Mr Carl W Fisher

: Paramedic

: PA01254

: Final Hearing

Date and Time of hearing:10:00 27/02/2017 End: 17:00 01/03/2017

: Health and Care Professions Council, 405 Kennington Road, London, SE11 4PT

: Conduct and Competence Committee
: Suspended

Allegation

(as amended at the Final Hearing)

 

During the course of your employment as a Paramedic for East Midlands Ambulance Service NHS Trust (‘the Trust’):

 

1. On 7 June 2015, you did not use the Trust-approved Paramedic Pathfinder to decide whether to convey Service User A to hospital;

 

2. On 7 June 2015, you did not undertake an adequate assessment of, and/or adequately complete a Patient Report Form for, Service User A, in that you did not undertake and/or record the following:

 

a) Airway assessment;

 

b) Breathing assessment;

 

c) Blood Sugar assessment;

 

d) Pain management assessment;

 

e) Pupil assessment;

 

f) Secondary observations;

 

g) National Early Warning Score (‘NEWS’) assessment;

 

h) A full Neurological assessment;

 

i) Chest examination;

 

j) Abdominal examination;

 

3. On 7 June 2015, you did not complete a Patient Report Form for Child A;

 

4. On 7 June 2015, you did not arrange for the following to be conveyed to hospital:

 

a) Child A;

 

b) Service User A;

 

5. On 7 June 2015, you did not complete a safeguarding referral in relation to Child A;

 

6. On 24 June 2015, you did not complete a Paramedic Clinical Assessment to an adequate standard;

 

7. Your actions described in particulars 1 to 6 constitute misconduct and/or lack of competence;

 

8. By reason of your misconduct and/or lack of competence your fitness to practise is impaired.

Finding

Preliminary matters

 

Proof of Service

 

1.             The Panel had sight of a letter dated 17 November 2016 sent to the Registrant at his registered address, giving details of today’s hearing, and determined that Notice of the hearing had been properly served in accordance with Rule 3 of the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 (“the Rules”).

 

Proceeding in the absence of the Registrant

 

2.             Mr Kewley applied to proceed in the absence of the Registrant.

 

3.             The Panel accepted the advice of the Legal Assessor, who took the Panel to the HCPC Practice Note on “Proceeding in the Absence of the Registrant”, to Rule 11  of the Rules and to the guidance given in the cases of R v Jones (2003) 1 AC 1 and Tait v The Royal College of Veterinary Surgeons [2003] UKPC 34.

 

4.             The Panel was provided with a copy of a Response Pro-Forma signed by the Registrant on 19 January 2017, stating that he would not be attending the hearing.

 

5.             The Panel was also provided with a file note of a telephone call from the Registrant on 18 November 2016, in which he stated that he would not be attending and that he did not want to attend by telephone.

 

6.             The Panel was also provided with a bundle of documentation entitled “Registrant’s Representations” dated 14 January 2016, in which the Registrant provided a response to the allegation.

 

7.             The Panel concluded, on the basis of the papers before it, that the Registrant was aware of the hearing and had voluntarily absented himself. He had not made an application to adjourn and the Panel concluded that it was highly unlikely that he would attend if the matter were to be adjourned. The Panel bore in mind that any potential unfairness caused by proceeding in the absence of the Registrant could be mitigated by taking into account the Registrant’s representations set out in his document of 14 January 2016. The Panel concluded that it was in the public interest for the matter to be heard expeditiously.

 

8.             In all the circumstances, the Panel decided to proceed in the absence of the Registrant.

 

Application to amend the allegation

 

9.             Mr Kewley applied to amend the allegation. The Registrant had been notified of the proposed amendments.

 

10.           The Panel decided to allow the amendments in their entirety because to do so was in the interests of justice and caused no injustice to the Registrant.

 

Witnesses

 

11.           The Panel heard from two witnesses called on behalf of the HCPC:

 

       LB – Locality Quality Manager, East Midlands Ambulance Service NHS Trust (“EMAS”);

 

       CS – Clinical Education Development Specialist, EMAS.

