Mr Karl A Hough

Preliminary Matters

The sequence in which it was agreed the Panel would decide matters.

1. At the commencement of the hearing it was decided that the Panel would initially decide the factual elements of the case, and only after announcing its decisions on the facts would it proceed to consider any other stages that it might then be appropriate to consider.

The Registrant’s response to the Allegation.

2. When invited to respond to the Allegation at the commencement of the hearing, the Registrant denied the matters alleged with the following exceptions:

• Particular 1(b) was admitted;
• Particular 1(f) was admitted;
• Particular 2(a) was admitted;
• He stated that he “partially agreed” with particular 2(b);
• Particular 3(a) was admitted;
• Particular 3(c) was admitted;
• He stated that he “partially accepted” particular 4;
• Particular 5(c) was admitted.

3. Following the Registrant’s response to the Allegation the Panel was advised that consistent with the terms of the HCPTS Practice Note entitled, “Admissions” issued in October 2024, it could declare at that stage that the matters admitted by the Registrant were proven on the basis of those admissions. The Panel sought submissions from the parties on the issue.
4. The parties submitted that in view of the fact that matters relating to both incidents remained in dispute, little would be gained by declaring those matters admitted by the Registrant to be proven. It was submitted that it would still be necessary for evidence to be produced in relation to the incidents attended by the Registrant, and that to avoid calling evidence relating to the specific aspects of those attendances were they not to be further considered by the Panel would be undesirable.
5. After considering the matter the Panel agreed with the submissions of the parties that as the issues denied by the Registrant were inextricably intertwined with those he admitted, this was a case in which it would not be desirable to remove from the evidence to be received by the Panel any of the evidence relating to the two incidents. Accordingly, nothing would be gained by declaring the admitted particulars to be proven.  The Registrant’s admissions would be included in the material considered by the Panel when it decided the facts.
6. When giving his evidence in chief on 20 March 2025, the Registrant changed his response to particular 2(a) to one of partial admission.

Amendment of the Allegation

7. On the second day of the hearing the HCPC applied to amend the stem of particular 3 to include “and/or” between “Joint Royal Colleges Ambulance Liaison Committee guidelines” and “NWAST Patient Group Direction”, which in the referred Allegation ran without any conjunction. It was submitted that this was a clear error as reference was being made to two distinct documents.
8. No objection was made to the proposed amendment by or on behalf of the Registrant, and it was not suggested that his response to the Allegation would need to be reconsidered were the amendment to be allowed.
9. The Panel agreed to the proposed amendment, finding that it was appropriate that the wording of the particular should made clear that two distinct documents were being relied upon by the HCPC.

Background

10. The Registrant is registered with the HCPC as a Paramedic. At the time of the incidents being considered by the Panel, he was employed by the North West Ambulance Service NHS Trust (hereafter “NWAS”) as an Advanced Paramedic.
11. The HCPC’s case against the Registrant relates to two quite distinct incidents. The first occurred on 14 March 2018, when the Registrant attended an incident concerning Patient A.  The other occurred on 11 July 2020, when the Registrant attended upon Patient D.  When the Panel explains its decisions on the facts it will provide a short explanation of why the two patients required Paramedic attendances, and of how matters stood when the Registrant arrived at the scenes of the two incidents.

Decision on Facts

12. In reaching its decisions on the facts, the Panel has reviewed the entirety of the evidence, both oral and written. The Panel has also kept in mind the fact that the HCPC carried the burden of proving the facts against the Registrant on the balance of probabilities; at no stage has there been an obligation on the Registrant to disprove a matter alleged against him.  Furthermore, in reaching its decisions the Panel has had the advantage of written submissions prepared by the Presenting Officer, Mr Irving, and Ms Yeghikian, on behalf of the Registrant.  In explaining its decisions, the Panel will provide sufficient detail for it to be understood why it has reached the conclusions it has, but to ensure that the decision is of a manageable length, it is not intended that every element of the evidence or every argument advanced by the advocates will be addressed.
13. The HCPC called seven witnesses to give evidence before the Panel. In explaining their relevance to the narrative their roles and employments at the time of incidents will be described.  In addition to the seven HCPC witnesses who gave evidence before the Panel, a further factual witness (Ms CG) was relied upon by way of a hearsay statement, the introduction of which had been permitted by a panel conducting an earlier Preliminary Hearing.  Furthermore, and also the subject of a direction at an earlier Preliminary Hearing, the HCPC relied upon a section of a report prepared by an expert witness, Dr Timothy Kilner.  Dr Kilner was unable to attend the hearing, and so the elements of his report relating to the opinion evidence that had been permitted by an earlier panel were relied upon without him giving oral evidence about them.
14. The Registrant gave evidence in his defence.

Patient A and the events of 14 March 2018, before the Registrant’s arrival at the scene.

