Adele J Copeman-King

: Paramedic

: PA29957

: Final Hearing

Date and Time of hearing:10:00 27/06/2017 End: 17:00 05/07/2017

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

: Conduct and Competence Committee
: Suspended

Allegation

Matter 1

 

During the course of your employment as a Paramedic with South Western Ambulance Service:

 

1. On 25 March 2013, you attended to Patient A who suffered head injuries and did not:

 

a. commence immobilisation of the patient;

 

b. complete a full spinal mobilisation;

 

c. clear the patient's neck;

 

d. examine the patient's skull;

 

e. conduct a chest or abdominal examination of the patient;

 

f. take the patient's blood pressure;

 

g. correctly calculate the patient's GCS (Glasgow Coma Scale);

 

h. accurately complete the Patient Clinical Record for the patient.

 

2. The matters set out in paragraph 1 constitute misconduct.

 

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

 

Matter 2

 

While registered with the HCPC as a Paramedic following your dismissal from your employment at South Western Ambulance Service NHS Foundation Trust, you:

 

1. harassed ex colleagues by sending emails to witnesses who had participated in the disciplinary process that resulted in your dismissal for Gross Misconduct on 29 October 2013, in that you:

 

a. sent an email to your ex-colleague, Colleague A, on 18 December 2013 in which you:

 

i. described your ex-colleagues as being "gutless" or words to that effect; and

 

ii. accused Colleague A of giving an "embellished exaggerated complaint to the ambulance service"; and

 

iii. accused Colleague A of giving a "wildly exaggerated and inaccurate account" during your disciplinary investigation; and

 

iv. told Colleague A to "cut out the lies, exaggerations and embellishments".

 

b. sent an email to your ex-colleague, Colleague A, on 09 January 2014, in which you:

 

i. demanded a response to a previous email;

 

ii. criticised his capacity for empathy.

 

c. sent an email to your ex-colleague, Colleague B, on 09 January 2014, in which you:

 

i. accused her of an "inappropriate lack of care" towards a patient;

 

ii. suggested that she could make a self-referral to the Health and Care Professions Council; and

 

iii. requested details of an investigation that had been conducted by South Western Ambulance Service NHS Foundation Trust into a complaint that had been made against Colleague B.

 

2. The matters set out in paragraph 1 constitute misconduct.

 

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

Finding

Preliminary matters:


Application by the Registrant for Adjournment and Recusal of the Panel:


1. Ms Rutter, representing the Registrant, made an application for the hearing to be adjourned, and for the Panel to recuse itself from any further hearing of this case, on the grounds that the Registrant would not receive a fair hearing.


2. The background to the application is as follows. The case was originally due to be heard on 18 May 2015, but was postponed on the application of the HCPC for joinder of a second allegation.  The case was relisted for hearing in May 2016, but it had to be further postponed because the Registrant was due to undergo surgery.  The final hearing was eventually listed on 24 October 2016.  The Registrant made an application to adjourn that hearing primarily on the grounds that there had been a recent change of representation and further time was required for preparation and to secure the attendance of an important witness.  The Panel hearing the case accepted that submission.

  
3. The decision of the Panel hearing the case in October 2016 was reinforced in its decision to adjourn by the fact that the HCPC exhibits bundle contained details of a previous finding against the Registrant by the HCPC.  The then Panel was aware of the nature and facts of the previous case.   The reference to the previous finding was described as extremely prejudicial in their written decision.  They made a direction to redact any reference to previous proceedings from the exhibits bundle.

4. The parties subsequently complied with the direction by agreeing the sections of the bundle that were to be redacted for the next hearing.  However, an unredacted exhibit bundle of 248 pages was inadvertently sent to the current Panel and all parties.  This was an administrative error on the part of the HCPC that arose from attaching the wrong document to an email.  One page of the unredacted exhibits bundle contained a brief summary of the actual facts of the previous matter.  There were two other oblique references on two other exhibit pages.  There was no reference to the previous matter in the statements bundle. 


5. The error was not noticed by the HCPC and only noticed by the Registrant and her representative shortly before the hearing.  On being alerted of the error, the HCPC emailed the Panel members on the day before the hearing to advise them not to read the exhibits bundle, although one panel member did not in fact receive this email.   The Panel members were again advised not to read their exhibit bundles on arrival on the day of the hearing. The relevant pages were subsequently removed from their bundles by Ms Partos on behalf of the HCPC.

6. It was agreed by the parties that the Legal Assessor should pose a question to the members of the Panel in open session after initial introductions and before the allegation was amended or put to the Registrant.  The agreed question was as follows:  “During the course of your reading of the bundle, have you read or noticed any reference to a previous matter in relation to this Registrant?” The Panel members all individually replied that they could not recall reading any such reference.  There followed a short adjournment for the parties to reflect and to take instructions.


7. Ms Rutter, on behalf of the Registrant, subsequently applied for the hearing to be adjourned and for the Panel to recuse itself.   She brought to the Panel’s attention the fact of the previous matter, as identified in the agreed question that they had answered, although she was scrupulously careful to avoid disclosing any detail of the previous matter.  Ms Rutter then set out the history of the present case, including the direction of the previous Panel that the previous matter be redacted and the fact that the HCPC was at fault.  She submitted that there was now a real possibility that the Panel would be perceived as biased in the mind of the Registrant and in the view of the reasonable and fair minded observer (Porter v Magill [2002] 2 AC 357).  Ms Partos, for the HCPC, accepted that the HCPC was at fault for the administrative error that led to unredacted bundles being sent out.  However, she submitted that an experienced professional regulatory panel should be trusted to be impartial and expected to disregard knowledge of the existence of a previous matter, especially when they had no knowledge of the facts of that matter. She further relied on the case of Maufouz v GMC [2004] EWCA Civ 233 in support of the contention that a properly directed panel can proceed with impartiality in these circumstances.  Ms Partos also reminded the Panel that this case related to matters four years ago, that witnesses had attended the hearing and that there was a public interest in proceeding expeditiously as well as fairly.


8. The Legal Assessor advised the Panel that they must ensure that the Registrant had a fair trial.  He set out the test of bias in the case of Porter v Magill but advised the Panel that this was not so much a case of bias as a case of whether they could give the Registrant a fair and impartial hearing and disregard information which was inadmissible and irrelevant, as set out in the words of Carnwath LJ at paragraph 33 of Maufouz v GMC: “Bias or apparent bias on the part of the tribunal cannot be corrected. On the other hand…knowledge of prejudicial material need not be fatal: its effects must be considered in the context of the proceedings as a whole, including the likely impact of the oral evidence and the legal advice available.”


9. The Legal Assessor further reminded the Panel that members of a professional regulatory panel were expected to be able to put irrelevant material that had been inadvertently disclosed out of their minds (see also Subramaniam v GMC [2003] Lloyds Rep Med 69) and that he would direct them to do so in emphatic terms at the close of the fact finding stage of the hearing in the way that was recommended by Carnwath LJ at paragraph 37 of Maufouz v GMC if the hearing were to proceed. 

 
10. The Panel accepted the advice of the Legal Assessor.  The Panel carefully considered the Registrant’s submissions in favour of recusal and adjournment and the effect of the decision of previous panel.   They found that the HCPC was at fault in failing to comply with the previous direction that the material should be redacted from the bundle.  They also accepted the Registrant’s submission that a perception of unfairness may arise in these circumstances.


