Mr Edward D Henderson

: Paramedic

: PA29915

: Review Hearing

Date and Time of hearing:12:30 05/05/2017 End: 17:00 05/05/2017

: Health and Care Professions Tribunal Service (HCPTS), 405 Kennington Road, London, SE11 4PT

: Conduct and Competence Committee
: Struck off

Allegation

The following allegation was considered by a panel of the Conduct and Competence/Health Committee at the substantive hearing on 9-10 May 2016.

During the course of your employment as a Paramedic at the North East Ambulance Service NHS Foundation Trust you:

1. Did not keep accurate records of the Controlled Drugs in your possession, in that;

a. On 01/10/11, you did not record the batch number for 100ml Oramorph;

b. On 01/12/12, you did not record the batch number for 100ml Oramorph;

c. On 15/06/13, you did not record the batch number for 5ml Oramorph given to a patient;

d. On 03/10/13, you ordered Oramorph, it was dispatched on 07/10/13, but you did not record it in stock;

e. On 04/11/13, you did not record the batch number for 5ml Oramorph given to a patient;

f. On 03/03/14, you were issued with a new bottle of Oramorph but you did not record the bottle in stock;

g. Did not record receipt of Oramorph that was dispatched to you on 13 October 2011;

h. Administered 10ml/20mg of Oramorph to Patient C on 23 November 2011, and did not record this in your Controlled Drugs Register;

i. Administered 5ml/10mg of Oramorph to Patient D on 25 February 2012 and did not record this in your Controlled Drugs Register.

j. On 22 September 2013, administered Morphine Sulphate to Patient A but did not record the quantity given in your Controlled Drugs Register;

k. Did not record receipt of 20 units of Morphine Sulphate between 11 April 2013 and 15 May 2013 in your Controlled Drugs Register.

2. Inappropriately destroyed 2 vials of Morphine Sulphate to cover the fact that you had not kept an accurate record of your Controlled Drug administration.

3. Did not ensure that the destruction of Morphine Sulphate vials, as set out in paragraph 2, was witnessed and/or reported via the approved North East Ambulance Service reporting system.

4. Administered out-of-date Morphine Sulphate on 2 separate occasions, one being on 01 March 2014.

5. Your actions described in paragraphs 2 and/or 3 were dishonest.

6. The matters set out in paragraphs 1 – 5 constitute misconduct and/or lack of competence.

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

Finding

Preliminary Matters

Service

1. The Panel was satisfied on the documentary evidence provided that the Registrant had been given proper Notice of this review hearing in accordance with the Rules. Notice of this hearing was sent by first class post to his address on the Register by letter dated 5 April 2017. The Notice contained the relevant required particulars.

 Proceeding in Absence

2. The Panel heard the application from Ms Royer on behalf of the HCPC to proceed in the absence of the Registrant.

3. The Panel heard and accepted the advice of the Legal Assessor, who advised that the discretion to proceed in the absence of the Registrant was one that must be exercised with the utmost care and caution.

4. Having considered the circumstances, the Panel determined to proceed in the absence of the Registrant. The reasons are as follows: Service of the appropriate Notice of this hearing has been properly effected; There has been no correspondence or engagement from the Registrant, notwithstanding the duty on a registrant to engage with his Regulator and keep it up to date with his circumstances. He did not attend the Final Hearing and he has not engaged with the HCPC since the Final Hearing; The Registrant has not requested an adjournment, nor would the Panel suppose that an adjournment would result in his future attendance; This is a statutory review of an Order which is due to expire on 7 June 2017, and it is in the public interest to review the Order.

5. The Panel concluded that the Registrant had voluntarily absented himself, thereby waiving his right to attend.

Background

6. The Registrant is a qualified Paramedic who first started working for the North East Ambulance Service (NEAS) in August 2005. At the time of the incidents he was working as a Band 5 Paramedic.

7. Paramedics employed by NEAS were required to conduct monthly audits of their controlled drug stocks. Team Leaders also undertook monthly audits of their controlled drugs of all paramedics every three months.