 

Background

 

12.           At the material time, the Registrant was employed by EMAS, with whom he had been employed for more than 20 years.

 

13.           In 2014/2015, the Registrant had two periods of sickness absence: 8 February 2014 to 8 July 2014 and 2 January 2015 to 14 May 2015.

 

14.           On 15 June 2015 the Leicester Royal Infirmary (“LRI”) contacted EMAS regarding Service User A and her baby, Child A, who had both attended LRI. Child A had been diagnosed with a fractured skull.

 

15.           It was discovered that the Registrant had attended to Service User A and Child A approximately one week earlier, on 7 June 2015, when Service User A had fainted whilst holding Child A in her arms. The Registrant had discharged Service User A and Child A at the scene.

 

16.           A Serious Incident investigation was conducted by LB, who ascertained that the Registrant had responded to the incident in a solo fast response vehicle following concerns that Child A had been dropped.

 

17.           LB analysed the Patient Report Form (PRF) completed by the Registrant in relation to Service User A. LB informed the Panel that Paragraph 1.2 of Appendix B of the EMAS Clinical Record Keeping Policy identified the purpose of a PRF as follows: “a PRF records comprehensive, accurate clinical and non-clinical information. It records details about the incident to which an operational response has been made and provides space for recording care provided to a patient”. LB’s review led to the concerns set out in the allegation.

 

18.           CS was then asked to conduct a Paramedic Clinical Assessment of the Registrant on 24 June 2015. It is alleged that the Registrant did not complete the Assessment to an adequate standard.

 

19.           The Panel was provided with representations that had been put forward by the Registrant in the course of:

 

           an interview conducted by LB on 16 June 2015;

 

           the Registrant’s response to the Investigating Committee dated 15 April 2016;

 

           the Notice to Admit facts dated 19 September 2016;

 

           the Response to Service of Papers Pro-Forma dated 19 January 2017.

 

Decision on Facts

 

20.           The Panel accepted the advice of the Legal Assessor. In reaching its decision it took into account the evidence provided by LB and CS, the bundle of documentation supplied by the HCPC, and the representations provided by the Registrant.

 

21.           The Panel concluded that both LB and CS were credible and reliable witnesses.

 

22.           Both witnesses stated in their evidence that they had wanted the assessment process to be fair and unbiased for the Registrant. During their evidence, the witnesses were measured in criticising the Registrant’s clinical practice. Both witnesses were able to explain the basis of any criticism when challenged, and also pointed out positives in the Registrant’s career history and practise. 

 

Particular 1

 

On 7 June 2015, you did not use the Trust-approved Paramedic Pathfinder to decide whether to convey Service User A to hospital

 

23.           Mr Kewley did not invite the panel to find Particular 1 proved. LB had given evidence that the Registrant had not been trained in how to use the Paramedic Pathfinder. As such, it could not be said that there was an obligation on the Registrant to use the Paramedic Pathfinder when he was dealing with the incident on 7 June 2015.

 

24.           The Panel accepted this reasoning.

 

25.           Accordingly, the Panel found Particular 1 not proved.

 

Particular 2

 

On 7 June 2015, you did not undertake an adequate assessment of, and/or adequately complete a Patient Report Form for, Service User A, in that you did not undertake and/or record the following:

 

a) Airway assessment;

b) Breathing assessment;

c) Blood Sugar assessment;

d) Pain management assessment;

e) Pupil assessment;

f) Secondary observations;

g) National Early Warning Score (‘NEWS’) assessment;

h) A full Neurological assessment;

i) Chest examination;

j) Abdominal examination

 

26.           It was alleged:

 

         That the Registrant did not record certain assessments/examinations on the PRF and therefore did not adequately complete the PRF (the “did not record” allegations);

 

         That he did not carry out certain assessments/examinations on Service User A (the “did not do” allegations);

 

         That his assessment of Service User A was not adequate.