11. However, the Panel was also satisfied that they could maintain their impartiality as a professional panel who were experienced in hearing cases in which issues of this kind can and do arise in the course of the hearing.  The potential prejudice was also substantially mitigated by the fact that the Panel had no knowledge of the actual facts of the previous matter.   The Panel did not consider that their knowledge of the mere fact of a previous finding, without any detail of the nature or the facts of that matter, could affect its impartiality in the present case.


12. The Panel had regard to the case of Maufouz v GMC to the effect that knowledge of prejudicial material need not be fatal to the fairness of the proceedings if the Panel can maintain its impartiality, especially when that impartiality is reinforced with the additional safeguard of a clear and unambiguous direction to disregard irrelevant matters from the Legal Assessor.

13. In making its decision to proceed with the hearing, the Panel also had in mind the previous delays in proceeding with this hearing, the convenience of the two witnesses who had attended or travelled to the hearing, and the need for expeditious disposal.  These concerns were of less significance than ensuring the fairness of the hearing, but they were also relevant and important factors.


Application to amend the Allegation:


14. The HCPC applied to amend the allegation in order to simplify and clarify the particulars. The Registrant did not oppose the application. The Panel accepted the advice of the Legal Assessor and allowed the application on the basis that the Registrant had been given sufficient notice of the proposed amendments, some of which were technical in their nature, and because there was no prejudice to her position or other unfairness if the amendments were permitted.


Response to Allegation


15. Ms Rutter indicated the Registrant’s response to the allegation as amended.  The particulars of allegation 1(a)(i) to (vii) and 1 (b) in relation to alleged deficiencies in her treatment and assessment of Patient A were not admitted.  The particular of allegation 2(a) to (c) in relation to emails amounting to harassment of Colleague B and Person 1 were admitted.  It was not accepted that misconduct was established in respect of any particular of the allegation or that fitness to practise was impaired.


Background


16. Ms Partos, for the HCPC, gave the Panel an overview of the allegation and the evidence in opening the case. The Registrant was employed as a Paramedic with the South Western Ambulance Service Foundation Trust (SWASFT).  She had been employed by the Trust since 1997 and had been a Paramedic since 2008, based at Christchurch ambulance station.  On 25 March 2013, she was responsible for attending an emergency call as a rapid responder with her mentee, Colleague C, a paramedic student in his first year at university with 3-5 weeks’ practical experience as an observer. Patient A was aged 78 years.  She had fallen down stairs whilst visiting a friend at the Oakdene care home near Verwood, Dorset, at about 16.00 on 25 March 2013.  She sustained a head injury and suffered a short period of unconsciousness.  The Registrant and Colleague C arrived on the scene at 16.18.


17. Colleague B, together with another Paramedic (CDV), attended the incident about thirteen minutes later at 16.31 as a two person back-up crew. Colleague B and CDV ultimately transported the patient to the Accident & Emergency department of Poole Hospital.  Patient A subsequently spent three days in hospital following a diagnosis of concussion, a rotator cuff (shoulder) injury and bruised ribs. She was later readmitted to hospital with ongoing complications associated with her head injury.


18. Following this incident, Colleague B completed a “Datix” incident report in which she set out concerns about the Registrant’s failure to immobilise the patient, as recommended by the Canadian c-spine rules, and her apparent failure to have conducted appropriate examinations. 


19. Patient A’s son (Person 2), a former nurse, wrote a letter of complaint about his mother’s treatment dated 30 March 2013. Colleague A, the Quality Lead for Somerset and Dorset, subsequently investigated the case.  Colleague A emailed Person 1 (Person 2’s partner), who was present at the scene at the time of the Registrant’s arrival, in order to ascertain his recollection of the incident.  She also gathered witness statements from others at the scene.


20. Ms Partos set out how the HCPC put its case.  In relation to the first allegation, it was said that the Registrant had failed to conduct assessments that were required when attending on an elderly female patient who had fallen down stairs and who had suffered a head injury and period of unconsciousness.   The Panel was referred to guidance in relation to examination of the spine and the neck, the assessment of head injuries and blood pressure and the examination of the chest and abdomen.  The HCPC also relied on the hearsay evidence of the student Paramedic (Colleague C) and the patient’s relative (Person 1) to the effect that the Registrant had not undertaken examinations and had let her untrained student Paramedic undertake examinations without proper supervision. The HCPC case was also that the Registrant should have immobilised the patient as soon as possible.  The HCPC also alleged that the Registrant had failed to complete the Patient Clinical Record (PCR).


21. The Registrant referred herself to the HCPC as a result of this investigation.  She was eventually dismissed by the Trust on 25 October 2013 on the grounds of gross misconduct, following an internal disciplinary investigation and hearing.  The Panel has disregarded this internal finding and has decided the facts of the case solely on the written and oral evidence presented at the final hearing.


22. The second allegation in relation to emails arose from the Registrant’s contact with two of the Trust’s witnesses during the investigation: Colleague B and Person 1 in December 2013-January 2014.  She accused Person 1 of exaggerating and embellishing his account.  She accused Colleague B of an inappropriate lack of care towards another unrelated patient and encouraged her to report herself.  By admitting the allegation, the Registrant accepted that sending the emails was conduct amounting to harassment.


The evidence


23. The Panel read written statements and heard direct oral evidence from Colleague B, the other Paramedic who arrived later at the scene of the incident, and from Colleague A, who conducted the subsequent investigation.  The Panel was able to assess each witness and the reliability of their evidence.


24. The HCPC relied on the hearsay evidence of witnesses who did not attend the hearing, in particular Colleague C and Person 1, as to what happened when the Registrant first arrived at the scene.


Colleague C (first year student Paramedic)


25. Colleague C made a statement dated 24 April 2013 for the internal investigation. He stated that the patient was lying on the floor, conscious and talking with a bandaged wound to the head and some blood on a pillow.  He said that the Registrant let him take the lead in checking her head, spine and abdomen and she did not double check what he had done or re-examine the patient afterwards.  The Registrant applied the collar to the patient but he did everything else. He had done a spinal examination at college but never on a real patient.  He had shown the Registrant that he was capable on 3-4 previous shifts, but on this occasion he felt out of his depth and on his own.   Colleague C was interviewed by Colleague A for the purpose of taking the statement.  Colleague A’s view was that Colleague C had a good recollection of the incident at that time.


26. When questioned at the internal disciplinary hearing on 25 October 2013, Colleague C said that Patient A was on the floor, that he felt out of his depth and that he could not recall whether the Registrant had helped him.  He said that immobilisation was not done until the back-up crew arrived.  He agreed that the patient’s relative, Person 1, was quite agitated and aggressive.  He had only been on placement for 3-5 weeks and he had not done any previous examinations on a real patient.


27. The Panel read an email dated 2 October 2014 in which Colleague C stated that he was unable to recall the detail of the case and was struggling to recall detail at the internal disciplinary hearing.
Person 1 (the patient’s son-in-law and partner of Person 2)


28. Person 1 was said to be on scene within seconds in Person 2’s complaint letter.  The Panel read an email dated 6 May 2013, in which Person 1 stated that the male attendant (Colleague C) examined the patient’s head and spine.  He could not remember the female attendant (the Registrant) examining the patient. Persons 1 and 2 did not attend the internal disciplinary hearing.  Colleague A said that it would not be usual policy or appropriate to involve patients and relatives in internal disciplinary hearings.