15. Patient A was a child with a rare neurological condition.
16. Mrs MM, who gave evidence before the Panel, and who is described in particulars 1(a), (b) and e) as “Witness 1”, was a Highly Specialist Community Respiratory Physiotherapist working in the Community Physiotherapy Service of Alder Hey Children’s Hospital (“the Hospital”). In that role, she worked with children with complex neurological conditions.  Her first contact with Patient A had been when he had been an intensive care patient at the Hospital.  Mrs MM worked alongside a Respiratory Consultant at the Hospital, and with that Consultant had prepared in respect of Patient A, a long-term management plan and an acute plan.  Mrs MM worked closely with both the Respiratory Consultant and Patient A’s mother in the treatment of Patient A within the Community Service.
17. After she arrived for work at the Hospital on 14 March 2018, Mrs MM received a telephone call from Patient A’s mother who stated that Patient A’s oxygen saturation levels had been 95% overnight (lower than they ordinarily were) and that he had experienced more secretions than usual. Patient A’s mother had not been unduly concerned, and Patient A had gone to school, but, given Patient A’s history, which included rapid deterioration, his mother thought it important to report the matter to Mrs MM.  At some point in the morning, Mrs MM went to Patient A’s school.  When she arrived the staff at the school were transferring Patient A from a hoist, and they informed Mrs MM that they were concerned about Patient A's oxygen saturation levels.  Mrs MM assessed Patient A’s levels and found them to be low and asked the staff to retrieve Patient A’s bag and mask device with an oxygen reservoir attached.  The bag could administer Positive End Expiratory Pressure (“PEEP”) of around 5cm water.  PEEP is used to open the lower airways using oxygen delivered at pressure to prevent airway collapse and improve gas exchange.  Mrs MM and the Respiratory Consultant had previously drafted an Emergency Treatment Plan for Patient A and determined that 5cm of water was appropriate in an emergency situation due to previous episodes of sputum plugging.  Mrs MM assessed Patient A, conducted physiotherapy manoeuvres and performed nasopharyngeal airway suction and cleared a small amount of secretions.  Reassessing Patient A’s oxygen saturation levels, Mrs MM found them to have dropped to a level in the low 80s. Mrs MM asked the staff to make a 999 call and placed a bag mask device over Patient A’s mouth and nose and turned him on his back so that he was in a supine position.  He appeared to be floppy and blue in colour with poor respiratory effort.
18. Patient A’s saturation rates improved to the high 80s, and, with the assistance of a member of the school staff, nasopharyngeal suction was undertaken while Mrs MM used two hands to hold the face mask over Patient A’s face. Patient A’s saturation rates improved and were stable at 94%.  Soon after this improvement was achieved, the first ambulance crew arrived.
19. Mr RJ, a Senior Paramedic, arrived at the scene at the same time as another NWAS employee, Mr GB. Mrs MM gave them a comprehensive handover, explaining Patient A’s condition, needs and medical history.  Although by this stage, Patient A’s condition had improved, when Mrs MM stopped her hand ventilation of Patient A, his saturation levels dropped from 94% to 90%.  It was decided that it would be desirable for Patient A to be transferred to the Hospital.  Mrs MM offered to travel in the ambulance with Patient A, there being mention of the need to ventilate and possibly suction during the journey.  Mrs MM’s offer to travel in the ambulance was accepted with thanks expressed by the Paramedics then in attendance. Mrs MM described the treatment of Patient A to this stage as a collaborative effort between herself and first ambulance crew to attend.
20. It was at this stage that the Registrant arrived at the scene. He entered the school with two other people, Mr AS, a Paramedic and Mr MH.
21. Before explaining its decisions on the relevant factual particulars, it is appropriate for the Panel to explain its findings about the reliability of the evidence it received from those who were present that day. In relation to this incident, the HCPC called Mrs MM, Mr RJ and Mr AS.  Neither Mr GB nor Mr MH was called as a witness by either the HCPC or the Registrant.  As already stated, the Registrant gave evidence in his own defence.
22. In assessing whether a consistent picture was painted by the individuals who gave evidence about the events of 14 March 2018, it was important for the Panel to remember that the incident was one concerning an acutely ill child. This factor was important not only for a fair assessment of how people should have been expected to behave, but also relevant in deciding if their recollections after the event were reliable, not least because at the time they would have been focused on Patient A.  However, so far as the three witnesses called by the HCPC were concerned, Mrs MM, Mr RJ and Mr AS, the Panel was satisfied strove to describe events as they genuinely remembered them.  Each of them made a statement nearer the time.  In the case of Mrs MM, she wrote an account which she submitted to the Hospital very shortly after the incident. She was interviewed by the NWAS investigator, Mr JC, on 20 June 2018, and a summary of that interview was provided to the Panel.  Mr RJ made a statement dated 12 May 2018 in the context of the NWAS investigation and a witness statement for these proceedings dated 15 May 2021.  Mr AS made a witness statement for these proceedings on 2 June 2021.  In the judgement of the Panel, when due allowance was allowed for the fact that they were describing events that occurred seven years earlier, the oral evidence of each of these witnesses to the Panel was consistent with their earlier written accounts.  Furthermore, the Panel did not detect any sign that any of them had chosen to exaggerate the criticisms they made of the Registrant’s behaviour.
23. The HCPC also called as a witness Mr JC, at the time a recently appointed Consultant Paramedic. Mr JC conducted the NWAS investigation into the incident.  Given his role, Mr JC was not able to give direct evidence about what or did not happen during the incident.  He was able, however, to give evidence about his investigation, and the Panel accepted his evidence in this regard, including his evidence that the summaries of the interviews in which he participated were fair summaries of what was actually said by those interviewed.
24. It has already been stated that the Registrant gave evidence in his own defence. The Panel found him to be an unconvincing witness for three distinct reasons.
25. The first aspect of the Registrant’s evidence the Panel found to be unsatisfactory was that when asked questions about his own actions, he had a tendency to answer by referring to what other witnesses had said or written in their accounts. This was very unhelpful when the point of the question was to discover what his own account was, and in reality, amounted to an argument or submission rather than evidence.
26. The second aspect of the Registrant’s evidence was that he had a tendency to reply by reference to the motivations or qualifications of people who gave evidence that conflicted with his own case. The Panel found that his was a highly personalised approach to giving evidence. Indeed, on occasions it appeared that he believed that people had decided to work against him. An example of this was provided when he described the other NWAS staff present at the school on 14 March 2018 being “complicit” with Mrs MM.
27. Third, there were significant respects in which the Registrant’s oral evidence to the Panel was quite simply inconsistent with earlier accounts he had given. There were examples of this both in relation to Patient A and Patient D.  For example:

• In his oral evidence, the Registrant stated that Mrs MM was forcibly holding Patient A down, and that accordingly, he thought she presented a risk to the child. He did not mention this in his responses in the NWAS investigation.
• In his oral evidence, the Registrant stated that he was told by Mrs MM that there was a treatment plan in respect of Patient A. In the NWAS investigation he stated that, “No treatment plan was discussed by the Physiotherapist”.
• In his oral evidence, the Registrant stated that there was a discussion about Mrs MM travelling in the ambulance, that he knew why she wished to travel, but that he thought she presented a risk to Patient A. That account was wholly inconsistent with the account he submitted to NWAS under numbered paragraph 40 on 23 July 2018. What the Registrant did refer to in that paragraph was that he considered that Mrs MM would herself be exposed to risk were she to be permitted to travel in the rear of the ambulance.
• With regard to Patient D, the description of the patient given in oral evidence that he was trying to climb out to the extent that he brought the stretcher up with him, did not accord with earlier accounts given by the Registrant of the patient’s behaviour.
• Again, in relation to Patient D, in oral evidence, the Registrant stated that he had delegated the connection of the oxygen supply to Ms CP-J, but there was no mention by the Registrant of that delegation in the NWAS investigation in 2020.

28. These various factors had the effect that the Panel felt unable to accept the evidence of the Registrant save to the extent that what he said was the case was inherently likely to be correct or unless there was some corroborative material.

Particular 1(a) – On 14 March 2018, whilst attending an incident involving Patient A, you ignored the advice of Witness 1, who was the primary care giver.

29. Before addressing the question whether Mrs MM’s advice was ignored by the Registrant the Panel should first consider the question of whether she can properly be described as “the primary care giver”. The submission is made on behalf of the Registrant that this particular falls on that ground alone because, it is submitted, “The primary care giver is the person who has responsibility for taking care of the child on a daily basis.”  The Panel does not doubt that in some contexts that would be an appropriate definition to apply to the term.  However, what is in issue is what was occurring with the child at the school during the morning of 14 March 2018, not the issue of who generally had responsibility for taking care of Child A.  On the evidence it has received, the collaborative efforts of Mrs MM and the NWAS employees who were present before the Registrant attended, were led by Mrs MM, a state of affairs that was unsurprising given her professional expertise and her prior knowledge of Child A and his condition.  That being the case, the Panel rejects the submission made as to the construction of the term.
30. In order to decide if it can properly and fairly be said that the Registrant “ignored” Mrs MM’s advice, the Panel concluded that there were several aspects that were relevant. They were that (i) the Registrant knew that Mrs MM was proffering advice that he was not accepting, (ii) that the Registrant did not have a sound clinical reason for not accepting that advice, and (iii) that he did not communicate to Mrs MM a reason why he did not accept her advice.  The Panel found that each element was satisfied by the evidence it received.  The Registrant’s oral evidence was that he fully understood what Mrs MM was suggesting, albeit that he said he did not accept it because he thought it was positively harmful to Child A.  The Panel did not accept that the Registrant had a sound clinical reason for not accepting Mrs MM’s advice, and his evidence that he did was rejected by the Panel.  Furthermore, the Registrant not only did not communicate his reason for not accepting Mrs MM’s advice, but he was positively discourteous in his dealings with her in the respects that will be referred to in relation to particular 1(e) below.
31. Particular 1(a) is proven.

Particular 1(b) – On 14 March 2018, whilst attending an incident involving Patient A, you refused to allow Witness 1 to travel with Patient A in the ambulance.

32. The Registrant admitted this particular. The admission is consistent with the evidence produced by the HCPC, and the Panel was satisfied that the admission could properly be accepted.  The Panel considers that it is necessary to add some contextual findings in relation to this particular.  As already recorded, Mrs MM had made the offer to travel in an ambulance before the Registrant’s arrival, and that stage she had been thanked for her offer, and it had been accepted.  The Panel was satisfied that Mrs MM made it clear to the Registrant that she was offering to travel with him, and why she made that offer.  In the judgement of the Panel she was clearly very well qualified to assist with the management of Child A. She had Child A’s specialist device and she knew the action plan she had devised with the Respiratory Consultant.  The Panel rejected the Registrant’s evidence that he had a genuine belief that Mrs MM presented a risk to the well-being of Child A.
33. Particular 1(b) is proven.