 

27.           LB informed the Panel that Service User A had undergone the delivery of a baby by caesarean section seven days prior to the incident. He said that there was therefore a risk that internal bleeding had caused Service User A to faint. LB asserted that he would have expected the PRF to record a collection of baseline observations, along with Service User A’s medical history.

 

28.           In his witness statement, LB said that from his clinical review of the PRF, there was only one set of observations recorded on the PRF. He told the Panel that the importance of recording more than one set of observations was that this could be an indicator of a deterioration or improvement in a patient’s condition. In his witness statement LB stated that the matters set out in Particulars 2(a) to (j) inclusive had not been recorded on the PRF.

 

29.           The Registrant set out his most recent response to this particular in the Notice to Admit Facts dated 19 September 2016 and in the Response to Service of Papers Pro-Forma dated 19 January 2017. The Panel concluded from the documentation submitted by the Registrant that he accepted not recording the assessments/examinations identified in Particular 2, but maintained that he did carry out the assessments/examinations, save that he accepted not carrying out a blood sugar assessment (particular 2(c)) and asserted that he was not trained to carry out the NEWS assessment (particular 2(g)).

 

30.           The Panel approached Particular 2 by asking:

 

     Did the Registrant fail to record one or more of the assessment/examinations particularised at 2(a) to (j)?

 

     Did the Registrant fail to carry out one or more of the assessments/examinations particularised at 2(a) to (j)?

 

     Was the Registrant’s assessment of Service User A adequate?

 

31.           In relation to the “did not record” allegations, the Panel concluded as follows:

 

     In relation to sub particulars 2(a) (airway) and 2(b) (breathing), it was evident that these had not been recorded separately in the observations area of the PRF. However, the Panel had regard to LB’s evidence in response to Panel questioning, namely that it was acceptable for the Registrant to rely on his initial assessment of Service User A’s airway and breathing carried out at around 03:42, where a recording had in fact been made on another part of the PRF. The Panel therefore concluded that there was in fact a recording of Service User A’s airway and breathing on the PRF.

 

     In relation to sub particulars 2(c) to (f), the Panel accepted LB’s evidence and the Registrant’s admissions that these were not recorded.

 

     In relation to sub particular 2(g) (NEWS score assessment), it was evident that the NEWS score itself had not been recorded on the PRF. However, each component of the NEWS score had been recorded.  Furthermore, LB had accepted in his evidence that training on NEWS would have been part of the Paramedic Pathfinder training which, the HCPC accepted, had not been undertaken by the Registrant.  The Panel concluded that there was no obligation on the Registrant to record a NEWS score in light of LB’s evidence.

 

     In relation to sub particulars 2(h) to (j), the Panel accepted LB’s evidence and the Registrant’s admissions that these were not recorded on the PRF.

 

32.           In relation to the “did not do” allegations, the Panel concluded as follows:

 

     In light of LB’s evidence in relation to 2(a), (b) and (g), as set out above, (a) and (b) were carried out in the initial assessment and in relation to (g) the Registrant had carried out every component of the NEWS and as he had not been trained in NEWS there would have been no obligation on him in this regard. The Panel therefore found these three sub-particulars not proved.

 

     In respect of the remaining sub-particulars of particular 2, with the exception of a blood sugar assessment (2(c)), the Registrant’s case appeared to be that he did in fact carry out the remaining assessments, but that he failed to record them in the PRF.

 

     In relation to 2(c) the Panel accepted the Registrant’s admission together with the lack of record and found this proved.

 

     In relation to the remaining sub-particulars (d), (e), (h), (i) and (j), the Panel noted that in his interview with LB on 16 June 2015 the Registrant had not listed any of these observations when asked what he had done.  In relation to sub-particular (f), the Panel was of the view that the observations that the Registrant said that he had carried out were insufficient to amount to “secondary observations”. This, combined with the lack of records, led the Panel to find these sub-particulars proved.