Colleague B


29. There were four witnesses at the scene other than the Registrant, only one of which (Colleague B) was called to give evidence at the hearing.  Colleague B had made an undated written statement within one month of the incident. She made a further statement for the HCPC dated 13 January 2016 in which she described the incident on 25 March 2013.  She has been employed by the Trust as a Paramedic since 2011 and is now an Operations Officer with the same Trust.  As a Paramedic, she was responsible for the assessment, care, treatment and transportation of patients.  She had worked with the Registrant occasionally, as a backup but not as a crew member, before March 2013. 


30. The call on this occasion was an emergency P2 call for a female patient with a head injury.  P2 refers to an injury that is not immediately life threatening but which is sufficiently serious to require blue emergency lights and sirens. Colleague B attended with her colleague, CDV, who also made a written statement for the internal investigation.  When Colleague B arrived at the scene, she noted the presence of the student Paramedic (Colleague C) with the Registrant.  Nobody appeared to have instructed Patient A to remain immobile on the floor or to have held her head and neck still and in neutral alignment.


31. Colleague B gave evidence-in-chief that she would have expected immobilisation, as recommended by the Canadian c-spine rules, in the case of an elderly patient who had fallen down stairs and suffered loss of consciousness. She would have taken the decision to immobilise even if the patient was talking without difficulty.  Her understanding was that the patient could have fallen down as many as ten steps.  She did not accept the suggestion in cross-examination that she had over-reacted in her assessment of the patient.  In further cross-examination, Colleague B recalled that the student Paramedic was positioned on the floor next to the patient.  She agreed that the patient’s son-in-law had a heated conversation with the Registrant.  Given her age, immobilisation was required.  She accepted that it was not clear whether the patient had fallen down two or three steps or as many as ten steps.


32. Colleague B accepted that a first responder must make a dynamic risk assessment on arrival at the scene.  She was referred to the JRCALC neck and back trauma guidelines (dated April 2006) and it was suggested that none of the criteria requiring immobilisation applied in this case.  Colleague B disagreed and pointed out the Glasgow Coma Score (GCS) was 14 and that the patient had a painful and distracting injury, both of which criteria suggested that immobilisation was necessary.  She did not accept that she was over cautious in administering oxygen or in her overall assessment, irrespective of the fact that there was no actual fracture.  Her evidence was that a precautionary approach had to be taken at this early stage.


33. Colleague B also noted from the PCR (Patient Clinical Record) that the Registrant had not assessed the patient’s blood pressure.   The Registrant said she had not done so because the patient was wearing a coat.   When cross-examined, Colleague B could not recall who took the blood pressure, or whether the patient was wearing a coat, but her statement recorded that they rolled up the patient’s sleeve without apparent difficulty.


34. On 9 January 2014, Colleague B received an email from the Registrant, the content of which made her feel victimised and harassed. The email suggested that she should report herself in respect of another unrelated incident. Colleague B therefore forwarded the email to Colleague A.


Colleague A


35. Colleague A gave evidence before the Panel.  She is employed as a Quality Lead by the Trust, in which capacity she conducts investigations in relation to disciplinary issues, grievances and incidents of concern.  She has been employed by the Trust in various positions for 14 years.  She was asked to investigate the incident as a result of the Datix report submitted by Colleague B and the complaint from Person 2 (Patient A’s son) expressing concern as to the standard of clinical care provided to his mother at the scene of the incident.  Colleague A identified two issues for investigation, namely whether Colleague B had failed to immobilise the patient when it was necessary to do so, and whether she had failed to conduct a complete and adequate primary and secondary survey of the patient. 


36. Colleague A conducted an interview with the Registrant on 18 April 2013.  The Registrant said that she had manually examined the patient’s spine and had ruled out any need for spinal immobilisation, and that she concluded that the patient had sustained a superficial laceration of the scalp following palpation of the injury site. Colleague A identified issues relating to the Registrant’s apparent disregard of the risks of spinal injury and her failure to act in accordance with clinical guidelines, and her lack of initial intervention to mitigate those risks.


Primary survey, immobilisation and assessment of the patient’s neck


37. Patient A had not been immobilised when the back-up crew arrived.  The Registrant told investigators that she had not done so, because she had ruled out the risk of spinal injury.  However, Colleague A would have expected the Registrant to follow the JRCALC Paramedic Guidelines for Head Injury and Neck and Back Trauma, together with the Trust’s Guidelines and Standard Operating Procedures (SOP) for Head Injury and Spinal Assessment. The SOP (Cervical Spine Assessment) was issued to all staff in July 2012 and it is based on the Canadian c-spine Rules.


Examination of Patient A’s neck


38. Colleague A’s view was that the Canadian c-spine Rules require that any patient with high risk factors should be immobilised.  Patient A’s age and mechanism of fall meant that high risk factors were present, especially because she had been unconscious.  The Registrant had determined that full immobilisation was not required. Colleague A concluded that it was only Colleague C who had examined Patient A and he had not done this before on a “real patient”. Colleague A therefore concluded that the Registrant had not examined the patient’s neck herself and had let an inexperienced student perform a palpation without confirming the result.


Examination of Patient A’s head injury


39. The Registrant’s description of the head injury as superficial or “slow haemorrhage” conflicted with other evidence of loss of blood.   Colleague C had examined the head and found a golf ball sized haematoma and stated that the Registrant did not examine the wound. Colleague A therefore concluded that the Registrant did not examine the injury adequately or at all and should not have relied only on the findings of an inexperienced student when assessing whether there had been a fracture.


40. Colleague A gave evidence before the Panel that she would have expected the Registrant to examine the skull personally for signs of crepitus in the event of head injury.   It was also important to assess the nature of the head injury in order to assess whether immobilisation was required.  When interviewed, the Registrant said that it was a superficial laceration and she did not “root around” to find it.  This contrasted with the evidence of Colleague B of some bleeding and the account of Colleague C that the injury had caused a golf ball sized lump to the back of the head.


Immobilisation


41. It was Colleague A’s assessment that the history and mechanism of injury, the head wound, the age of the patient, and the fact of unconsciousness, together with confusion at the scene, should have suggested to a Paramedic that the risk of significant head injury was high and that immobilisation was necessary.  The Canadian c-spine rules show that the age of the patient is an important factor in this decision.


42. When giving evidence, Colleague A described how Paramedics used to be trained to routinely immobilise patients.   The Canadian c-spine rules were widely recognised as giving a set of criteria to determine when to immobilise a patient or not.   She referred to the Trust’s adoption of that guidance.  Immobilisation is required in any case of someone over the age of 65, or who has suffered a dangerous mechanism of fall or who is suffering paraesthesia (numbness, tingling) in their extremities.  The Trust’s head injury guideline recommends full immobilisation for patients who have an altered Glasgow Coma Score (GCS) at any time.  This patient clearly had an altered level of consciousness, as confirmed by the GCS of 14 recorded on the PCR.


43. Colleague A would therefore have expected the Registrant to immobilise the patient’s spine before examination.  The fact that Patient A did not in fact have a spine fracture was a matter of good fortune rather than a sound diagnosis or a proper risk assessment.  The patient had the hallmarks of potential spinal injury and precautionary immobilisation was required. 


