received. It considered the first stage of the test for dishonesty in the case of ‘Ivey.’

121. The Panel found as a fact that there was a dog in SU A’s house and that the dog was barking and scratching at a door. It accepted the Registrant’s evidence that he was distracted and afraid of the dog. The Panel noted that the Registrant was a man of good character. It noted that two witnesses appearing for the HCPC, Person B and Person C, gave evidence that they did not consider the Registrant to be a dishonest person. Person B’s evidence was that he had never had cause to doubt the Registrant’s honesty apart from this one-off incident.

122. The Panel found that the Registrant’s inaccurate completion of SU A’s patient records was reprehensible. This could clearly have misled other medical professionals and could have had serious consequences for SU A. However, the Panel found that something could be reprehensible and misleading without being created dishonestly. It applied the test in Ivey and took into account the Registrant’s state of mind at the time of the completion of the record. It noted that the HCPC had not put forward any motive for the Registrant’s dishonesty as to why he would have chosen to deliberately falsify SU A’s patient record.

123. The Panel weighed the evidence carefully. It was mindful that the Registrant did not have to prove anything or disprove anything, and that the burden of proof was with the HCPC. Where there is doubt, it should be resolved in the favour of the Registrant. It found that the HCPC had not provided objective and cogent evidence to support the allegation of dishonesty.

124. Accordingly, the Panel found Particular 5 was not proved.

Decision on Grounds
Reconvened Hearing – 18 March 2024
125. The Registrant applied for an adjournment. Due to the nature of the request, the HCPC applied for this to be heard in private, which the Registrant supported.

126. The Panel heard legal advice and agreed to hear the application to adjourn in private, in order to protect the private life of the Registrant.

127. The Registrant explained that the adjourned hearing had not been at the front of his mind. He had looked at his calendar and saw he had booked annual leave for this week and would be a convenient time to travel. The Registrant had forgotten that this was the purpose of the pre-booked annual leave. He was reminded of the hearing last week when the HCPC emailed him and he replied to the HCPC at that stage.

128. In his submissions, the Registrant said he thought he had booked the flight in mid-February. There was a date of 4 March on the flight documentation, and in response to a question the Registrant confirmed it may have been on that date that he booked it.

129. Having heard from the Registrant and considered the evidence produced, the HCPC representative took a neutral approach to the application. She submitted that there had been one previous adjournment of a final hearing due to the childcare commitments of the Registrant, and that on the second occasion this hearing had adjourned part-heard. The HCPC representative drew the Panel’s attention to practice note ‘Postponement and Adjournment’s of proceedings’ (dated June 2022).

130. The Panel heard advice from the Legal Assessor as to the guidance and the relevant issues they should take into account as set out in the case law.

Decision on Adjournment.

131. The Panel were concerned that the Registrant had not been in contact with the HCPC about his trip to Kenya or his mother’s health before last week despite the Registrant booking the tickets at least two weeks prior to the hearing date. The hearing notice had been sent to him on 22 November 2023 and the first contact from him had been on 14 March 2024.

132. The Registrant had told the Panel that he had forgotten about the hearing when he had booked his flight, and forgotten that his annual leave was booked for this purpose. The Panel found that it is the Registrant’s responsibility to engage with the Regulator in respect of the conclusion of the hearing.

133. The Panel noted that there was no evidence that this was a medical emergency in respect of the Registrant’s mother. It noted that the Registrant was distressed when talking about how he had not seen his mother for 3 years, and felt sympathetic to his predicament. However, the Registrant did have other options available to him, for example travelling to Kenya for one week rather than two in order to engage with the hearing.