Particular 1(c) – On 14 March 2018, whilst attending an incident involving Patient A, you provided inconsistent information to Emergency Operations Centre (EOC), regarding the patient’s condition and/or observations.

34. In relation to the Registrant’s communication with the Emergency Operations Centre, the Panel accepted Mr JC’s evidence that he had listened to a recording of the exchange involving the Registrant, and that he had prepared an accurate transcript provided to the Panel. That transcript records the Registrant stating at 11:24:19, “Oxygen saturations currently at 89% ….”.
35. Particular 1(c) is apparently advanced on the basis that the information communicated with regard to oxygen saturations at 89% at the time of the conversation does not accord with the oxygen saturation values recorded on the Patient Report Form (“PRF”) at around the same time. The level recorded on the PRF at 11:25 is 96%.
36. As a matter of construction of particular 1(c), it was necessary for the Panel to identify the inconsistency alleged. On the evidence provided to the Panel, only one communication was made by the Registrant to EOC, and that was the one already referred to.  It follows that although the information provided to EOC might have been incorrect, it cannot have been inconsistent for the simple reason that there was no other information provided to EOC with which it could have been inconsistent.  The issue of the significant disparity between the oxygen values recorded less than a minute apart is one that the Panel considers is more appropriately considered under particular 1(d).
37. Particular 1(c) is not proven.

Particular 1(d) – On 14 March 2018, whilst attending an incident involving Patient A, you did not complete the patient records to an acceptable standard in that you incorrectly recorded Patient A’s oxygen saturation and/or you did not record the consultation or assessment model followed.

38. In the judgement of the Panel, the PRF completed by the Registrant in respect of Patient A was woefully inadequate for a practitioner of the Registrant’s seniority. Box 2, “History”, did not record the particular syndrome that Patient A had been diagnosed as suffering from.  There was no reference to medication.  In relation to particular 1(c) mention has already been made in the discrepancy between the oxygen saturation level of 89% communicated at 11:24:19, and the 96% recorded on the PRF at 11:25.  In the judgement of the Panel, whichever value represented the true level of oxygen saturation at that time (and they cannot both have been correct), disclosure of the level communicated to the EOC should have been included in the PRF, and if  the reading of 96% was a genuine reading, an explanation for it should have been given.  A zero value for verbal response (as recorded by the Registrant on six occasions on the PRF) is not a value recognised for the purposes of the Glasgow Coma Score.  Had the Registrant considered Mrs MM to present the risk to Patient A he claims he thought she did because of her inappropriate management at the school, that was also a matter that should have been recorded on the PRF.
39. In his evidence, the Registrant relied upon the fact that at no stage in his career as a Paramedic had he been trained in the how to complete a PRF. The Panel feels bound to say that it would find that an unconvincing argument for any Paramedic to mount.  For an Advanced Paramedic it is an argument that lacks credibility.  The role of Advanced Paramedic is one at Masters or postgraduate level.  The Registrant gave evidence about his clinical and managerial responsibilities at NWAS, and the Panel is satisfied that as an Advanced Paramedic, he would have been regularly providing review and critical analysis of PRFs completed by other clinicians.  It is also relevant to note that PRFs are completed retrospectively, directly after any patient handover, and accordingly there would have been time for an adequate PRF to complete the necessary level of detail.  The incident concerning Patient A was a complex one and, in the view of the Panel, required a level of detail and accuracy to support the on-going care of Patient A at the Hospital.
40. The Panel was satisfied that the HCPC had discharged the burden of proving particular 1(d).

Particular 1(e) – On 14 March 2018, whilst attending an incident involving Patient A, you displayed unprofessional communication towards Witness 1 and colleagues on scene.

41. In the judgement of the Panel, there are three aspects that are relevant to this particular, namely: (i) the Registrant’s behaviour towards Mrs MM, (ii) his conduct towards Mr AS and Mr MH, and (iii) the effect on all those who were present at the school.
42. The Panel finds that the assessment expressed by Mr RJ in his witness statement that, “Karl Hough displayed no professional courtesy towards [Mrs MM]” properly summarises what occurred. Mrs MM felt ignored and described her reaction as one of being “shell shocked”.  The Registrant switched Patient A to a re-breather mask against her advice, not acknowledging her indication that an airway was not required and that Child A’s mother would be unhappy with one being used, snatching the catheter out of her hand without explanation, not making eye contact and giving short answers, not allowing her to travel in the ambulance, and, in relation to all of the issues, not explaining to Mrs MM why he did not accept her views.  The situation that these actions resulted in can be gauged by the fact that when the Registrant left the room, both Mr RJ and Mr AS apologised to Mrs MM for the behaviour they had witnessed.
43. When the Registrant arrived at the school premises, at a time when Mr RJ and Mr GB were inside the building with Patient A and Mrs MM, Mr AS and Mr MH were attending to matters in the rear of the ambulance in which they had arrived. It was the evidence of Mr AS, accepted by the Panel, that the Registrant shouted at Mr AS and Mr MH in an abrasive manner, telling them to get inside the building because of the urgency of the report that caused him to be dispatched.  The Panel does not doubt the urgency of the matter, or of the reasonableness of the Registrant’s wish for Mr AS and Mr MH to enter the building, but it does not accept that the urgency of the matter required him to shout in an abrasive manner.
44. In assessing this particular, the Panel also considered that the more general effect of the Registrant’s behaviour was relevant. The Registrant’s behaviour towards Mrs MM undoubtedly had an effect on the actions of Mr RJ and Mr AS.  Using the word “communication” in a wider sense than merely words spoken directly to a specific individual, the strained atmosphere caused by the Registrant’s behaviour constituted communication with others in the room, including the NWAS employees and the teaching staff.
45. Particular 1(e) is proven.

Particular 1(f) – On 14 March 2018, whilst attending an incident involving Patient A, you did not demonstrate infection prevention control awareness in that you did not change your gloves between touching equipment and treating of Patient A.

46. This particular was admitted by the Registrant. That admission was consistent with the evidence produced by the HCPC, and the Panel was satisfied that the admission could properly be accepted.  Particular 1(f) is therefore proven.

Patient D and the events of 11 July 2020 before the Registrant arrived on the scene.