44. It was put to Colleague A in cross-examination that a Paramedic may reasonably decide that immobilisation is not required if the patient is moving about and talking freely.  Colleague A agreed that may be so, but the evidence of the patient’s relative and Colleague C was that the patient was lying on the floor at the point of arrival.  The Registrant had also accepted that the patient was in a foetal position in her interview. Colleague A agreed that the guidelines are not mandatory or inflexible rules, but she would expect them to be followed unless there is good reason not to do so, because the guidelines are intended to reflect good practice in the care of patients.


45. Colleague A’s assessment was that no reasonable Paramedic would have acted as the Registrant did. Patients are to be managed on a worse case scenario when a Paramedic arrives at the scene.  The circumstances indicated a high risk of a neck fracture and those attending should respond accordingly. Immobilisation would have been the preferred course in these circumstances, unless a Paramedic has undertaken a controlled assessment to determine if the patient can move her neck with 45 degree rotation (Canadian c-spine rules) and there was no indication that the Registrant had done so - this is even if the patient is sitting up and talking when the Paramedic arrives. Colleague A therefore concluded that the absence of fracture was more a matter of good fortune than good care.


Examination of Patient A’s chest and abdomen


46. Given the nature of the injury sustained after a fall down stairs, it was entirely possible that other injuries may have existed.  Colleague A would therefore have expected the Registrant to conduct a full secondary survey, including chest and abdominal examination to determine whether there were other injuries.  The Registrant did not do this.  Colleague C palpated the chest but did not examine the abdomen.


Blood pressure


47. A blood pressure observation is of high priority in the event of a patient with a history of unconsciousness and a significant head injury, because low pressure may indicate internal bleeding and high pressure may show more significant head injury.  The Registrant had reported that she was unable to check blood pressure because the patient was wearing a coat.  However, the back-up crew simply rolled up her sleeve in order to assess blood pressure.  It appeared to Colleague A that the Registrant had prioritised completing paperwork over this essential task.


Calculation of the Patient’s Glasgow Coma Score (GCS)


48. For a head injury patient, pupil size and GCS are the key neurological assessment tools that paramedics are expected to use to assess severity of head injury. Accurate GCS assessment is an early part of training and is undertaken for every patient attended.  The Registrant recorded a GCS of 14, indicating verbal confusion, on the PCR.  During her disciplinary hearing, the Registrant said she wished she had recorded this as 15 (normal).  This concerned Colleague A because a score of 15 would have misled a future hospital doctor into thinking that the patient had never been confused.  Colleague A described the GCS as an assessment of the patient’s level of consciousness.  Full consciousness was 15.  A GCS score of 14 indicates verbal confusion.  It was important to ascertain the patient’s level of consciousness, because that determines the possible level of injury and consequent treatment.


Patient Clinical Record (PCR)

49. Every Paramedic should complete a full PCR.  The PCR contained significant omissions. Colleague A considered that there was no reference to neurological assessment within the PCR, for example no record of dizziness or headache and no detail of neck or cervical/spinal assessment.


Email correspondence


50. On 9 January 2014, Colleague A was notified that the Registrant had sent emails to both Colleague B and to Person 2, a family member of Patient A.  Person 2 informed Colleague A that his partner, Person 1, had received emails from the Registrant on 18 December 2013 and 9 January 2014.  The emails contained the comments set out in the allegation that are accepted as amounting to harassment of Colleague B and the relatives (Persons 1 and 2) of the patient.


51. Colleague A was concerned to protect the reputation of the Trust and the profession.  It was unacceptable to approach the relative of a service user and to suggest that they were responsible for the outcome of disciplinary proceedings.  She was personally ‘horrified’ that the Registrant had involved the family of the patient in any recriminations arising from the disciplinary proceedings.  She regarded the emails to both the relatives and Colleague B as evidence of unprofessional behaviour.


Evidence of the Registrant


52. The Registrant said that Colleague C was excited about the driving and blue lights side of the job. He was doing well with patients and at observations and paperwork.  On the 4th day of his placement with her an overtime shift became available.  He said he had enjoyed working with her so much that he asked to do an overtime shift on the 5th day, 25th March 2013.  They had not yet responded to any trauma incidents.  His ability was still very basic and primary.  The training department had assured her that students should be involved in hands-on learning from the start.

53. They were called to the P2 head injury incident on 25 March 2013.  The Registrant had assumed that this incident might also involve neck trauma.  A care assistant told them on arrival that she had heard two bumps and found a lady at the bottom of the stairs.  The Registrant was informed that the patient was unconscious for about two minutes before their arrival.  The Registrant found the patient lying on her right hand side, but up on her elbows, moving and flailing.  She turned her head and she was talking normally to care home staff.  She rotated or “swivelled” her head right and left to acknowledge the arrival of the Paramedics.  The Registrant said she decided that it was not therefore necessary to perform the 45 degree neck rotation procedure. 


54. The Registrant conducted what she described as the patient’s “assessment triangle”. The patient had turned to say hello, so her initial response was good her airway was clear.  She was breathing and her skin colour was good, indicating that she was well oxygenated. The Registrant considered the position of the patient.  Her head was next to the skirting board and her back was close to the stairs in a confined space. The head was bandaged and there was blood on the carpet at the bottom of the stairs and on the pillow. She estimated 10-15 millilitres of blood. The Registrant asked the patient to lie still whilst she gave her a “check over”. 


55. The Registrant said that she considered immobilising the patient.  The patient’s head was tight to the wall and lying on her right hand side close to the stairs.  She did not have sufficient confidence in Colleague C to perform the immobilisation on the first occasion of a trauma incident together.  It seemed far safer to ask the patient to simply lie still in the relatively confined space at the foot of the stairwell.  The patient was compliant. 


56. The Registrant then checked her condition by feeling the base of her skull, her face and her neck, asking her whether she felt pain, to which she said no.  She then checked the scalp wound, which was no longer bleeding significantly. She felt the patient’s skull for depressions and pain.  She did not accept the evidence of Colleague C that there was a golf ball sized lump on the scalp.  She said that Colleague C was speaking to the patient and that he unzipped her winter coat.  The Registrant took her blood pressure by an assessment of her radial pulse, which gives an accurate indication of heart rate.  Her heart rate was slightly slow.  There was no indication of major trauma so as to suggest the necessity to remove or cut off clothing for a blood pressure assessment.


57. The Registrant then maintained that she proceeded to palpate and assess the spine, checking the vertebrae, with Colleague C watching what she was doing.  She pulled her jumper and trousers away so that she could feel the patient’s vertebrae then her pelvic and hip area, then down her legs.  The Registrant then gave Colleague C the opportunity to copy what she had done.  She had one eye on Colleague C and spoke to the patient. Patient A said that she had felt dizzy when descending the stairs. She said that she had facial trigeminal neuralgia, a condition that causes severe pain to the side of the face.  She had been told that her medication might cause dizzy spells and she had experienced such dizziness. When asked about the account of Colleague C, who had said that he had been left to examine the head, neck and spine unsupervised, the Registrant said that his account was rubbish.