134. It was acknowledged by the Panel that the Registrant could be seriously disadvantaged by not being in attendance at the hearing, particularly when it came to considering whether his fitness to practice was currently impaired. However, findings of fact had been made, and the matter needed to be concluded expeditiously. The Panel considered its own availability and noted that any adjournment was likely to be for between 3 months and 9 months as a minimum. Although there was potentially a significant disadvantage to the Registrant in not allowing the adjournment, the Panel took the view that the Registrant had put the hearing out of his mind. He had chosen not to do the things that would have mitigated the disadvantage to him and booked a flight to Kenya when he should have been aware that he was required to attend this hearing. The Registrant had chosen not to contact the HCPC and discuss his concerns about his mother’s health and his possible need to travel to see her at any time, having not had contact with the HCPC since 24 November 2023.

135. The Panel was mindful that blame could not be attached to the Registrant for the two previous adjournments. However, proceedings still needed to be concluded expeditiously. It weighed up the disadvantage to the Registrant in not allowing the adjournment but concluded that there was a public interest in proceeding with the matter, given the length of time already taken in terms of time scale and the public interest in proceeding. The Panel therefore determined not to allow the Registrant’s application for an adjournment.

Service and Application to Proceed in Absence.

136. The HCPC indicated that there would be an application to proceed in the Registrant’s absence. Accordingly, it was necessary for the Panel to determine if good service had taken place. The Panel considered the documentation provided by the HCPC and received legal advice. It determined that the notice of hearing had been properly served on the Registrant by email to his Registered address, and that he had been given sufficient notice in accordance with the Rules. The Panel noted that the Registrant had attended briefly and had not raised any issues about the service of the documents.

137. The HCPC applied to proceed in the Registrant’s absence under Rule 11. It drew the attention of the Panel to the relevant HCPTS Practice note, ‘Proceeding in the Absence of the Registrant’. It was submitted that the Registrant was aware of the hearing and that there was a general public interest in expeditious disposal of the proceedings. It was important to note that the Allegation dated from January 2020. The evidence as to the facts stage had been heard in November 2023 having first been listed in August 2023.

138. The HCPC submitted that the Registrant had voluntarily absented himself, as he was aware that his application to adjourn might be refused. It was submitted that although he might attend at a later date, this could lead to considerable delay. The Panel were invited to weigh the disadvantage to the Registrant in proceeding in his absence. The HCPC submitted that there was sufficient time for the Registrant to be emailed at each stage of the proceedings, and invited to provide written representations. There could be a pause between each stage of the proceedings to allow for this. This suggestion would mitigate the disadvantage to the Registrant. The HCPC submitted that it was fair in all the circumstances to proceed.

139. The Legal Assessor provided legal advice and directed the Panel to the ‘Proceeding in the Absence of the Registrant’ HCPTS Practice Note dated June 2022. Principles from the cases of GMC v Adeogba (2016) EWCA Civ1 62, Ramaswamy v GMC (2021) EWHC (1619) (Admin), GMC v Visvardis (2004) EWCA Civ 162 and R v Jones (Anthony William) HL 20 Feb 2002 were summarised for the Panel.

Decision – Proceeding in Absence
140. The Panel determined that it was in the public interest to continue given the time that had so far been taken to resolve the Allegation. It noted that there was a disadvantage to the Registrant in proceeding. However, the Panel had already heard evidence relevant to the Registrant’s character and work, as well as having heard his own evidence in response to questions and seen a number of reflective documents that the Registrant had written. This, together with the suggestion to pause at each stage of the proceedings, could mitigate some of the disadvantage to him.

141. The Panel acknowledged that if they chose not to proceed, the Registrant was likely to try his best to attend at a later date. It also noted that the choice he had made to visit his mother in Kenya during the week of the hearing did generate a degree of sympathy. However, the Registrant had an obligation to engage with his Regulator. He was aware that his application for an adjournment may not be granted. The Panel found his non-attendance was a choice and that he had voluntarily absented himself.

142. The Allegation was already 4 years old and the Panel considered that the public interest in concluding the matter expeditiously outweighed the disadvantage to the Registrant of proceeding in his absence. It had already noted the length of time an adjournment might take and that feasibly the Registrant as well as the Panel could have professional or other commitments which would lead to even more delay.