47. Patient D was a gentleman who suffered a cardiac arrest while at home.
48. Two Newly Qualified Paramedics (“NQPs”), Ms CP-J and Mr BB, had been travelling to another patient when they were re-directed to attend a Category 1 call relating to Patient D. This incident occurred during the Covid-19 pandemic, and so it was necessary for attending Paramedics to wear personal protective equipment (“PPE”) when attending patients.  Mr BB was driving the ambulance, and so it was possible for Ms CP-J to put on her PPE before Mr BB.  For that reason, Ms CP-J reached the patient shortly before Mr BB.
49. Before arrival at the scene, an update from NWAS’s control centre had passed the information that two Community First Responders (“CFRs”) in attendance had achieved “ROSC” (return of spontaneous circulation). On entering Patient D’s home, Ms CP-J went upstairs to the bedroom where Patient D was located and she discovered that the information that had been passed before arrival that ROSC had been achieved was correct.  She saw that the CFRs were carrying out chest compressions and that Patient D was breathing on his own.  She confirmed the presence of a palpable carotid pulse and confirmed that ROSC had been achieved.  She requested the CFRs to cease performing chest compressions, but as the patient’s respiratory rate was low and his oxygen saturation levels were low, his ventilations were assisted with a bag valve mask.  Ms CP-J obtained intravenous access and obtained an initial blood pressure reading of 79/55.
50. When Mr BB entered the bedroom having put on his PPE, he performed a 12-lead ECG and confirmed that Patient D had suffered a myocardial infarction. At about this time, another ambulance crew arrived and the CFRs and the second crew assisted with the extrication of Patient D from the property.
51. After the Patient was placed in the back of the ambulance that was being used by Ms CP-J and Mr BB, a message was received that an Advanced Paramedic was a matter of a few minutes away. The arrival of the Advanced Paramedic was awaited and the second ambulance crew to arrive were told they could leave the scene as they were no longer needed.
52. When the Advanced Paramedic arrived, it proved to be the Registrant. He was accompanied by a Senior Paramedic, Ms CG.
53. Before addressing the specific factual particulars alleged in relation to Patient D, the Panel assessed the reliability of the evidence of the witnesses who gave evidence about the matter. Both Ms CP-J and Mr BB gave evidence before the Panel.  Each submitted a DATIX concerning the incident very shortly after the incident, and they were both interviewed in the context of the NWAS investigation into the matter, the written summaries of what was said by them being provided to the Panel.  Furthermore, each of them made a witness statement in September 2021 for the purposes of the present proceedings.  Having given due allowance for the fact that different people will inevitably remember a given event differently, as well as to the fact that the incident occurred nearly five years ago, the Panel found that their evidence was consistent with the earlier accounts they had given.  The Panel was satisfied that the evidence of them could safely be relied upon in deciding the relevant factual particulars.
54. The HCPC also called as a witness, Mr NS, a Consultant Paramedic. Mr NS’s role was that of investigator for the purposes of the NWAS investigation.  As such he did not have any personal knowledge of the events of the incident on 11 July 2020, but the Panel accepted his evidence that the documents he produced were accurate in the sense that they were what they purported to be, and that records of interviews he had attended accurately reflected what was said in those interviews.
55. The HCPC also relied upon the hearsay statement of Ms CG, permission for the use of it having been given by another panel at an earlier Preliminary Hearing.

Particular 2(a) – On 11 July 2020 you administered a bolus of 10 mg morphine to Patient D to sedate Patient D contrary to Joint Royal Colleges Ambulance Liaison Committee guidelines and/or safe clinical practice.

56. It has already been recorded that at the commencement of the hearing, the Registrant admitted this particular, but that on 20 March 2025, he qualified that admission. As the Panel understood his case, he did not dispute that he had requested that a bolus of 10mg of morphine was administered to Patient D, but he did not accept that the purpose of the administration of it was to sedate him.  Given the equivocal nature of the Registrant’s response, the Panel decided that it should make its decision on the particular as if no admission had been made.
57. The clear evidence was that a bolus dose of 10mg of morphine was administered to Patient D. That was confirmed by Ms CP-J and recorded on the PRF as having been administered at 14:45. That morphine was administered to sedate Patient A is demonstrated by the evidence of Ms CP-J whose evidence was that the Registrant said to her on two separate occasions it was to flatten Patient A (being heard by Mr BB on the second occasion).  The purpose of sedation is corroborated by the terms of the PRF completed by the Registrant, which records, “P/T severely Aggitated settled with Morphine Midazolam”.
58. While the Panel accepts that the administration might be appropriate in certain circumstances for pain relief, the Panel finds that there are no circumstances in which morphine would be an appropriate medication for the purposes of sedation, and having been given for that purpose was contrary to the circumstances in which its administration could be justified by reference to the JRCALC guidelines or safe clinical practice.
59. For these reasons, the Panel finds particular 2(a) to be proven.

Particular 2(b) – On 11 July 2020 you administered a bolus of 10 mg morphine to Patient D which was an excessive dosage for pain relief.

60. The Registrant’s response to this particular was to say that he partially agreed with it. The Panel considered it necessary to decide this particular as if it had been denied.
61. The Panel accepts that a total dose of 10mg might be administered in appropriate circumstances, but the allegation is that 10mg was administered as a bolus, in other words in a single administration. In the judgement of the Panel, in view of the fact that morphine would have had the effect of depressing the cardiac and respiratory function of Patient D, it was completely inappropriate for a 10mg bolus to be administered even if Patient D had not been unconscious at the time (as the PRF records him to have been).
62. Particular 2(b) is proven.

Particular 2(c) – On 11 July 2020 you administered a bolus of 10 mg morphine to Patient D without having conducted an adequate risk assessment.

63. The Registrant denied this particular, contending, in effect, that he did conduct a risk assessment dynamically in his head.
64. The Panel finds on a balance of probabilities that the Registrant did not conduct a risk assessment, whether adequate or otherwise, in relation to the administration of a 10mg bolus dose of morphine. The reasons for that finding were as follows:

• No risk assessment is recorded where it would be expected in the “History” section of the PRF beyond the entry already quoted, which appeared to explain the administration of morphine to settle Patient D.
• It would have been expected that the Registrant would have explained the rationale for the administration of the use of a bolus dose of 10 mg of morphine to his more junior colleagues present in the rear of the ambulance at the time of administration, Ms CG the Senior Paramedic and Ms CP-J, a NQP (save for his mention to the latter of the need to “flatten”, which, for the reasons already stated, was not a legitimate reason). In their respective evidence they both state that he did not.
• When the morphine was administered at 14:45, Patient A had been unconscious for not less than four minutes (his GCS score is recorded on the PRF as 3 at 14:41). Had a risk assessment been undertaken, it is inconceivable that such a dose would have been given to an unconscious patient.

65. Particular 2(c) is proven.

Particular 3(a) – On 11 July 2020 whilst attending an incident involving Patient D, contrary to Joint Royal Colleges Ambulance Liaison Committee guidelines and/or NWAST Patient Group Direction, you directed Colleague 1 to administer 3 doses of 2.5mg midazolam to Patient D, when Colleague 1 was not authorised to administer midazolam under NWAST Patient Group Direction.

66. The Registrant admitted this particular. That admission was consistent with the evidence produced by the HCPC, and the Panel was satisfied that the admission could properly be accepted. The Panel will return to the Registrant’s knowledge and belief about the ability to authorise another to administer Midazolam when it explains its decision on dishonesty.
67. Particular 3(a) is proven.

Particular 3(b) – On 11 July 2020 whilst attending an incident involving Patient D, contrary to Joint Royal Colleges Ambulance Liaison Committee guidelines and/or NWAST Patient Group Direction, you directed Colleague 1 to administer 3 doses of 2.5mg midazolam to Patient D when it was not clinically indicated.

68. The Panel accepts that in appropriate circumstances, Midazolam could properly be administered to sedate a patient. However, in the circumstances that existed in the back of the ambulance taking Patient D to hospital between 14:50 and 15:10 (the times of the first and third dose administered), the Panel finds that it was not clinically indicated.  Quite apart from the fact that the Panel accepted the evidence of Ms CP-J that she had been able to calm Patient D’s agitation by speaking to him, between those two times Patient D is recorded by the Registrant as having been unconscious.  The Registrant recorded Patient D’s GCS score to be 3 at 14:41, 14:58, 15:03, 15:08, 15:13 and 15:18.  An unconscious patient would not require sedation, and, accordingly, Midazolam was not clinically indicated for Patient D when it was administered.
69. Particular 3(b) is proven

Particular 3(c) – On 11 July 2020 whilst attending an incident involving Patient D, contrary to Joint Royal Colleges Ambulance Liaison Committee guidelines and/or NWAST Patient Group Direction, you directed Colleague 1 to administer 3 doses of 2.5mg midazolam to Patient D, which is a higher dose than that indicated by the NWAST Patient Group Direction for high risk adults.