58. This was the point at which Person 1 interjected by instructing the patient to tell the Registrant about her history.  The Registrant did not realise that he was a relative until he called the patient “mother”.  He was in fact her son-in-law. The patient started to get confused in her answers, so the Registrant asked Person 1 to tell her about his mother’s medication. Person 1 became offended and said that the patient was his mother-in-law then he left to call his husband, the son of the patient (Person 2). There was also some confusion in the Registrant’s mind about whether Person 1’s partner was his husband or his wife, a fact that offended and angered Person 1.  She accepted in cross-examination that Person 1 had been present from the start of the incident.
59. The head bandage had been removed or fallen off by this stage, revealing an 8cm diameter area of coagulated mass that was no longer bleeding. The Registrant deduced that the hair covered scalp laceration was 2-3cm on the scalp. 

 
60. The Registrant then asked the patient if she would like to sit up, which she did, but then she wished to lie back down, a fact which did cause concern.  Person 1 was screaming that she should not be moved.  This was the point at which the patient declared that her right shoulder was sore, which the Registrant described as a possible “distracting injury”.  The Registrant asked her to rate the pain on a scale of one to ten, to which the patient responded that it was a two. The Registrant therefore palpated the patient’s neck and arms. She had no deficit on motor movement, sensation and circulation (MSC). 


61. The Registrant and Colleague C repositioned the patient with Person 1 still shouting. The Registrant retreated to sit on a chair to escape the proximity of Person 1 in the hope of calming him down and started to note findings on the PCR. It was at this stage that the back up crew, Colleague B and CDV, arrived on the scene. This was thirteen minutes after the Registrant and Colleague C arrived.  Colleague B walked past the Registrant, declared that this was a major trauma situation and called for collar, oxygen and spinal board immediately.  The Registrant viewed this as premature because she had not properly handed over the patient and relayed the facts to her. Colleague B then told the patient that they were going to strap her onto a spinal board because she had a head injury. 


62. Following the intervention of Colleague B, Colleague C then immobilised the patient under the Registrant’s instructions and was carried to a stretcher into the lounge. The Registrant’s evidence was that there was further blood loss (80-120 millilitres) on the way to the ambulance.  
63. As to her failure to immobilise the patient before this stage, the Registrant referred to neck and back trauma guidance.  In her view, none of the criteria requiring immobilisation were met.  The Registrant also considered that unnecessary immobilisation might increase blood pressure by stimulating the vagal nerve, thus causing further bleeding, hence the bleeding and raised blood pressure in the ambulance in the opinion of the Registrant. When referred to the JRCALC guidelines, which she regarded as the leading authority, her view was that none of the criteria applied to this case.


64. When referred to her concession at the disciplinary hearing that she should, with hindsight, have immobilised the patient, the Registrant responded that she had in fact eventually supervised Colleague C in immobilising the patient.  She added in re-examination that she stood by her initial decision not to immobilise the patient.
65. When referred to the SWAST Standard Operating Procedure document, also known as the Canadian c-spine rules, the Registrant maintained that the criteria did not apply, even though the patient was over 65 years. She considered the patient’s age, but weighed up the risks of immobilisation and judged that it was not necessary in this case.  She understood that guidelines are subject to deviation on the grounds of clinical judgment and autonomy. She assessed there was no dangerous mechanism of injury because her view was that the fall was from a height of less than five steps.


66. The Registrant said she was unable to complete the paperwork because the blood loss appeared to be worsening and it was necessary to get the patient to hospital. The Registrant was also distracted by dealing with the relatives, so she handed the PCR over to Colleague B. When shown the PCR, she agreed that she had completed some parts of the form but that the remainder was completed by Colleague B.   She would have completed the PCR if she had more time.


67. In relation to blood pressure, the Registrant noted the findings of her radial pulse palpations on the PCR, as opposed to a more comprehensive assessment with a blood pressure monitor that would have required rolling up the sleeve.  She said there was too much going on to be able to do that at the scene.


68. In relation to the Glasgow Coma Score (GCS), she scored Eyes at 4, Verbal at 5 and Movement at 6, which totals the normal consciousness score of 15 on arrival.  She did not insert a total of 15 in the appropriate box initially.  However, when the patient later became confused, she crossed out the score of 5 for vocal and substituted a score of 4, then totalled the GCS score at 14.  However, she changed her assessment and wanted to correct the GCS score back to 15 as soon as she wrote down 14, but she did not get a chance to do so, because the other crew walked in at that stage. She accepted in cross-examination that recording a varying GCS of 15-14-15 would have been more accurate.


69. She did not carry out an assessment of the chest and abdomen. There was insufficient time before the back-up crew arrived.  She said Colleague C started to make an attempt to do so but she did not know what his findings were.


Decision on Facts


70. The Panel accepted the advice of the Legal Assessor that they should apply the civil standard of proof and that they may rely on hearsay evidence, but only if it was fair to rely on such evidence in all the circumstances.  Factors to consider included whether the witness could have attended the hearing, whether their hearsay statements were made within a reasonable time, the extent of the disadvantage to the Registrant in being unable to cross-examine and test their evidence and whether the witness had any reason to lie. The Panel accepted and applied the Legal Assessor’s direction to disregard irrelevant references to any previous allegation and the findings of the internal disciplinary investigation.


71. The Panel found that Colleague A was credible, reliable and knowledgeable and that her testimony was also consistent with other documentary evidence.  She readily accepted when she could not recall certain facts during her evidence. Colleague B was also a credible witness.  Whilst there were some details that she could not recall, her evidence was consistent with her earlier witness statement.  By contrast, the Panel found that much of the evidence of the Registrant was inconsistent and unreliable. The Panel noted how her evidence changed more than once in response to different questioners, for example on the issue of whether she would do now what she had done then.  The Panel also found her very detailed account of events at this hearing difficult to reconcile with her less detailed recollection in her initial interview and disciplinary hearing four years ago in 2013. 


72. As to the hearsay evidence, the Panel accepted that caution must be applied to evidence that has not been tested in cross-examination in this case (with particular reference to evidence of Colleague C and Person 1) at this hearing and accepts that less weight should be attached to such evidence.  However, the Panel also notes that the evidence of Colleague C was broadly consistent with Person 1.  They did not know each other and there was no suggestion of collusion between them.  The Panel noted that there was evidence of Person 1 making a heated response to the Registrant, which is a possible motive for his forming an adverse view of her.  However, the Panel accepted the accuracy of his responses to the open questions posed in Colleague A’s email.  The Panel did not accept that the questions could be fairly described as leading questions.   The Panel accorded rather less weight to the complaint letter of Person 2 who was not present at the scene.


73. The Panel made the following findings of fact on the basis of the evidence that has been summarised above. 

 
Particular 1 (a)(i): did not conduct or adequately supervise Colleague C to conduct an examination of the patient’s neck/spine – proved.


74. The Panel accepted the evidence that the Registrant had about ten or eleven minutes with the patient before the arrival of the back-up crew at 1631.  The Registrant’s evidence, which is set out in detail above, was that she performed an extensive range of detailed examinations and assessments in this time. The Panel was not persuaded that she could have done so, in addition to overseeing Colleague C in his performance of the same tasks. In deciding whether the Registrant had conducted and/or adequately supervised Colleague C in conducting an examination of the neck/spine and skull (see particular 1 (a) (iii)), the Panel had to balance the unconvincing evidence of the Registrant with the hearsay evidence of Colleague C and Person 1 that she had not performed these tasks herself, and that she left Colleague C to conduct the examinations unsupervised.   On balance, the Panel preferred the hearsay evidence of Colleague C and Person 1 that she had failed to conduct these examinations.  