8. In February 2014, NEAS’s Director of Clinical Care and Patient Safety requested a review of all policies and procedures in matters of medicine management. In April 2014, as part of this process, an audit of controlled drugs was conducted, which identified that 42 paramedics within the organisation had administered out-of-date morphine, oramorph or diazemuls.

9. From the audit, the Registrant was initially identified as having administered one dose of out-of-date morphine to a patient. On 23 September 2014, he attended an informal meeting to highlight the issue, but during the course of the meeting, other concerns became apparent, resulting in an investigation being carried out into the management and recording of controlled drugs by the Registrant. The findings of that investigation were the basis of the particulars within the allegation.

10. On 9-10 May 2016, a Final Hearing was held, which the Registrant did not attend, and the Hearing proceeded in his absence. The original panel found facts proved in relation to repeated failures in recording batch numbers of controlled drugs; one administration of Oramorph and two administrations of morphine sulphate without recording the fact of the respective administrations in his Controlled Drugs Register; two occasions of administering out-of-date morphine sulphate; and the dishonest destruction of and non-reporting of 2 morphine sulphate vials.

11. The original panel found that the Registrant had breached a number of the relevant standards for registrants generally and for paramedics specifically. It concluded that his actions and omissions individually and collectively amounted to misconduct.

12. The original panel concluded that the Registrant’s fitness to practise was impaired in respect of the ‘public component’, finding: “…the Panel has nothing to show that the Registrant is currently working within his profession and without cause for concern. There is no evidence that the Registrant has taken any steps to address his record keeping failings or to ensure that there would be no repetition of his misconduct. There has been no expression of remorse, apology or regret for his actions and little by way of demonstration of insight into misconduct. This being the case there is a likelihood of repetition of his misconduct and his dishonest actions.”

13. The original panel also concluded that the Registrant’s fitness to practise was impaired in respect of the ‘public component’, finding: “The Registrant’s actions have brought him into disrepute and his profession and a failure to mark that would undermine the public confidence in the profession and in turn the regulatory process.”

14. The original panel imposed a 12 month Suspension Order, noting that: the Registrant had successfully practised as a Paramedic since 2005 without any concerns about his clinical practice; a lack of steps taken by NEAS to address previously the practice of entering deficient information on the Controlled Drugs Registers; the Registrant’s acknowledgement that his record-keeping had deteriorated to the level of being ‘abysmal’; that he had not sought to deflect blame; and that he had not been alerted to the need to undertake professional reflection on events. The original panel stated that it hoped “that the Registrant would avail himself of the opportunity to address and correct his previous failings”, and identified a number of matters which it felt may assist a future reviewing panel, namely:

• Evidence of either a course of study, or suitable record keeping practice;

• Evidence of how the Registrant has reflected on his actions;

• Evidence that the Registrant would be able to work with minimum supervision in the future.

Decision

15. This is the first review of a Suspension Order of 12 months. This Panel is reviewing the Order pursuant to Article 30(1) of the Health and Social Work Professions Order 2001.

16. The Panel considered the submissions of Ms Royer on behalf of the HCPC, who submitted that the Registrant remains impaired, as there is no material from the Registrant to demonstrate that he has taken any steps to remediate his practice. She invited the Panel to extend the current Suspension Order.

17. The Panel heard and accepted the advice of the Legal Assessor

18. The Panel noted that the Registrant had not attended the Final Hearing in May 2016. The allegation considered at the Final Hearing was in respect of failings regarding controlled drugs, and culminating in dishonesty by concealing a failing in record-keeping of morphine sulphate. In the original panel’s view, this had formed a pattern of behaviour over a significant period of time, namely some three years. The original panel had formed the view that this amounted to serious misconduct and this Panel agreed with that assessment.