70. The Registrant admitted this particular. That admission was consistent with the evidence produced by the HCPC, and the Panel was satisfied that the admission could properly be accepted.
71. Particular 3(c) is proven.

Particular 4 – On 11 July 2020 you did not ensure that an oxygen supply tube was connected to the bag valve mask whilst ventilating Patient D and or recognise a prolonged period of hypoxia in Patient D.

72. It was the Registrant’s oral evidence to the Panel that he had delegated the responsibility for connecting the oxygen supply, a contention that he had not previously made. Be that as it may, it was the Registrant who was positioned at Patient D’s head, and it was the Registrant who was nearest to the oxygen supply.  In the judgment of the Panel, the responsibility for ensuring that equipment is functioning properly is that of the professional using the equipment.  In this instance that means it was the responsibility of the Registrant.
73. In evidence the Registrant appeared to take issue with the HCPC’s contention that there was a “prolonged” period of hypoxia, and he contended that it was a period of approximately 4 minutes. Even if the period of hypoxia had been as short as that contended for by the Registrant, the Panel is satisfied that such is the seriousness of an unconscious patient being without oxygen, in context it would constitute a prolonged period.
74. Particular 4 is proven.

Particular 5(a) – On 11 July 2020 you did not keep adequate and/or accurate records in relation to Patient D in that you did not record a complete history.

75. The Registrant denied this allegation (although the Panel notes that in the NWAS investigation, on 20 July 2020, he described the quality of it as “very poor”).
76. In the judgement of the Panel, the history recorded in section 2 of the PRF was inadequate. The patient’s medical history is not recorded, and save for recently prescribed Lansoprazole, there is an absence of reference to whether the patient was taking medication.  No rationale for the needle decompression is provided.  As the patient was presumably unable to provide consent to being treated, there is no reference to a “best interests” justification for interventions. Furthermore, there is no evidence of airway assessment or management being performed despite it being apparent from the section 5 of the PRF that suction was performed and an I-Gel being placed.  This was a complex case.  A significant degree of detail and accuracy was required in order to ensure that the most effective care of Patient D could be provided once he was at the hospital.
77. Particular 5(a) is proven.

Particular 5(b) – On 11 July 2020 you did not keep adequate and/or accurate records in relation to Patient D in that you did not record accurate observations.

78. In the view of the Panel there were omissions from the observations section of the PRF. The matters omitted included the absence of a NEWS score, no capillary refill recorded, the ETCO2 carbon dioxide recording was not included until 13 minutes after administration of morphine and 8 minutes after the administration of Midazolam.  Furthermore, Patient D’s pupillary response/size was not recorded at any stage, and BM (blood sugar) was not recorded at any stage (a particularly significant omission as Patient D was recorded as being unconscious).
79. Particular 5(b) is proven.

Particular 5(c) – On 11 July 2020 you did not keep adequate and/or accurate records in relation to Patient D in that you recorded yourself as having administered midazolam when this was not the case.

80. The Registrant admitted this particular. That admission was consistent with the evidence produced by the HCPC, and the Panel was satisfied that the admission could properly be accepted.
81. Particular 5(c) is proven.

Particular 6 – Your conduct in respect of Particular 5 (c) was dishonest.

82. It is important that the Panel should make it very clear what it understands the HCPC allegation of dishonesty to be. This is important not only so that the Panel’s decision will be understood, but also because the way in which the Registrant’s written submissions have been framed suggests that might be understood believed that the issue is a wider one than the Panel believes it to be.  The bold heading under paragraph 18 in the written submissions reads, “Dishonesty, recording a complete history and accurate observations”.
83. It is particular 5(c), and only particular 5(c), that is alleged by the HCPC to have been done dishonestly. Particular 5(c) alleges that the Registrant recorded himself as having administered Midazolam when that was not the case.
84. Particular 5(c) was admitted by the Registrant, the Panel accepted that admission and it has already declared particular 5(c) to be proven. However, in order to decide if that incorrect recording was dishonest, it is necessary for the Panel to reach findings about the (subjective) belief and/or motivation of the Registrant in making that admittedly incorrect record in order to answer the (objective) question whether ordinary and decent people would categorise what he did as dishonest.
85. For the Panel to answer why the Registrant incorrectly recorded himself as having administered the administration of Midazolam, the Panel first asked itself what it found about the Registrant’s understanding at the relevant time (i.e. 11 July 2020) about the restrictions concerning the administration of that medication resulting from the Patient Group Direction (“PGD”). The Panel had no hesitation in accepting the evidence of Mr NS that, as a proposition of fact, authority to administer granted under a PGD is not one that can be delegated.  But the acceptance of that evidence did not mean that the Registrant knew on 11 July 2020 that the authority granted to him under the PGD was one that could not be delegated.  To answer the objective “ordinary and decent people” question, there might be a world of difference between, on the one hand, positively knowing that delegation was not permitted, and, on the other hand, it being said that someone should have known.
86. The Panel was satisfied that the Registrant received training on PGDs. The absence of that training from the NHS ESR record of training does not negate Mr NS’s clear evidence that the Registrant received training.  The Panel is also satisfied that the Registrant knew at the material time that authority under a PGD was not one that could be delegated, as the restriction to senior staff with the required qualification is the very purpose of a PGD, to permit the administration of medication that is not within JRCALC guidelines.  The Panel does not consider that the apparent ignorance of Ms CG (who administered the Midazolam) of the inability to delegate supports the Registrant’s case for the simple reason that she was not working at a level that qualified for inclusion in PGD authority.
87. In the view of the Panel, the fact that the Registrant positively knew that he could not delegate the responsibility for administration of Midazolam explains why he falsely recorded himself as having administered it. It was an excessive dose. The desire to avoid it being apparent that it was administered by a person who was not permitted to do so is supported by the fact that the box against the words, “Tick if a PGD drug has been given” was not ticked.
88. When the Panel asked itself the question whether ordinary and decent people would consider it to be dishonest for the Registrant to have recorded himself as having administered Midazolam when he did not, but he was the only person permitted to do so, the answer to that question was that they would.
89. Particular 6 is proven.

Summary of findings on the facts.

90. The Panel has found all of the factual particulars, save for particular 1(c) to be proven. It is therefore necessary to go on to consider the issues of misconduct, and (if misconduct is established) current impairment of fitness to practise.

Decision on Misconduct

91. After the Panel handed down its decision on the facts, the parties were allowed time to consider the document before addressing the issues of misconduct and current impairment of fitness to practise. The Panel asked that it should receive any evidence and submissions on those issues in one section of the hearing, acknowledging that the two issues would be decided separately and sequentially.  The Registrant gave further evidence at this stage, but as that evidence was related to the issue of impairment of fitness to practise, reference will be made to it when the Panel describes its decision on that issue.
92. In relation to misconduct, the Presenting Officer submitted that the findings of fact made by the Panel demonstrated conduct by the Registrant that fell well below the standards reasonably to be expected of a Paramedic, particularly given the senior level at which the Registrant was working. He submitted that the finding of dishonesty in isolation would be likely to result in a finding of misconduct, but he also submitted that all of the proven facts, when viewed individually and collectively should result in that finding.
93. On behalf of the Registrant, Ms Yeghikian submitted that the Registrant had a long and unblemished career of some 30 years as a Paramedic and she asked the Panel to deal with the issue on the basis that it was an isolated incident. Ms Yeghikian acknowledged that the Panel would be likely to take a serious view of the finding of dishonesty, but she submitted that if the Panel applied the test of whether there had been a serious falling short of what would be proper in the circumstances, the result should be that there was not.
94. The Panel first considered whether the proven facts amounted to breaches of standards promulgated by the HCPC. The Panel accepted that a mere breach, or more than one breach, of such standards had been established, that would not, without more, justify a finding of misconduct; it would be necessary for the Panel to be satisfied that any breach (or breaches) were serious before it would be appropriate to categorise the proven facts as misconduct.
95. By his Case Summary dated 4 March 2025, the Presenting Officer identified a large number of the Standards of Proficiency for Paramedics he submitted had been breached. The Panel does not find it necessary to refer to these standards.  The findings of fact made by the Panel demonstrate that the Registrant acted in a way that was contrary to the standards required by the Standards of Proficiency for Paramedics, but, in the view of the Panel, this is not a case of the Registrant not being able to perform differently.  As will be apparent from the Panel’s findings that, as a long-established Paramedic working at a senior level, the Registrant had the ability to perform to a higher standard; this is a case in which it has been demonstrated that the Registrant chose not to perform in a manner he was able to.
96. The Panel considered that the HCPC’s Standards of conduct, performance and ethics that applied from January 2016 were the appropriate standards by which the Registrant’s actions should be assessed. In the judgment of the Panel, the following standards were breached:

Standard 1.2, “You must work in partnership with service users and carers, involving them, where appropriate, in decisions about the care, treatment or other services to be provided.”