Particular 1(a)(ii): did not conduct or adequately supervise Colleague C to conduct an immobilisation of the patient’s neck/spine - proved

75. The Registrant’s case was that she had eventually conducted the immobilisation, following the arrival of the back-up crew.  The Panel’s view is that the mischief of this allegation is whether she conducted the immobilisation herself within a reasonable time of arrival and it is clear that she did not do so, because she judged that an immobilisation was unnecessary and she went to great lengths in her evidence to explain why not. She only joined others in conducting an immobilisation at the instigation and insistence of Colleague B who arrived 13 minutes later. It is clear that she would not otherwise have done so.


76. The Panel went on to consider whether the Registrant should have immobilised the patient.  In fairness to the Registrant, there are some differences between different sets of guidelines, but the criteria of age, dangerous mechanism of fall and neurological deficit are risk factors in the SWAST Standard Operating Procedure guidelines. This case concerned a 78 year old woman who had suffered a head injury after falling down a number of stairs.   The Panel does not therefore accept that this was an appropriate case for deviating from the guidelines.  The Panel does not accept the Registrant’s evidence that the patient was actively and spontaneously rotating her neck so as not to require any immobilisation.


77. The Panel also noted the contradiction between the Registrant’s evidence and her interview as to whether she took age into account or whether she considered the guidelines.   She also changed her answers on the question of whether to adopt a precautionary “worst case scenario” approach to the decision to immobilise, sometimes saying she followed that approach and then saying she had not heard of this approach.


Particular 1 (a)(iii): did not conduct or adequately supervise Colleague C to conduct an examination of the patient’s skull - proved


78. The Panel found this matter proved for exactly the same reasons as stated in relation to particular 1(a)(i) above.


Particular 1(a)(iv): did not conduct or adequately supervise Colleague C to conduct an accurate calculation of the patient’s Glasgow Coma Score (GCS) – not proved


79. The Panel was satisfied that the Registrant had accurately calculated the GCS so this charge was not proved.  The problem was that she had failed to accurately record her finding, for which see Particular 1(b) below.


Particular 1(a)(v): did not conduct or adequately supervise Colleague C to conduct an assessment of the patient’s blood pressure - proved


80. The issue for the Panel was whether a radial pulse palpation is a proper assessment of the patient’s blood pressure.  The Panel found that the diastolic reading cannot be obtained by means of a radial pulse palpation, which only gives an estimated systolic reading.  Colleague B accepted radial pulse can give an estimation of the systolic reading, but it was not a reliable assessment.   The Panel therefore concluded that a radial pulse assessment was not a sufficient assessment of the patient’s blood pressure.


Particular 1(a)(vi): did not conduct or adequately supervise Colleague C to conduct an examination of the patient’s chest - proved


Particular 1(a)(vii): did not conduct or adequately supervise Colleague C to conduct an examination of the patient’s abdomen - proved


81. Notwithstanding the Registrant’s denial of the particulars above, she admitted during her evidence that she had not conducted or supervised Colleague C in conducting the examination of the chest or abdomen.  The Panel found that she could and should have performed both in the time that was available to her at the scene


Particular 1(b): did not accurately complete the Patient Clinical Record - proved

82. The Panel found that the PCR was incomplete in that the Registrant failed to accurately record the Glasgow Coma Score of 15 then 14 then 15 that she related in her evidence.  The PCR also described the patient sitting up spontaneously, whereas the Registrant accepted in her evidence that she had asked her to sit up.


Particular 2(a) (b) and (c) - proved


83. The Panel accepted the Registrant’s admission that she had written and sent the relevant emails.


Decision on Grounds


84. By agreement, the parties called evidence and made submissions on the issues of misconduct and impairment together, in part because the issue of misconduct was no longer in issue, following the findings of fact made by the Panel and admissions made by the Registrant in her evidence. 


85. At this stage, Ms Partos for the HCPC presented evidence of the facts of the previous findings of the HCPC, of which the Panel was hitherto unaware.  It was accepted by Ms Rutter on behalf of the Registrant that this evidence was relevant for the purpose of determining the issue of impairment. On 15 September 2011, a previous Panel of the HCPC found that the Registrant failed to keep an adequate clinical record of drug administration times, patient observation times and had not provided an accurate treatment timeline on the PCR (patient care record) in relation to an emergency call out on 17 January 2010.  It was also found that she had undermined a crew mate, failed to give appropriate clinical advice and treatment to a chest pain patient on 26 August 2010.  It was found that her failings amounted to misconduct and that her fitness to practise was impaired. The Registrant was made subject to a Caution Order for a period of three years. 

86. The Registrant was also subject to a further concurrent two year Caution Order that was imposed by the HCPC on 18 June 2012 in respect of a further incident on 19 July 2010 in which she had not discouraged a patient from smoking a cigarette, despite identifying that the patient was suffering with a respiratory condition and had a history of chronic obstructive pulmonary disease and asthma.  She had also encouraged the patient to have a cigarette and offered him a light.


87. The Panel noted that the incident under consideration at this hearing occurred on 25 March 2013, which was well within the currency of both the previous Caution Orders above.


88. The Panel heard further oral evidence from the Registrant at this stage as to her conduct and career since the incident in March 2013.  She expressed her deepest regret for sending the emails in December 2013 and January 2014 that are the subject of the second allegation, which she described as ‘appalling and unprofessional’.  She had sent the emails during a period of recovery from an operation when she was also in a state of despair and depression at her dismissal from her position as a Paramedic as a consequence of the March 2013 incident.


89. The Registrant said that she regretted the tone of anger in the emails and that she wished to apologise for them. When cross-examined on the content of the emails, she accepted that colleagues must be free to report concerns in the interests of public protection without harassment and that sending the emails was behaviour of a kind that was likely to bring her profession into disrepute.  In answer to a question from the Panel Chair, she accepted that sending the emails amounted to misconduct.


90. The Registrant then gave evidence that went to the issues of insight and remediation.  She started work in January 2014 for a private ambulance service, including working as a Paramedic at public events.  She attended a horse riding event in August 2014 in which a rider had fallen heavily on her head and she immobilised the patient. She described treating patients with spinal injuries at sports events, including treating a teenager who suffered a major injury after a motorcycle accident and a kite surfer who sustained a serious injury.


91. She started to work on a ‘bank basis’ for Bristol Ambulance Emergency Medical Services from 2015. She has trained a group of students in relation to the spinal immobilisation of patients and has undertaken recent further training in pre-hospital trauma life support herself.  She produced a certificate from a course that she had taken and passed in April 2017.  She currently works for various private ambulance and medical services on a self-employed basis. Her clinical abilities have not been called into question during this period.  She has disclosed her dismissal and regulatory proceedings to all her employers.


92. The Registrant said that she now accepted the factual findings of the Panel in this case.  She maintained that she was clinically capable, having had four years to reflect on her conduct in 2013 in which she had gained substantial further experience and training. She said that her line manager at Bristol Ambulance was Mr Richard King, although there was no system of regular review or supervision.  She had attended one supervision meeting in 2015.