143. The Panel accepted the HCPC submission that pausing at each stage of the proceedings could further mitigate the disadvantage to the Registrant. He would be able to provide written submissions or potentially even attend later in the week, depending upon his mother’s health and his internet access.

144. Having carefully weighed the competing factors, the Panel determined to proceed in the Registrant’s absence.

145. The HCPC emailed the Registrant with a copy of the Panel’s decision and some guidance as to the next stage of the proceedings, to provide a further opportunity for him to make submissions. The misconduct stage of proceedings began at 10am on 20 March 2024.
HCPC Submissions.

146. The HCPC submitted that the statutory ground of misconduct was made out in relation to all of the particulars that the Panel had made findings on. It was submitted that this was a matter for the Panel’s professional judgement, and there was no burden or standard of proof. The Panel were directed to the HCPC Standards of Conduct, Performance and Ethics from 2016 (the Standards), and it was put forward that Standards 1.1, 2.1, 2.2, 6.1, 9.1 and 10.1 had been breached.

147. The HCPC put forward that for misconduct to be found, the acts or omissions must be serious. Single negligent acts are unlikely to meet the threshold. It was submitted that the failure to conduct an abdominal assessment when warranted amounted to misconduct, and this was compounded by false recording. Failure to conduct the abdominal assessment could have led to a risk of serious harm. Accurate clinical records are of utmost importance. The false record could have misled other professionals and put SU A at risk.

148. It was submitted by the HCPC that analgesia should have been offered to SU A. Although Person B had said that overall, the care plan was appropriate, it was also stated by Person B that analgesia should have been and could have been provided in the meantime. Oral morphine was available as long as SU A was left with a competent adult, and SU A’s partner had arrived home before the Registrant left. The HCPC submitted that the Registrant’s explanation of paracetamol not having reached its full therapeutic value was not accepted. SU A was in a considerable level of pain and verbal reassurance was unlikely to address this.

149. Finally, the HCPC submitted that there was a failure to communicate professionally because the Registrant was dismissive and this constituted misconduct. SU A had stated her pain was not likely to be a UTI due to its location. There were negative consequences for failing to communicate with service users professionally and appropriately and this could have presented an unnecessary risk. The HCPC submitted that the conduct found proved falls far below reasonable conduct for a Paramedic and that each of the particulars found proved amounted to misconduct.

150. The Panel heard independent legal advice. It was reminded that there is no burden or standard of proof in respect of misconduct and that this is a matter for the Panel’s own judgement. The Legal Assessor took the Panel through the case law, which emphasises the need for the conduct to fall far below that which is reasonable to constitute misconduct. The misconduct must be serious and more than negligence to be characterised as professional misconduct.

The Panel’s Decision.

151. The Panel considered each of the Particulars in turn.
Particular 1:
On 17 January 2020, you did not conduct an abdominal assessment of the Service User when you should have done so.

152. The Panel found this omission fell short of what would be expected in the circumstances and was serious. It considered ‘hindsight bias’ in relation to the condition that SU A was later diagnosed as suffering from, and noted that the out of hours GP had not been able to confirm the diagnosis of this. The Panel found that a qualified Paramedic should have conducted the physical abdominal assessment as this was a basic and fundamental element of the assessment that needed to take place given SU A’s presenting symptoms. This would identify any potentially concerning signs for example if there was guarding or a pulsatile mass. The risk of failing to conduct this assessment was serious and could have been life threatening, for example in the case of ectopic pregnancy.

153. The Panel found that this was an omission and not a considered act. It was not the case that the Registrant chose not to do it for valid reasons (for example, lack of consent) and recorded it as such. If there are practical barriers to carrying out such an assessment, there would be an expectation on a Paramedic to take reasonable steps to discuss and overcome those. The Registrant had accepted in his evidence that he should have carried out a physical examination.

154. Given these considerations, the Panel found that this was more than negligence and that the Registrant’s failing was serious to the extent that this constituted misconduct.
Particular 2:
On 17 January 2020, you falsely recorded that you had conducted an abdominal assessment of the Service User.