Standard 2.1, “You must be polite and considerate.”

Standard 2.5, “You must work in partnership with colleagues, sharing your 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 4.1, “You must only delegate work to someone who has the knowledge, skills and experience needed to carry it out safely and effectively.”

Standard 6.1, “You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible.”

Standard 6.2, “You must not do anything, or allow someone else to do anything, which could put the health or safety of a service user, carer or colleague at unacceptable risk.”

Standard 9.1, “You must make sure that your conduct justifies the public’s trust and confidence in you and your profession.”

Standard 10.1, “You must keep full, clear, and accurate records for everyone you care for, treat, or provide other services to.”

97. When the Panel then asked itself the question whether these breaches constituted sufficiently serious matters properly to result in a finding of misconduct, it recognised that some of the factual findings, taken in isolation, would be more serious than others. The finding that a professional person has acted dishonestly is a very serious matter for reasons too obvious to require elaboration.  The administrations of inappropriate medication and of excessive quantities of medication to an acutely unwell patient were also particularly serious matters.  When the Panel considered whether it would be appropriate to exclude from a finding of misconduct any element of the established facts, it concluded that it would not.  This is because each part of the findings in relation to each patient represented part of the overall management of the patient performed by the Registrant, and those managements were of the utmost seriousness and would be regarded as deplorable.
98. The Panel was satisfied that its findings of fact amounted to misconduct.
99. The Panel therefore went on to consider the issue of current impairment of fitness to practise.

Decision on Impairment

100. The Presenting Officer submitted that the matters found proven by the Panel amounted to attitudinal shortcomings on the part of the Registrant, and for that reason they would be difficult for him to remediate. He submitted that there was insufficient insight demonstrated by the Registrant, and for that reason there remains a real risk of repetition.   For that reason, he submitted, a finding of current impairment of fitness to practise is required in relation to the personal component. Furthermore, it was submitted on behalf of the HCPC that the matters found to be proven were so serious the wider public interest is engaged, and that a finding of impairment of fitness to practise is required in respect of the public component.
101. Before Ms Yeghikian made submissions on behalf of the Registrant, the Registrant gave further evidence under affirmation. He informed the Panel of the work he had been doing since the later incident considered by the Panel. He disclosed that since January 2021, he has been working under interim conditions of practice, and, with his consent, these conditions were provided to the Panel.  In the past he has worked delivering Covid-19 vaccine injections.  His current placement involves working with patients with a high level of clinical need. In addition he stated that he currently works on a number of levels, including conducting telephone triages, streaming services, working in a urgent treatment centre and patient discharges. He informed the Panel that he had developed necessary techniques to discharge the functions he has been performing, and these techniques included active listening, empathy and negotiation.  He gave the Panel an example of an incident when she had become upset with a doctor whom he had consulted, and the steps he took with the patient to resolve the matter.
102. The Panel was also provided with a further bundle of testimonials which supplemented those that had been previously provided.
103. When she made her submissions on behalf of the Registrant, Ms Yeghikian submitted that there was no realistic prospect of a finding of current impairment of fitness to practise. She submitted that the Panel was dealing with an isolated incident in relation to which there is no risk of repetition.  She submitted that it could not be said that the Registrant was not fit to practise.  Furthermore, relying on a passage from the judgment of Cox J. In the case of Grant, she submitted that this is not a case in which a finding of current impairment of fitness to practise should be made to satisfy public interest considerations.
104. The Panel accepted the advice it received from the Legal Assessor as to the correct approach to making a decision on the Registrant’s current impairment of fitness to practise. In reaching its decision, the Panel paid close attention to the HCPTS Practice Note entitled, “Fitness to Practise Impairment”.  Consistent with the terms of that document, the Panel separately addressed the personal and public components.
105. In explaining its decision on personal component impairment of fitness to practise, the Panel does not consider it necessary to repeat matters already explained in the decision on the facts. It is, however, necessary for the Panel to analyse in broad terms what happened, and to express its view on why those events occurred.  It is only with those matters explained that the Panel can properly assess the issues that have to be decided in relation to personal component impairment of fitness to practise.
106. Both Patient A and Patient D were acutely unwell patients. The circumstances of each of them were complex, and obviously so to the Registrant.  Any Paramedic, even one who had not been qualified as long as the Registrant or working at his senior level, would know that when there is a complex case involving an acutely unwell patient it is of paramount importance to follow best clinical practice including established guidelines such as (but not limited to) JRCALC guidance. If those requirements are departed from, there must be a very good reason for doing so, and those reasons would require careful and detailed explanation. Yet, in each case, the Registrant departed from the manner in which he unquestionably understood he should have acted, and he did so when there was insufficient rationale to do so, and did not explain why he acted. 
107. It is only by attempting to answer the question why the Registrant acted as he did, that it is possible to attempt an answer to the question whether there remains a risk that he is likely to act in a similar manner in the future.
108. In the judgement of the Panel, the underlying reason for both incidents was the same, namely the Registrant pursing his own course of action whilst ignoring established requirements. The Panel has paid no heed to the NWAS internal view of either incident, but it is material to the Panel’s decision to note that when the incident on 11 July 2020 occurred, the Registrant was working under a two-year written warning imposed in respect of the first incident.  It might have been expected that that warning would have served to make him mindful about the way he practised.
109. In the light of these findings, the Panel addressed the question whether it considered that there is a risk that the Registrant would repeat behaviour of the type reflected in the Panel’s findings. It is clear from the Panel’s findings that it is of the view that at the root of the problem was an attitudinal shortcoming on the part of the Registrant.  Conceptually, even if the shortcoming is attitudinal in nature, it is capable of remediation in the sense that, with a change in attitude, it might not be repeated.  The all-important question in the present case is whether there is material before the Panel from which it could conclude that the Registrant would not repeat this type of behaviour.
110. In reaching its decision the Panel paid close attention to the Registrant’s evidence about his professional activities since leaving his employment with NWAS. The Panel accepts that in the work he has done under the interim conditions of practice since leaving NWAS, there is no suggestion that any further untoward incidents have occurred. It also fully considered both sets of testimonials provided by the Registrant.  The Panel does not doubt the fact that the Registrant has the knowledge and skills to practise safely and effectively. Nor does the Panel doubt that, on the whole, the Registrant did in the past, and continues to, practise safely and effectively.  The issue that has concerned the Panel is whether the Registrant can be relied upon consistently to practise safely and in a manner he undoubtedly knows he should.  The limited value of testimonial evidence in answering this question is demonstrated by the fact that the extremely serious incident concerning Patient D occurred after every one of the documents submitted to the Panel on 26 March 2025, had been written.
111. The Registrant admitted some of the factual particulars found proven by the Panel, but the case he has advanced does not suggest that he has, even now, after all the time that has passed since the incidents occurred, a true understanding of just how inappropriate his actions were. The Panel noted that, in his oral evidence, the Registrant appeared to lack awareness of his impact on others, including junior staff who would have been looking to him to set an example. The Panel was concerned that the Registrant relied heavily on the idea that views of how he exercised his authority amounted to ‘perceptions’ over which he had little or no control. It was enough, to his own mind, that his intentions were good. If others could not recognise or decipher those intentions, that ultimately was on them. It was the evidence of the Registrant that the apologies he offered to the participants in the 14 March 2018 incident were along the lines that he was sorry if anything he did or said upset the person to whom he was making the apology. In the view of the Panel, this did not involve a real understanding of how serious his behaviour was, and, importantly, did not actually accept any wrongdoing. Indeed, throughout his evidence, there was a sense of the Registrant distancing himself from the impact on others of his own actions. The Registrant’s case was advanced on the basis that there was no complaint by Patient A’s mother or by Patient D or his wife, matters that the Panel did not consider to be relevant to the allegations in hand. The Registrant informed the Panel in evidence of how working under conditions of practice impacted on him, but there was an absence of a meaningful expression of an understanding of the consequences of his actions on his profession or the effect of them on those involved.
112. To be clear, the Registrant is entitled to advance and stand by any case he chooses. But at the same time it must be understood that the Panel is entitled to decide the case on the basis of that case.  Furthermore, when a hearing lasts as long as the present one, the Panel conducting it is very likely to be able to form a view of the demeanour of those involved.  The Panel’s assessment of the Registrant is one that is consistent with what it has described as the fundamental reason these incidents occurred. 
113. The consequence of these findings is that the Panel has concluded that there remains a significant risk that the Registrant’s character is such that he would in the future choose to act outside clinical standards and professional expectations. For that reason the Panel finds that his fitness to practise is impaired on the personal component.
114. When the Panel considered the public component, it had no hesitation in deciding that a finding of current impairment of fitness to practise is required. In the light of the finding that there is a risk of repetition, that finding is inevitable.  However, the Panel considers that it is necessary to declare that even if that risk of repetition had not been present, so serious were these matters, that finding would be required.  Were there to be no finding of current impairment of fitness to practise in these circumstances, fair-minded and informed members of the public would not have the confidence they can reasonably expect to have in the Paramedic profession or the regulation of it.  Furthermore, without a finding of current impairment of fitness to practise, the Panel would be failing to discharge its duty to establish for other professionals the proper bounds of acceptable professional practice.
115. For these reasons, the Panel finds that the Registrant’s current fitness to practise is impaired in relation to both the personal and public components. The consequence of that finding is that the Panel must go on to consider the issue of sanction.