93. She was cross-examined about the incidents in 2010 that were the subject of previous HCPC findings and Caution Orders. She had admitted all the factual allegations, except for one particular that was not found proved.  She accepted that she was made aware that her conduct in 2010 had breached HCPC standards 8 and 10 in relation to effective supervision of others and accurate record keeping. She acknowledged the findings that her previous misconduct had the potential to bring her profession into disrepute.


94. The Panel also read a bundle of testimonials and heard oral evidence from Mr Garry Spicer with whom the Registrant has previously worked.  Mr Spicer had worked with the Registrant for approximately 5 months during 2013 when he was a student and she was his mentor. Mr Spicer described her as sympathetic, supportive and an outstanding teacher of clinical skills, the best of the three mentors who had supervised him.  He attended a serious trauma incident with the Registrant after her return to work at which she had impressed him with her professionalism. The Panel also heard evidence by telephone from Mr David Archard, a first aid trainer and Director of Amass Medical and Security Services. The Registrant works for him three to four times per month on a self-employed basis and has done so since 2014. He has checked the standard of her paperwork and he has never had any complaint about her or cause for concern. He recalled incidents at medieval re-enactment events at which she was present, including the horse riding incident mentioned above.  Mr Christopher Johnson, a retired Dentist and volunteer first responder, also gave evidence by telephone.  He met the Registrant through his voluntary service at monthly training sessions. He was impressed by the professional way in which she ran the training scheme.  He worked and attended critical cases with her from 2013 to 2015.  He described how she was able to build a strong personal rapport with patients and how she used her sense of humour to put them at ease.

95. The Panel found the three witnesses called on behalf of the Registrant to be honest, credible and reliable.  Mr Spicer had worked closely with the Registrant for five months in 2013 and he provided a positive reflection on her abilities. Mr Archard could not comment on the Registrant’s clinical competence but his evidence was also very positive.  Mr Johnson had accompanied her on call outs and he was very complimentary about her work.  The Panel also noted the content of numerous positive testimonials, some of which praised her clinical abilities.


96. Following the conclusion of the evidence, the parties made submissions on the issue of misconduct. Ms Partos for the HCPC submitted that the findings of the Panel in relation to the incident in March 2013 and the emails in December 2013 and January 2014, whether taken together or separately, amounted to misconduct.  She invited the Panel to consider whether the Registrant had breached HCPC Standards of Conduct, Performance and Ethics and the Standards of Proficiency for Paramedics. Ms Rutter for the Registrant accepted that the Panel’s findings of fact, which were now accepted by the Registrant, and her admissions on the second allegation were such that the ground of misconduct was made out.

97. The Panel accepted the advice of the Legal Assessor and was assisted by the submissions on behalf of the HCPC and the Registrant. The Panel had in mind the definition of misconduct in Roylance v GMC [2011] 1 AC 311. Misconduct is “some act or omission which falls short of what is proper in the circumstances. The standard of propriety may often be found by reference to the rules and standards ordinarily required to be followed by a medical practitioner in the particular circumstances.”


98. By reason of the Panel’s findings on the facts as set out above, the Panel found the Registrant to have breached the following standards of the HCPC Standards of conduct, performance and ethics:-
i. Standard 1: “You must act in the best interests of service users”
ii. Standard 3: “You must keep high standards of personal conduct”
iii. Standard 7: “You must communicate properly and effectively with service users and other practitioners”
iv. Standard 8: “You must effectively supervise tasks that you have been asked to carry out.”
v. Standard 10: “You must keep accurate records.”
vi. Standard 13: “You must behave with honesty and integrity and make sure that your behaviour does not damage the public’s confidence in you or your profession.”


99. The Panel also found the Registrant to have breached the following standards of the HCPC Standards of proficiency for Paramedics:-


i. Standard 1a 1: “be able to practise within the legal and ethical boundaries of their profession”
ii. Standard 1a 5: “be able to exercise a professional duty of care”
iii. Standard 1a 6: “be able to practise as an autonomous professional, exercising their own professional judgment”
iv. Standard 1b 1: “be able to work, where appropriate, in partnership with other professionals, support staff, service users and their relatives and carers.”
v. Standard 1b 2: “be able to contribute effectively to work undertaken as part of a multi-disciplinary team.”
vi. Standard 1b 3: “be able to demonstrate effective and appropriate skills in communicating information, advice, instruction and professional opinion to colleagues, service users, their relatives and carers.”
vii. Standard 2b 2: “be able to draw on appropriate knowledge and skills in order to make professional judgements.”
viii. Standard 2b 4: “be able to conduct appropriate diagnostic or monitoring procedures, treatment, therapy or other actions safely and skilfully.”
ix. Standard 2b 5: “be able to maintain records appropriately.”


100. In deciding the issue of misconduct, the Panel applied its factual findings in relation to the Registrant’s lack of attention to patient safety during the incident in 2013.  There was a high risk of serious injury in view of the patient’s age, unseen mechanism of fall from a height, the presence of unconsciousness, which was indicative of neurological deficit, and the failure to immobilise the patient.  This was a single incident, but these failings were serious enough to amount to misconduct, as the Registrant has now accepted.  There was no suggestion that she did not know what to do.  This was not an issue of competence, because an assessment after the event found her to be clinically competent.  The second allegation in relation to sending emails that amounted to harassment of the recipients was a clear instance of misconduct.  Accordingly, the Panel found that the evidence of the Registrant’s conduct, taken as a whole, amounted to misconduct.


Decision on Impairment


101. Ms Partos for the HCPC submitted that the Registrant had not shown sufficient insight and remorse in respect of her treatment of the patient or her conduct in the presence of members of the public, or in relation to the emails. Ms Partos invited the Panel to consider the previous findings of the HCPC and the fact that the Registrant was subject to two Caution Orders at the time of the incident in this case.  She referred the Panel to the cases of Cohen and Grant and submitted that a finding of impairment was necessary to declare and uphold public confidence in the standards of the profession, notwithstanding the evidence of remediation called by the Registrant.


102. Ms Rutter submitted that the Registrant’s fitness to practise was not currently impaired. It was significant that this case concerned misconduct in 2013 and that the Registrant had demonstrated remediation by working as a Paramedic since that time and displaying competence and professionalism on a regular basis, as reflected in both the oral and the written testimonial evidence. The Registrant regretted sending the emails and wished to apologise for doing so. Ms Rutter submitted this was a remediable situation in which the Registrant had shown sufficient insight and remorse and that no finding of impairment was required.


103. The Panel considered the submissions of the parties and accepted the advice of the Legal Assessor. The Panel reminded itself of the public interest component in Cohen v GMC [2008] EWHC 581: “the need to protect the individual and the collective need to maintain confidence in the profession as well as declaring and upholding proper standards of conduct and behaviour which the public expect…and that the public interest includes, amongst other things, the protection of service users and the maintenance of public confidence in the profession.”


104. The Panel also had regard to the criteria that were set out by Dame Janet Smith in the Fifth Shipman Report, as endorsed in Council for Healthcare Regulatory Excellence v NMC and Grant [2011] EWHC 927, namely whether our findings of fact in respect of the Registrant’s misconduct show that her fitness to practise is impaired in the sense that she has put patients at risk in the past, or is liable to do so in the future, whether she has brought her profession into disrepute or may do so in the future, and whether she has breached the fundamental tenets of her profession or may do so in the future. There was no need to consider whether she has acted dishonestly because this is not such a case.