 

33.           In light of the Panel’s findings as set out above, the Panel found sub-particulars 2(a), 2(b) and 2 (g) not proved, but 2(c), 2(d), 2(e), 2(f), 2(h), 2(i) and 2(j) proved on the basis that the Registrant had not undertaken an adequate assessment nor had he adequately completed a Patient Report Form.

 

Particular 3

 

On 7 June 2015, you did not complete a Patient Report Form for Child A

 

34.           LB informed the Panel that the Registrant completed a PRF for Service User A, but not for Child A.

 

35.           Paragraph 3.2 of Appendix B of the EMAS Record Keeping Policy provides: “The Patient Report Form is to be completed by all personnel for each patient attended….”

 

36.           LB gave evidence that Child A was a separate patient and should have had an individual PRF completed. This was not done. In the absence of a PRF for Child A, there was no record of, for example, Child A’s condition, how far the child had fallen and the nature of the surface onto which Child A had fallen.

 

37.           In his interview with LB on 16 June 2015, the Registrant appeared to accept that he did not complete a PRF for Child A.

 

38.           In the Notice to Admit Facts and the Response Pro-Forma, the Registrant accepted that he did not complete a PRF for Child A.

 

39.           In light of all the evidence, the Panel concluded that the Registrant had not completed a PRF for Child A and found this particular proved.

 

Particular 4

 

On 7 June 2015, you did not arrange for the following to be conveyed to hospital:

 

a) Child A;

b) Service User A.

 

40.           LB’s evidence was that both patients should have been conveyed to hospital.

 

41.           LB referred the Panel to the specific features of the case that suggested Service User A required conveying, namely:

 

     Service User A had a sudden collapse;

 

     Service User A had no recollection of the event;

 

     Service User A had a history of loss of consciousness;

 

     Service User A had recently given birth by caesarean section and was noted to have had pre-eclampsia.

 

42.          In relation to  Child A, LB referred to the following points:

 

     Child A was a newborn;

 

     Child A had been dropped and by virtue of the baby’s age, this should have been considered as a “fall from height”;

 

42.           The Registrant admitted this particular in the Notice to Admit Facts and in the Response Pro-Forma.

 

43.           On the basis of all the evidence, the Panel found this particular proved.

 

Particular 5

 

On 7 June 2015, you did not complete a safeguarding referral in relation to Child A.

 

44.           LB’s evidence was that amongst the many patients that EMAS attend, attendance at an incident in which a mother has dropped a baby is rare. LB said that this should have alerted the Registrant of the need for matters to be investigated further. LB said that he would have expected the Registrant to have completed a safeguarding referral to the EMAS safeguarding team.

 

45.           The Registrant admitted this particular in the Notice to Admit Facts and the Response Pro-Forma.

 

46.           On the basis of all the evidence, the Panel found this particular proved.

 

Particular 6

 

On 24 June 2015, you did not complete a Paramedic Clinical Assessment to an adequate standard

 

47.           An assessment was arranged for the Registrant on 24 June 2015, conducted by CS, in the following five areas: advanced life support (adult), newborn/paediatric resuscitation, adult medical, adult trauma and paediatric trauma. CS’s evidence was that the objective of the assessment was to check the Registrant’s base level knowledge. CS’s evidence was that the level of the assessment was that of basic paramedic knowledge.

 

48.           In summary, CS had real concerns regarding the Registrant’s competence. CS said that she was not convinced that the Registrant could manage, for example, a child in cardiac arrest. CS said that it was “shocking and concerning” that the Registrant was not able to use basic kit during the assessment. CS’s evidence was that the Registrant did not appear to realise how poor his practice was and that the Registrant’s lack of basic knowledge was evidenced by his inability to undertake, for example, scene size up (first impression/initial risk assessment of the scene) or follow the DR ABC mnemonic.  

 

49.           Only three of the five areas could be assessed on 24 June 2015 because a decision was taken to stop the assessment owing to the Registrant becoming upset.