155. The HCPC Professional standards set out the expectation that clinical records will be accurate, clear and comprehensive. The Registrant had to take active steps to create the record. The Panel found that a false record could pose a high risk to patients in their future care. A false record could mislead other professionals at a later stage in treatment. The Registrant should have been taking care with what he was doing, and ensuring that the record of the care provided an accurate clinical picture of SU A both for the record and for other health professionals. Inaccurately recording that an abdominal assessment had taken place could create a false reassurance for other professionals involved in treatment and put a patient at risk.

156. The Panel found that this Particular therefore also constituted misconduct.
Particular 3:
On 17 January 2020, you did not offer and/or provide analgesia medication despite recording the Service User’s pain score as 8.

157. The Panel noted that the role of Paramedic is not just to save lives, but also to reduce suffering. It took the view that the Registrant had worked out a different pain score mechanism and decided that SU A’s pain score was not 8/10.

158. The Panel found that it was unlikely that any further therapeutic benefit would have been gained by SU A from the paracetamol she had taken 2 hours previously, and that the Registrant should have been aware of this. Although an out of hours GP appointment was offered, the Registrant left SU A without pain relief for several hours when she was describing severe pain for which she had called 111 which resulted in an ambulance being sent.

159. It was fully acknowledged by the Panel that there were clinical reasons as to why morphine was the only option available to give to SU A. It found that there should have been a further discussion around the provision of morphine. Even if there was no adult in the house at the time the referral to the GP out of hours’ service was made, a discussion should have been had as to other ways to provide this analgesia to SU A. Options included the Paramedics waiting for SU A’s partner to return home (which happened before they left the premises) or conveying SU A to hospital. The Panel found that pain score is subjective and that the Registrant should have accepted what SU A was telling him and progressed her treatment accordingly, which should have included pain relief.

160. Accordingly, the Panel found that this went beyond mere negligence and constituted misconduct.
Particular 4b:
On 17 January 2020, you did not communicate professionally with the Service User and/or present with a professional attitude towards the Service User. In that: You were dismissive of the Service User’s presenting symptoms.

161. The Panel found that the presenting symptom was severe pain. The Registrant was dismissive of this because he did not believe the pain score was 8/10.

162. The Panel concluded that this dismissive communication created a risk in the decision-making process, given that the Registrant was the lead clinician. It created a clear risk of going down the wrong path in terms of treating the clinical symptoms.

163. The Panel found that SU A was competent, coherent and able to convey her own clinical information to the Registrant. She was not aggressive or abusive to the Registrant in any way, and was just endeavouring to explain severe pain. There was a significant failure on the part of the Registrant to listen and a dismissal of what SU A was likely to be telling the Registrant.

164. It was the decision of the Panel that on this occasion, the failure to communicate professionally did constitute misconduct. Professional communication includes effective listening. This failure had the effect of undermining SU A’s confidence in the ambulance service and her evidence was that this had impacted her decision-making around contacting ambulance services. This was not only detrimental to SU A, but could have a wider impact on the profession if other members of the public came to learn about it.

165. The Panel found that this Particular therefore also constituted misconduct.

166. Throughout its decision-making process, the Panel had regard to the Standards.

It found the following Standards had been breached:
1.Promote and protect the interests of service users and carers.
Treat service users and carers with respect.
1.1 You must treat service users and carers as individuals, respecting their privacy and dignity.
2. Communicate appropriately and effectively.
Communicate with service users and carers.
2.1 You must be polite and considerate.
2.2 You must listen to service users and carers and take account of their needs and wishes.
6. Manage risk.
Identify and minimise risk.
6.1 You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.
6.2 You must not do anything, or allow some-one else to do anything, which could put the health or safety of a service user, carer or colleague at unacceptable risk.
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.
10. Keep records of your work.
Keep accurate records.
10.1 You must keep full, clear and accurate records of everyone you care for, treat or provide other services to.