19. The original panel had identified steps for the Registrant to take which it felt may have assisted a reviewing panel. However, this Panel was concerned that the Registrant has now completely disengaged with the HCPC, such that it amounts to a disregard for his Regulator. He has provided no information for this Panel to consider, so the Panel has no information regarding the Registrant’s current personal circumstances. It was of the view that the Registrant has not, therefore, provided any information to demonstrate whether or not he has gained insight into his failings, or has taken any steps to remediate his practice. Therefore, in the Panel's judgement, the risk of repetition remained high. The Panel concluded that the serious misconduct identified by the original panel had become aggravated by the Registrant’s disregard for his Regulator. The Panel therefore concluded that the Registrant’s fitness to practise is currently impaired, both in respect of public protection and on public interest grounds.

20. The Panel therefore went on to consider the sanctions available to it, from the least restrictive to the most severe. It had regard to the Indicative Sanction Policy (the Policy). It took into account paragraph 6 of the Policy, which states:

“The primary function of any sanction is to address public safety from the perspective of the risk which the registrant concerned may pose to those who use or need his or her services. However, in reaching their decisions, Panels must also give appropriate weight to the wider public interest which includes:

• the deterrent effect to other registrants;

• the reputation of the profession concerned; and

• public confidence in the regulatory process.”

21. The Panel first considered whether to take no further action and to allow the Suspension Order to lapse, or whether to impose a Caution Order. In light of its finding that the Registrant remained impaired, and that the risk of repetition remained high, the Panel concluded that neither option was appropriate. The issues in respect of the Registrant’s practice remain unresolved to date. Neither option would restrict his practice, so would not protect the public, nor would they address the wider public interest.

22. The Panel next considered imposing a Conditions of Practice Order. The Panel took account of paragraph 32 of the Policy, which indicates that the Panel will need to consider whether a registrant can be trusted to comply with them. In the absence of any engagement from the Registrant, the Panel could not be confident that the Registrant could be trusted to comply with conditions. Therefore, the Panel concluded that a Conditions of Practice Order was neither appropriate nor proportionate.

23. The Panel next considered extending the current Suspension Order. The Panel had regard to paragraph 39 of the Policy, which states: “Suspension should be considered … where the allegation is of a serious nature but unlikely to be repeated and, thus, striking-off is not merited”. As the Panel has previously found when considering impairment, the Registrant’s disengagement from and disregard for the Regulator has aggravated what was originally found to be serious misconduct. It was described by the original panel as both “wilful” and “reckless”. As stated above, this Panel has concluded that in the absence of insight and remediation, the risk of repetition remains high. The Panel therefore considered that a Suspension Order was no longer the appropriate and proportionate response in the specific circumstances of this case.

24. The Panel next went on to consider a Striking Off Order. The Panel considered that paragraph 47 of the Policy was relevant. It says, “Striking off is a sanction of last resort for serious, deliberate or reckless acts involving … dishonesty”. The Panel also had regard to paragraph 49, which states, “Striking off may also be appropriate where the nature and gravity of the allegation are such that … any lesser sanction would … undermine public confidence in the profession concerned…”. The Panel had regard to its earlier finding that the serious misconduct of the Registrant had been aggravated by his disregard of the Regulator. In light of this, the Panel did not consider that any lesser sanction than a Striking Off Order would meet the wider public interest, including acting as a deterrent effect to other Registrants, upholding the reputation of the profession and maintaining public confidence in the regulatory process. The Panel therefore determined that a Striking Off Order was the only appropriate and proportionate sanction.

25. The Panel acknowledged that such an Order would be likely to have a serious financial impact upon the Registrant as he will be unable to practise as a Paramedic. However, the Panel determined that the interests of maintaining public confidence in the profession and upholding professional standards outweighed the interests of the Registrant.

Order

The Registrar is directed to strike the name of Edward D Henderson from the Register on the expiry of the current Suspension Order.

Notes

The order imposed today will apply from 7 June 2017.

Hearing history

History of Hearings for Mr Edward D Henderson

Date Panel Hearing type Outcomes / Status
05/05/2017 Conduct and Competence Committee Review Hearing Struck off
09/05/2016 Conduct and Competence Committee Final Hearing Suspended
01/07/2015 Conduct and Competence Committee Interim Order Review Interim Suspension