 

50.           CS’s evidence was that she was assessing basic paramedic competencies using standard assessment forms. CS gave detailed evidence in her witness statement regarding the nature of her concerns. She expanded cogently in her oral evidence on her concerns.

 

51.           The Panel noted that the Registrant admitted this particular in the Response Pro-Forma.

 

52.           The Panel concluded from CS’s detailed evidence that the Registrant did not reach an adequate standard in the adult and paediatric resuscitation and adult medical assessments.

 

53.           On the basis of all the evidence, the Panel found this particular proved.

 

Decision on Grounds

 

54.           The Panel accepted the advice of the Legal Assessor, who addressed the Panel on the meaning of lack of competence, misconduct and impairment.

 

55.           The Panel was asked to consider whether Particulars 2-5 amounted to misconduct and whether Particular 6 amounted to lack of competence. The Panel was specifically discouraged from asking whether Particulars 2-5 amounted to lack of competence and whether Particular 6 amounted to misconduct.

 

56.           The Panel concluded that Particulars 2-5 inclusive amounted to misconduct.

 

57.           The Panel concluded on the basis of the material that had been presented to it that the Registrant had been under a duty to complete the actions particularised and found proved.

 

58.           The Panel concluded that the Registrant had breached the following HCPC “Standards of Conduct, Performance and Ethics” (2012 version):

 

1      You must act in the best interests of Service Users

 

5      You must keep your professional knowledge and skills up to date

 

10  You must keep accurate records

 

59.           The Panel concluded that the Registrant had also breached the following HCPC “Standards of Proficiency for Paramedics” (2014):

 

1      Be able to practise safely and effectively within their scope of practice

 

3      Be able to maintain fitness to practise

 

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

 

10  Be able to maintain records appropriately

 

13  Understand the key concepts of the knowledge base relevant to their profession

 

14  Be able to draw on appropriate knowledge and skills to inform practice

 

60.           The Panel accepted that the events of 7 June 2015 had amounted to one incident. However, it had involved two patients – one, a mother who had had lost consciousness, and the other, a baby who had been held in the mother’s arms and dropped. It was the judgement of the Panel that the Registrant had been capable of, but had failed to, recognise the potential seriousness of the incident and the safeguarding implications. His behaviour amounted to a serious falling short of the standard expected of him.

 

61.           In relation to Particular 6, the Panel concluded that the material provided had not amounted to a fair sample of the Registrant’s work. The Panel also took into account the Registrant’s emotional state during the assessment. In those circumstances, the Panel concluded that Particular 6 did not amount to lack of competence.

 

Decision on Impairment

 

62.           In considering whether the Registrant is currently impaired by reason of his misconduct, the Panel accepted the advice of the Legal Assessor and took note of the HCPC Practice Note on “Finding that Fitness to Practise is Impaired”.

 

63.           The Panel accepted that the misconduct had resulted from a single incident. However, it had involved multiple failings and two service users with different presentations.

 

64.           The Panel considered that the Registrant’s misconduct is capable of being remedied. However, it has been provided with no evidence of remediation.

 

65.           In considering the issue of insight, the Panel accepted that the Registrant had admitted some of the factual allegations. However, he had denied others. He had not provided any evidence of reflection. LB’s evidence was that the Registrant did not show any insight into the seriousness of the incident. The Panel therefore concluded that the Registrant’s insight was limited.

 

66.           The Registrant notified the HCPC in April 2016 that he had not practised as a paramedic since 16 June 2015. As such, it would appear that there has been no subsequent period of clinical practice as a paramedic from which the Panel could conclude that the risk of repetition is low.

 

67.           In those circumstances, the Panel concludes that there is a risk that the Registrant could repeat his failings if allowed to continue to work unrestricted. The Panel therefore finds the Registrant to be currently impaired on the basis of the personal component.