167. The HCPC emailed the Registrant with a copy of the Panel’s decision and some guidance as to the next stage of the proceedings, to provide a further opportunity for him to make submissions. The impairment stage of proceedings began at 11am on 21 March 2024.

Decision on Impairment
HCPC Submissions
168. The HCPC directed the Panel to the relevant practice note. It was submitted that impairment of fitness to practice was a matter for the Panel’s professional judgement, with no burden or standard of proof. The question was whether the Registrant was fit to practice without restriction today and in the future.

169. The HCPC referred to the test set out in the case of Cohen – and indicated the Panel should consider whether the conduct was easily remediable, whether it had been remedied and whether it was highly unlikely to be repeated.

170. It was submitted by the HCPC that all of the misconduct related to practice concerns and this was capable of remediation. Person B had reviewed other patients’ records and there were no other issues raised with the Registrant’s practice that had come to the attention of the Regulator.

171. It was also submitted that the Panel had seen no evidence of specific training or insight, reflection on the specific particulars found proved or evidence of remorse. It was submitted that the Registrant had demonstrated some insight by admitting a number of allegations at the outset of the hearing in November 2023. False recording was admitted, but there was no evidence of specific insight into those matters. It was submitted that although there was no proved dishonesty, the Panel could find the misconduct put patients at risk of harm.

172. The HCPC directed the Panel to the relevant case law. It was submitted that the Registrant had not demonstrated fully developed and complete insight, and was still impaired on the personal component.

173. The HCPC further submitted that a finding of impairment of fitness to practise in respect of the public component was required in order to uphold proper professional standards.

174. The Panel received independent legal advice. The Legal Assessor drew its attention to the practice note ‘Fitness to Practice Impairment’ dated November 2023. She summarised the key findings that the Panel should make, and explained both the personal and public component of impairment with reference to the relevant case law, including the cases of
CHRE V NMC (and Grant) (2011) EWHC 97 (Admin) and Cohen v GMC (2008) EWHC 158 (Admin.).

Panel’s decision – Impairment of Fitness to Practice.
Personal Component.

175. The Panel found as a starting point that the concerns raised were remediable. It noted that the Registrant had provided oral evidence that he had significantly changed his practice since the incident in terms of the way he communicated.

176. The Panel acknowledged Person B’s evidence that this was a one-off incident. It accepted the Registrant’s evidence that it had occurred at a time of immense personal stress and upset for him, due to issues in his private life at that time. It accepted that the Registrant had a fear of dogs which had potentially impacted his behaviour, his thinking and his clinical practice on this occasion. The Panel acknowledged the Registrant’s evidence as to the efforts he had made to combat this. The Panel noted that, when prompted, the Registrant fully admitted in his evidence that he should have thought of other ways of dealing with the situation, for example taking SU A into the back of the ambulance.

177. It remained a concern of the Panel that the Registrant lacked insight into the way in which his failings had impacted SU A, (or expressed remorse) and the impact of these failings on the reputation of the wider profession. The Panel accepted the HCPC’s submissions that the documentation submitted by the Registrant at an earlier stage in the proceedings did not demonstrate insight into the specific failings and findings that the Panel had made. The Panel acknowledged that the Registrant had not submitted any evidence of targeted CPD points, for example around conducting and documenting abdominal assessments.

178. The Panel found that the Registrant had fully co-operated with the initial, limited restrictions initially placed on him by the Trust and with the internal investigation by the Trust. He had done everything that the Trust had asked him to do. The Panel also noted that there was some positive evidence provided by Person B and person LD about the Registrant. Person B said that the Registrant was a competent clinician, who took decisive action in emergency clinical decision-making situations. LD, who was the Registrant’s line manager in November 2023 and had been since 2021, said that the Registrant was reliable and always had the best interests of the patient when at work.

179. It was noted by the Panel that the Registrant was a man of good character and that there were no previous regulatory findings against him. He had been in unrestricted practice as a Paramedic for four years since the time of the Allegation and no concerns had been raised by the Trust in that time. The Panel also noted that the Registrant had made admissions to the majority of the particulars that were found proved.