Decision on Sanction

116. After the Panel handed down its written determination explaining its reasons for finding that the statutory ground of misconduct was established and that the Registrant’s fitness to practise is currently impaired, time was allowed before the parties made submissions on sanction.
117. The Presenting Officer commenced his submissions by informing the Panel that the HCPC did not invite the Panel to impose any particular sanction. He stated that the HCPC submitted that the Panel should consider what would be a sufficient sanction whilst balancing the need to impose a sanction against the Registrant’s interests.  The Presenting Officer suggested various factors that the Panel might consider to be mitigating and aggravating.  The factors identified by the Presenting Officer will be described below when the Panel explains the features it took into account.  The Presenting Officer reminded the Panel of the need to consider the HCPC’s Sanctions Policy when reaching a decision, and, in that regard, he reminded the Panel that dishonesty and failing to work in partnership are both matters it is suggested in the Sanctions Policy are likely make a case a serious one.
118. On behalf of the Registrant, Ms Yeghikian asked the Panel to take into account the matters she had referred to when she made submissions on the issues of misconduct and impairment of fitness to practise. She urged the Panel to impose the least restrictive sanction, avoiding one that was either inappropriately serious or onerous.  She repeated submissions she had made in relation to misconduct and impairment of fitness to practise, in particular that there was no evidence to suggest that there would be a recurrence and that the matter was one of an isolated incident.  She also asked the Panel to take into account the positive references and commendations that had been supplied.  Submitting that the Registrant had complied with the interim conditions of practice that had been imposed, she stated that no further issues had occurred during the last five years despite numerous opportunities for there to have been a recurrence if that had been likely to happen.  She also asked the Panel to remember the financial consequences that would be visited upon the Registrant by a restrictive sanction.
119. After Ms Yeghikian’s submissions concluded, the Registrant addressed the Panel. He stated that he had been honest, self-referring in respect of each of the two incidents.  He stated that he had been open and transparent and had engaged with the investigation into both incidents, and had demonstrated honesty and integrity over the seven years since the first of those incidents occurred.
120. The Panel accepted the advice it received from the Legal Assessor as to the proper approach to making a sanction decision. A sanction must never be imposed with the intention of punishing a registrant against whom a finding has been made.  Rather, the factors that can justify the imposition of a sanction are the need to protect the public, the need to maintain a proper degree of confidence in the registered profession and the regulation of it, and the need to declare and uphold proper professional standards.  Any sanction determined upon must be the least restrictive outcome consistent with these proper sanction aims.  A finding that an allegation is well founded does not of itself require the imposition of a sanction.  To ensure that these principles are applied, the first question a panel must ask itself is whether the particular finding it has made requires the imposition of any sanction at all.  If the answer to that initial question is that a sanction is required, then the available sanctions must be considered in an ascending order of seriousness until one is reached that sufficiently addresses the proper sanction aims already identified.  The consideration of the appropriate sanction is to be undertaken with the guidance provided by the HCPC’s Sanctions Policy in mind.  Even after a sanction is tentatively identified by this process, it is necessary for a panel to be satisfied that it is proportionate in the sense that it strikes a proper balance between the factors that have resulted in the identification of that sanction and the legitimate interests of the registrant concerned.  The present Panel confirms that it has followed this approach in the present case.
121. When the Panel commenced its discussion, it began by identifying the facts that were serious and aggravating, and those that it would be proper to take into account on behalf of the Registrant.
122. A serious aspect of this case is that, contrary to the submission made on behalf of the Registrant, the Panel is dealing with two incidents. Two distinct incidents occurred, and there were features of both arising from the failure to work in partnership that were common to both, shortcomings that resulted in the Registrant failing to provide the example of leadership his senior position required him to demonstrate.  The second incident occurred when, as the Panel has already stated, it might have been expected the Registrant would have been mindful to ensure that he observed proper standards.  Another serious aspect of the case is that an aspect of the latter incident involved dishonesty.  The Panel accepts that it was a single incident of dishonesty, rather than a repeated pattern of dishonest behaviour, but it was nevertheless serious because it involved an attempt to cover up the improper administration of a controlled drug.  A further serious aspect is the risk of harm.  The HCPC’s case has not been advanced on the basis that either Patient A or Patient D suffered tangible long-term harm as a result of the Registrant’s actions, and the Panel has not made any decision on the basis that such harm was caused.  However, the simple fact of the matter is that both of those patients were very vulnerable and they were acutely unwell.  The risks the Registrant needlessly exposed them to were neither fanciful nor remote.  The Registrant’s incomplete insight into how he acted, coupled with his reluctance to acknowledge wrong-doing and tendency to shift blame has led the Panel to conclude that he presents a significant risk of repeating behaviour of the type he demonstrated when dealing with Patient A and Patient D.  Were he to repeat that behaviour, the patient being attended would be exposed to the same degree of risk Patient A and Patient D were exposed to.  To discharge its public duty, these are the factors the Panel is required to have in mind when reaching its decision on sanction.
123. On behalf of the Registrant, the Panel considered that the following matters could properly be taken into account. The Panel accepted that the Registrant self-referred to the HCPC in respect of the two incidents that have been considered by the Panel. It was also accepted that he has fully engaged in this fitness to practise process and admitted some aspects in relation to each incident while offering a limited apology.  The Panel acknowledged that the Registrant has undertaken some, albeit limited, reflection and recognised the need for some behavioural change on his part.  The Panel further acknowledged that it has not been suggested that there have been further problems with the Registrant’s practice in the period of a little over four years since he was dismissed by NWAS and has been undertaking alternative work under interim conditions of practice.
124. The Panel acknowledged that the factors identified in the immediately preceding paragraph are properly to be considered, but it is important to state (as indicated in paragraph 25 of the Sanctions Policy) that in proceedings such as these, mitigating factors are likely to be of less significance than in courts considering retributive justice. This is because the overarching concern of regulatory proceedings is protection of the public.
125. With these factors in mind, the Panel first asked the question whether the findings in this case required any sanction. The clear answer to that question was that a sanction is required; the findings are far too serious to result in no sanction being imposed.
126. The Panel then considered a caution order, and had regard to paragraphs 101 and 102 of the Sanctions Policy, which are in these terms:

“101.A caution order is likely to be an appropriate sanction for cases in which:

• the issue is isolated, limited, or relatively minor in nature;
• there is a low risk of repetition;
• the registrant has shown good insight; and
• the registrant has undertaken appropriate

102. A caution order should be considered in cases where the nature of the allegations mean that meaningful practice restrictions cannot be imposed, but a suspension of practice order would be In these cases, panels should provide a clear explanation of why it has chosen a non-restrictive sanction, even though the panel may have found there to be a risk of repetition (albeit low).”

127. In the view of the Panel, the circumstances of the present case did not meet these suggested features. The matters in issue are not relatively minor in nature, the risk of repetition cannot be described as low, the Registrant does not have good insight nor has he remediated the shortcomings identified by the Panel’s findings.  Importantly, the imposition of a caution order would provide the public with no protection against the risk of recurrence.
128. The Panel next considered whether a conditions of practice order would be appropriate. The guidance provided in paragraph 106 of the Sanctions Policy is in these terms:

“A conditions of practice order is likely to be appropriate in cases where:

• the registrant has insight;
• the failure or deficiency is capable of being remedied;
• there are no persistent or general failures which would prevent the registrant from remediating;
• appropriate, proportionate, realistic and verifiable conditions can be formulated;
• the panel is confident the registrant will comply with the conditions;
• a reviewing panel will be able to determine whether or not those conditions have or are being met; and
• the registrant does not pose a risk of harm by being in restricted ”

Paragraph 108 of the same document suggests that conditions of practice are less likely to be appropriate in serious cases, and cases involving dishonesty and a failure to work in partnership are specifically mentioned in that regard.

129. In the judgement of the Panel, the circumstances of the present case did not fall within the suggestions made in the Sanctions Policy as to when a conditions of practice order might be appropriate. However, in view of the fact that the Registrant has been working under conditions of practice, albeit interim conditions of practice, for a period of a little over four years without the suggestion of further failings having occurred, the Panel spent some time considering whether substantive conditions of practice of a similar nature to those imposed on an interim basis could properly be imposed.
130. It is important to note that when pre-final hearing interim conditions of practice are imposed, that order will be made on the basis that nothing has been proved against the registrant against whom an allegation has been made. The interim conditions will be crafted as the least restrictive measure that will address risks arising from the unproven allegation, recognising the seriousness of any restriction imposed on a person against whom nothing has been proven.  The considerations dictating whether substantive conditions of practice are appropriate are different, because at that stage established findings will have been made.  It follows that a panel considering the matter following a final hearing will have a much clearer picture of what protection is required than a panel dealing with an interim order application.  Another significant difference between an interim conditions of practice order and a substantive conditions of practice order is that a condition might be appropriate to impose as a “holding measure” as an interim condition that would not be appropriate as a substantive condition imposed after concluded findings of fact.  An example of that is provided in the present case.  One of the interim conditions imposed on the Registrant was that he was prohibited from administering any medication in relation to pain management or sedation (with the exception of oral pain medication) without first obtaining approval from a health professional with prescribing rights.  The Panel is of the view that that condition would not be appropriate as a substantive condition of practice because it would prohibit one of the core responsibilities of a Paramedic practising at any level.
131. Having carefully considered the matter, the Panel concluded that a conditions of practice order is not an appropriate sanction in the present case.
132. Having rejected a conditions of practice order, the Panel then considered a suspension order and paragraph 121 of the Sanctions Policy. Paragraph 121 of the Sanctions Policy provides guidance about when a suspension order is likely to be appropriate.  That paragraphs states:

“A suspension order is likely to be appropriate where there are serious concerns which cannot be reasonably addressed by a conditions of practice order, but which do not require the registrant to be struck off the Register. These types of cases will typically exhibit the following factors:

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

133. The present case does indeed represent a serious breach of the Standards of conduct, performance and ethics, but that element apart, the present case does not fit the circumstances suggested by the Sanctions Policy; the Registrant’s insight is limited, it cannot be said that the issues are unlikely to be repeated, and the fact that the second incident occurred while the Registrant was subject to a written warning and it is now nearly five years from that second incident with his insight still far from being developed, there can be no confidence that he would be able to resolve or remedy his failings.
134. The imposition of a suspension order would serve to protect the public from the risks that would arise were there to be repetition of behaviour of the sort found proved, but in the judgement of the Panel it would serve no other purpose because the risks presented at the conclusion of even the maximum period of suspension would be exactly the same as they are now. Despite the length of time since the incidents occurred, the risk of recurrence is still present and there is insufficient reason to conclude that the Registrant would be able to address matters satisfactorily during the period of a suspension order. For that reason, the Panel concluded that a suspension order would not be appropriate.
135. The rejection of a suspension order necessarily meant that the Panel considered a striking off order. The Panel noted that in paragraph 130 dishonesty and failure to work in partnership are two of the examples given of serious cases that might result in a striking off order being made.  It also noted that the guidance in paragraph 131 states that a striking off order is likely to be appropriate where the nature and gravity of the concerns are such that any lesser sanction would be insufficient to protect the public, public confidence in the profession, and public confidence in the regulatory process.
136. In considering whether a striking off order should be made, the Panel acknowledged the extremely serious nature of such an order. The effect on any professional will be significant, in terms of career, reputation and the ability to earn their livelihood.  For that reason it is right that striking off orders should be reserved for the most serious cases, and then only when there is no other appropriate alternative.  Nevertheless, having reminded itself of all these factors, the Panel was satisfied that a striking off order is indeed not only appropriate in the present case, but it is the only appropriate order.  No lesser sanction would provide the degree of public protection required, and no lesser sanction would ensure that public confidence would be maintained, and no lesser sanction would declare proper professional standards and serve to remind other registrants of the serious view that would be taken were they to breach standards in the way the Registrant did.  These factors outweigh the personal difficulties the Panel acknowledges the Registrant will suffer as a result of the imposition of this sanction.  For that reason the Panel is satisfied that it is proportionate response to the findings made.

Order:

The Registrar is directed to strike the name of Karl A. Hough from the Register on the date this Order comes into effect.

INTERIM ORDER

The Panel makes an Interim Suspension Order under Article 31(2) of the Health Professions Order 2001, the same being necessary to protect members of the public and being otherwise in the public interest. 

This order will expire: (if no appeal is made against the Panel’s decision and Order) upon the expiry of the period during which such an appeal could be made; (if an appeal is made against the Panel’s decision and Order) the final determination of that appeal, subject to a maximum period of 18 months.

History of Hearings for Mr Karl A Hough