 

68.           The Panel also concludes that the wider public interest demands a finding of impairment. The Registrant has failed two vulnerable service users. He failed to uphold proper standards of proficiency and the Panel concludes that public confidence in the profession and the regulatory body would be undermined if a finding of impairment were not made.

 

69.           The Panel therefore finds that the Registrant is currently impaired.

 

Decision on Sanction

 

70.           The Panel heard the submissions of the Presenting Officer.

 

71.           The Panel accepted the advice of the Legal Assessor.

 

72.           The Panel kept in mind that the purpose of sanctions is not to be punitive but is designed to protect the public interest, which includes protecting members of the public and maintaining proper standards within the profession, the reputation of the profession itself and public confidence in the regulatory functions of the HCPC.

 

73.           The Panel took into account the current “Indicative Sanctions Policy” published by the HCPC.

 

74.           In considering whether to make an order, and the nature and duration of any order to be made, the Panel applied the principle of proportionality, weighing the Registrant’s interests in balance with the need to protect the public interest.

 

75.           The Panel took into account both mitigating and aggravating circumstances.

 

76.           The Panel concluded that the following were mitigating factors:

 

     The Registrant’s long unblemished career hitherto;

 

     The positive evidence of the Registrant’s character provided by the witnesses;

 

     The Registrant’s acceptance of some of the allegations of fact.

 

77.           The Panel concluded that the following were aggravating factors:

 

     The Registrant’s misconduct had put two vulnerable service users at risk of harm;

 

     The incident had involved multiple failings of a fundamental nature;

 

     The Registrant had shown limited insight into the effect of his shortcomings.

 

78.           The Panel considered the sanctions available to it in ascending order of severity.

 

79.           The Panel concluded that in view of the continued risk to the public, to take no further action or to impose a Caution Order would not be sufficient to protect the public, maintain confidence in the profession and maintain confidence in the regulatory process. It could not be said that the Registrant’s failings had been limited or minor in nature; to the contrary the Panel had found that the failings had been numerous. Furthermore, there had been no evidence of remediation placed before the Panel, and the Registrant’s insight appeared to be limited.

 

80.           The Panel then considered a Conditions of Practice Order, but concluded that this would be neither appropriate nor workable. The failings were basic and fundamental. The Panel had no information regarding the Registrant’s current work situation or his future intentions. In those circumstances it was not possible to formulate workable conditions, as the Panel had no evidence that the Registrant would be prepared to abide by any conditions that the Panel might seek to impose.

 

81.           The Panel then considered a Suspension Order and concluded that this was both sufficient and proportionate in light of the seriousness of the Registrant’s failings and lack of remediation.

 

82.           The Panel concluded that a period of twelve months’ suspension was appropriate and proportionate, and would give the Registrant time to address his misconduct in order to demonstrate his remediation to a future Panel, and to develop full insight if that was the course he chose to take.

 

83.           The Suspension Order will be reviewed before it expires. A future Panel reviewing the order would be helped by:

 

     the Registrant’s attendance;

 

     evidence of training and remediation;

 

     testimonials relating to current paid or unpaid work;

 

     a piece of reflective writing addressing:

 

(i)       the effect of the Registrant’s misconduct on the vulnerable Service Users he had dealt with;

 

(ii)      any specific training the Registrant would need to undertake to return to practise.

 

84.           The Panel gave consideration to a Striking Off order, but concluded that this would be disproportionate and punitive at this time in all the circumstances of the case.

Order

That the Registrar is directed to suspend the registration of Mr Carl W Fisher for a period of 12 months from the date this order comes into effect.

Notes

The order imposed today will apply from 28 March 2017 (the operative date).

 

This order will be reviewed again before its expiry on 28 March 2018.

Hearing history

History of Hearings for Mr Carl W Fisher

Date Panel Hearing type Outcomes / Status
01/03/2018 Conduct and Competence Committee Review Hearing Struck off
27/02/2017 Conduct and Competence Committee Final Hearing Suspended