180. Despite a lack of evidence that the Registrant had developed insight into the misconduct and its potential impact, the Panel had to weigh this with the evidence that the incident was a one-off, that the Registrant was in difficult personal circumstances at the time and that the Trust continued to put faith in his ability as a Paramedic to the extent that he had now worked unrestricted for four years. The Panel was very clear that in any case in which full insight had not yet developed there remained some risk of repetition. However, given all the circumstances and facts of this particular case, the Panel found that the risk of repetition was low.

181. The Panel was mindful that its task was to determine the Registrant’s current fitness to practise rather than judge his past behaviour. It therefore concluded that the Registrant’s fitness to practise was currently not impaired on the personal component.

Public Component.

182. The Panel found that the Registrant had put SU A at unwarranted risk of harm. He had failed to complete an abdominal assessment, and falsely recorded that he had done so. Further, the Panel found that he failed to communicate effectively with or provide analgesia to SU A, all of which constituted misconduct. This had brought the profession into disrepute.

183. The Panel determined that in failing to alleviate the suffering of SU A and accurately complete documentation, the Registrant had breached fundamental tenets of the profession. Although there had only been one incident in the Registrant’s career as a Paramedic, this incident encompassed multiple failings. The conducting of basic abdominal assessments, accurate clinical record keeping, effective communication and an understanding of when analgesia should be provided are all things which the public would expect of a Paramedic.

184. An ordinary member of the public, fully informed of all the facts, would be concerned if a finding of impairment of fitness to practice were not made. The public confidence in both the profession and the Regulator would be undermined without such a finding.

185. The Panel therefore determined that the Registrant’s fitness to practice was impaired on the public component.

186. The HCPC emailed the Registrant with a copy of the Panel’s decision and some guidance as to the next stage of the proceedings (Sanction), to provide a further opportunity for him to make submissions. The Sanction stage of proceedings began at 10am on 22 March 2024.

Decision on Sanction
HCPC Submissions.

187. The HCPC submitted that sanction must be proportionate. Paragraph 21 of the Sanctions Guidance reminds the Panel not to be punitive and that it should only take the minimum sanction necessary.

188. It was submitted by the HCPC that the mitigating factors in this case were that there had been no previous regulatory findings, that there had been no known repetition and that this was an isolated incident. The aggravating factors included the lack of fully developed insight, remorse and apology, a lack of remediation and the potential for service user harm.

189. The HCPC took the Panel through elements of the Sanctions Guidance and submitted that a Caution Order may be appropriate, explained what should be considered before the Panel could impose Conditions of Practice and highlighted the relevant factors to consider in respect of a Suspension Order. It was made clear by the HCPC that a Striking Off Order was not deemed necessary in this case.

190. The Legal Assessor also referred the Panel to the HCPC Sanctions Guidance Policy dated March 2019 (the Guidance). She advised that as the Panel had made no finding of dishonesty, the case did not fall within the ‘Serious Cases’ referred to in pages 16-23 of the Guidance. The Legal Assessor clarified the meaning of proportionality and gave some further legal guidance from case law (Bank Mellat (Appellant) v Her Majesty’s Treasury (Respondent) (No 2) (2013) UKSC 39) in relation to proportionality only.

Aggravating and mitigating factors.

191. The Panel found the following mitigating factors:
• The Registrant had admitted the majority of the Particulars;
• The Registrant had complied with what the Trust had asked of him in terms of remediation;
• This was an isolated, one-off episode of misconduct;
• There was no previous regulatory finding or findings against the Registrant;
• The presence of a barking dog had created difficulties for the Registrant at the time of the Allegation;
• The Registrant was impacted by difficult personal circumstances at the time of the Allegation, which were unique to that immediate period of time.