105. Before making its findings on impairment, the Panel considered whether the Registrant had effectively remedied her past misconduct.  The Panel lacked confidence that she had done so, notwithstanding her positive testimonials and extensive work as a Paramedic since 2013.  In particular, the Panel noted how the Registrant changed her evidence on a number of occasions as to what she would do in similar circumstances and whether immobilisation was necessary.  It was difficult to discern whether she had fully accepted or understood that what she did was wrong on 25 March 2013. 


106. The Panel noted the Registrant’s fulsome apology in relation to sending the emails, but was also troubled by the Registrant’s lack of insight into the negative impact on Colleague B of sending emails about an unrelated investigation.  The Panel was concerned that the Registrant did not accept that she had made any demand on Colleague B simply because she had used the word ‘please’ in an email that was designed to cause distress.  The Panel accepted that the Registrant showed greater insight into the effect of sending emails to Person 1.

107. Applying the questions that were posed by Dame Janet Smith in the Fifth Shipman Report, the Panel found that the Registrant had put patients at risk in both 2010 and in 2013, and that there must be a risk that she will do so again, in view of her limited insight, as described above.  Answering the second question, it is clear that her misconduct, including denigration of colleagues, was such as to bring her profession into disrepute in both 2010 and 2013, and there must be a risk that she will do so again, in view of her limited insight. 

108. In failing to provide proper patient care and in undermining her professional colleague in 2013, the Panel has concluded, in answer to the third question, that the Registrant also acted in breach of the fundamental tenets of her profession and that she may do so in the future. In particular, the Panel noted that this is the Registrant’s third appearance before the HCPC within a relatively short period.  The risk of repetition is such that the Panel finds that the Registrant’s fitness to practise remains impaired.

109. The Panel’s finding of current impairment is made on the basis of the need to protect the public and in the wider public interest in order to maintain public confidence in her profession and in the regulatory process. The Panel considers that a reasonably informed member of the public with reasonable knowledge of the facts of this case and the history of the Registrant would expect a finding of current impairment.


Decision on Sanction


110. The Panel considered and applied the Indicative Sanctions Policy of the HCPC and accepted the advice of the Legal Assessor. The Panel kept in mind that the sanction must be proportionate and that its purpose was to protect the public and not to punish the Registrant, even if that was its effect. The Panel also took account of the submissions of both parties in reaching its decision.


111. The Panel started the process of determining the appropriate sanction by identifying and assessing the relative weight of the mitigating and aggravating features in this case. 


112. In mitigation, the Panel took into account the Registrant’s long service and noted that she has continued in practice for the four years since the incident in 2013. There was significant positive evidence as to her professional abilities and personal qualities in numerous testimonials and plaudits.  The Panel noted evidence that she is able to establish a strong rapport with patients and trainees, that she has applied better practice in subsequent emergency incidents and that she has undertaken further training herself.  The Registrant also expressed a fulsome apology when giving evidence in relation to sending the emails.  The Panel also had regard to the Registrant’s personal circumstances as the sole source of income in her household.


113. The principal aggravating features in this case were that Patient A was placed at a high risk of potential harm by the Registrant’s failure to undertake a proper examination and assessment and leaving that task to a junior student Paramedic without adequate supervision.  The risk of harm was increased by her decision not to immobilise an elderly patient who had suffered a fall and unconsciousness, a decision that was contrary to the recognised guidelines.  The Panel remains concerned as to the Registrant’s vacillating position in relation to whether immobilisation was necessary. The Registrant also displayed a wholly unprofessional disrespect for a patient’s relative and a colleague in sending emails that caused distress. This was misconduct that brought her profession into disrepute.


114. Furthermore, the Panel cannot overlook the fact that this incident in 2013 occurred whilst the Registrant was subject to previous Caution Orders that were imposed by the HCPC in 2011 and 2012 in respect of conduct in 2010 that had some similarities to the incident in 2013.   That is a significant aggravating factor, because it suggests a pattern of misconduct and it shows that the Registrant lacked the necessary insight to avoid repetition at that time.  In fairness to the Registrant, the Panel notes that there has been no further incident in the intervening period since 2013.


115. The Panel then considered the various sanctions in ascending order of seriousness. The nature of the misconduct was too serious to make no order or to consider mediation. The Panel then considered whether to impose a Caution Order, but decided that it was not in the public interest, because this was the third incident that has given rise to proceedings before the HCPC in three years and Caution Orders had been imposed in 2011 and 2012 to little effect.  It cannot be said that this was a minor or isolated incident or that more serious sanctions are disproportionate.  Furthermore, the level of insight was too limited to consider this sanction.


116. The Panel then considered carefully whether a Conditions of Practice Order was appropriate, but concluded that the risk of future harm was too great for the reasons stated above.  The Registrant’s failings were capable of remedy, but the nature of the Registrant’s work was that she worked for various employers and she has no regular supervisor or line manager, so it was not possible to formulate workable or easily verifiable conditions. Whilst it was accepted that the Registrant would seek to comply with conditions on her practice, the Panel found that such an order was not practicable, and would not meet the gravity of the misconduct or provide adequate public protection in any event.  
117. This was a case of serious misconduct, involving a high risk of harm to a patient and the harassment of a colleague and patient’s relative.  The Registrant has continued to vacillate as to her recognition of whether she was wrong in failing to immobilise the patient.  The Panel therefore considered that the facts of this case were at the upper end of seriousness for a Suspension Order and that the Registrant’s misconduct came very close to the level of gravity and need for public protection that is appropriate to a Striking-Off Order.


118. However, the Panel ultimately decided that the Registrant’s behaviour was capable of remedy and wanted to give her the opportunity to demonstrate this. The Panel did not think that it was able to conclude that the Registrant’s behaviour was fundamentally incompatible with her continued registration if she is able to gain greater insight and remedy her failings.


119. The Panel therefore determined that a Suspension Order of 12 months duration was an appropriate and proportionate sanction that reflected the gravity of the misconduct. The Panel is satisfied that this order will protect the public and maintain the confidence of the public in the profession, whereas any lesser sanction would undermine public confidence. Such an order will give the Registrant an opportunity to develop her insight and thereby reduce the risk of repetition.
120. The Panel concluded that it was in the public interest that the Registrant should be able to resume work in her profession if she can engage in the review process.  A future Panel reviewing this case would therefore be assisted by the following:-

• A written reflective statement as to the Registrant’s view on the findings in this case and how she might avoid repetition of her misconduct, taking into account the risk of harm to patient A and her conduct towards Colleague B;
• Character and/or employment references in the preceding 12 months;
• Evidence of continuing professional development, demonstrating that she is keeping up to date with new practices and developments in the profession.

Order

Order: The Registrar is directed to suspend the Registration of Adele Copeman-King for a period of 12 months from the date this Order comes into effect.

Notes

 The order imposed today will apply from 1 August 2017 (the operative date).
This order will be reviewed again before its expiry on 1 August 2018

Hearing history

History of Hearings for Adele J Copeman-King

Date Panel Hearing type Outcomes / Status
27/06/2017 Conduct and Competence Committee Final Hearing Suspended