192. The Panel found the following aggravating factors.
• The lack of apology or remorse to SU A;
• Limited remediation for the purposes of regulatory proceedings
• The potential for harm to SU A
• Lack of fully developed insight

193. The Panel was aware that the Guidance is just that, and that it was able to depart from it in accordance with its own judgement if there were reasons for doing so.

194. In accordance with the Guidance, the Panel started with the least restrictive sanction. It found that Mediation was not appropriate and would not meet the Panel’s express concern.

195. It also found that taking No Action would not satisfy the public interest or the deterrent effect of a Sanction, given the finding that the Registrant’s fitness to practice was impaired on the Public Component.

196. The Panel next moved on to consider a Caution Order. It had found the risk of repetition to be low and that the Registrant had undertaken some remediation in accordance with what the Trust had asked of him. It noted that a sanction was not imposed to be punitive and should be the least restrictive option to satisfy both the interests of the public and the purposes of the regulator. It noted the mitigation present in this case, and that the Panel’s role was not to punish for past misconduct.

197. The Panel remained mindful that it had found the Registrant to not have full insight. It therefore considered a Conditions of Practice Order. It noted that the Allegation related to one incident in an 8-year career. It had heard testimonial evidence as to the Registrant’s competent clinical practice. The Panel was mindful that it had not found the Registrant to be impaired on the Personal Component.

198. Accordingly, the Panel found that nothing could be gained from imposing a Conditions of Practice Order. The Registrant had co-operated fully with the suggestions of the Trust, and there were no gaps in his current clinical practice that could be addressed by Conditions of Practice. There were no on-going clinical concerns and the Panel had found the risk of repetition to be low. The Registrant’s role required him to work autonomously. Since the incident that led to the Allegation, the Registrant had been in unrestricted practice for four years. The Trust were aware of the full circumstances of the Allegation and had supported the Registrant to continue in unrestricted practice.

199. In the specific circumstances of this case, the Panel found that Conditions of Practice would be unworkable, unnecessary for public protection and illogical, given its previous findings.

200. The Panel therefore moved on to consider a Suspension Order. The Panel found that there was a risk that a Suspension Order in this case would be purely punitive in effect, rather than necessary and proportionate. It acknowledged the seriousness of its own findings but was also mindful that even a short Suspension Order could have long term consequences for both the Registrant and the public. Although a Suspension Order may have the benefit of reassuring the public, the Panel found that the overall public interest would not be served by suspending a competent Paramedic who had committed a single incident of misconduct in an 8-year career. The Panel determined that a Suspension Order was not the least restrictive option available to it in the circumstances of this case, and that to impose one would be disproportionate to the measures required to ensure the functions of a Sanction were met.

201. The Panel therefore found that a Caution Order was appropriate, and went on to determine the length of the Caution Order. It carefully applied the principle of proportionality to this decision.

202. The Panel found that a Caution Order would reassure the public that the Regulator had taken appropriate action given the misconduct found and would have a deterrent effect. Although this was a single incident, the Panel had found multiple failings within that incident. The Panel was also mindful that it had found that the Registrant had put SU A at potential risk of serious harm. For these reasons, the Panel found that a Caution Order of 1 year would be insufficient.

203. The Panel noted that the primary function of any sanction is to protect the public, and that a Caution Order was significant for any Registrant. It considered that the deterrent effect on other registrants, public confidence in the profession and public confidence in the regulatory process required a Caution Order to be imposed for longer than 1 year. It was mindful that it had the power to impose a Caution Order for between 1 and 5 years.

204. The Panel determined that, in all the circumstances of this case, a Caution Order of 2 years was necessary, appropriate and proportionate.

The Panel determined that, in all the circumstances of this case, a Caution Order of 2 years was necessary, appropriate and proportionate.

No notes available

History of Hearings for Francis Mwangi

Date	Panel	Hearing type	Outcomes / Status
18/03/2024	Conduct and Competence Committee	Final Hearing	Caution
06/11/2023	Conduct and Competence Committee	Final Hearing	Adjourned part heard
21/08/2023	Conduct and Competence Committee	Final Hearing	Adjourned