Mr Laurence P Milton
Allegations (as amended at Final Hearing):
During the course of your employment as a Paramedic for East of England Ambulance
Service NHS Trust, whilst attending to Patient A on 15 November 2015:
1. you did not adequately assess Patient A’s cardiac rhythm on arrival at the scene;
2. you did not carry out Cardio Pulmonary Resuscitation (CPR) on Patient A in a timely
3. you did not attach defibrillation pads to Patient A; and
4. you did not adequately carry out full Advanced Life Support (ALS) on Patient A in that;
a) you were prompted to cannulate Patient A;
b) ALS was not performed for a sufficient amount of time; and
c) Patient A did not receive an adequate dose of drugs;
5. as lead clinician, you:
a) asked Colleague A and Colleague B if they would like to insert the cannula;
b) said “It’s okay, you can do it on my ticket” or words to that effect.
6. You said to Colleague A and Colleague B, “I hope we don’t get a ROSC [return of spontaneous circulation] because I have already told the wife he is dead and we are just doing this for show for the family”, or words to that effect.
7. The matters set out in paragraphs 1 – 6 constitute misconduct and/or lack of competence.
8. By reason of your misconduct and/or lack of competence your fitness to practise is
1. The case for the Health and Care Professions Council (“HCPC”) was presented by Ms Kathryn Sheridan of Kingsley Napley, Solicitors. The Registrant was present and represented by Ms Rachel Wilson of Blackfords LLP. The Registrant admitted the facts of particulars 3, 5a) and 5b) and denied the remainder of the factual particulars.
Amendment of the allegation
2. At the outset of the case Ms Sheridan applied to amend the stem of the allegation by deleting the word "you"; to amend particular 1 of the allegation by deleting the word "fully" and substituting the word "adequately" and by deleting the words "clinical condition" and substituting the words "cardiac rhythm"; to amend particular 3 by adding the word "and" to the end of that particular; to amend particular 4 by adding the word "adequately" before the word "carry" and adding a new particular 4a) as follows- you were prompted to cannulate Patient A; by adding a new particular 4(b) as follows - ALS was not performed for a sufficient amount of time; and by adding a new particular 4(c) as follows – Patient A did not receive an adequate dose of drugs; and by inserting the word "You" to the start of particular 6.
3. Ms Sheridan advised that the notice of these amendments had been served on the Registrant and that they better particularised the allegation and did not cause any injustice to the Registrant. Ms Wilson, on behalf of the Registrant, confirmed that the application was not opposed. The Panel considered the submissions of Ms Sheridan, the submissions of the Registrant and the advice of the Legal Assessor. The Panel agreed to grant the application as it was satisfied that the amendments better reflected the evidence and did not cause any injustice to the Registrant.
4. Ms Wilson made an application to take any evidence relating to the Registrant’s health in private. Ms Sheridan had no objection to that application. The Panel therefore agreed that any evidence in relation to the Registrant’s health would be taken in private as his right to privacy in relation to his health outweighed the presumption that evidence should be taken in public.
5. The Registrant was employed as a Paramedic for the East of England Ambulance Service NHS Trust (EEAST) between April 2003 and August 2016. On 15 November 2015, a datix (concern for the care of a Patient) was completed by two student paramedics, Colleague A and Colleague B. The concerns related to the care provided to Patient A who had suffered a cardiac arrest. The Registrant is alleged to have failed to act in accordance with Advanced Life Support protocols, in addition to making inappropriate comments whilst attending to Patient A.
Decision on Facts:
6. The Panel heard evidence from three witnesses on behalf of the HCPC; NT, an Assistant Senior Locality Manager for EEAST who was appointed as the investigating officer and Colleagues A and B, both of whom were student paramedics and attended Patient A on 15 November 2015 following the Registrant's attendance as a solo responder. The Panel also heard evidence from the Registrant.
7. The Panel found all the witnesses for the HCPC to be honest and helpful. The Panel was of the view that NT was particularly clear and balanced in her evidence, conceding points and maintaining her position as appropriate, particularly in relation to key policy areas. The Panel considered that some elements of the evidence of Colleague A and Colleague B appeared to be strikingly similar, such as in relation to whether or not the Registrant was giving CPR to Patient A when they arrived on the scene. The Panel noted that under cross-examination Colleague A agreed that she had discussed the incident with Colleague B several times since the events, which the Panel considered may have given rise to the appearance of similarity.
8. The Panel found the Registrant to be a confident witness whose evidence was consistent throughout. He was clear in his recollection of key events and decisions, but stated that his active role in providing and leading care to Patient A meant that he was not monitoring timing or aware of which of his colleagues carried out each of the individual tasks. The Panel found him to be a credible witness who readily conceded where he had considered it appropriate to deviate from guidance and protocols.
9. The Panel carefully considered all of the evidence in this case. It noted the submissions of both Ms Sheridan, on behalf of the HCPC and Ms Wilson, on behalf of the Registrant. The Panel also accepted the advice of the Legal Assessor.
10. The Panel heard evidence from NT in support of this particular and has had sight of the Electronic Patient Record and of the Incident Timeline produced by NT in the course of her investigation. The Panel has also heard evidence from Colleagues A and B that when they arrived on the scene, Patient A had ECG leads attached to him, but not defibrillation pads. The Registrant’s position is that the steps he had taken on arrival at the scene were appropriate in that he conducted an initial assessment by “looking, listening and feeling” and that he attached the three lead ECG, and was about to assess the cardiac rhythm when Colleagues A and B arrived on the scene. The Registrant accepts that he did not attach defibrillation pads or turn his ECG monitor on.
11. The Panel recognises that the Registrant was required to carry out a number of actions on arrival at the scene, including assessment of the Patient, dealing with the Patient’s wife and conducting a safety assessment. In the circumstances of the case, the Registrant should assess the Patient’s cardiac rhythm as a matter of priority. Having decided to use a three lead ECG, the Registrant should have carried through this action until a cardiac rhythm assessment was made. However, having attached the leads, he abandoned this course of action prior to switching on the ECG monitor and on arrival of the ambulance crew, changing his mind and allowing the ambulance crew to attach the defibrillator which they had brought with them. In doing so, the Registrant delayed the assessment of cardiac rhythm by the time taken to attach the defibrillator pads and to switch on the defibrillator. Thus the Panel finds that this delay amounts to a failure on the part of the Registrant to adequately assess Patient A’s cardiac rhythm on arrival at the scene. The Panel therefore finds the facts of particular 1 proved on the balance of probabilities.
12. The Panel has heard evidence from Colleagues A and B that the Registrant had started CPR when they arrived on the scene. The Registrant’s evidence is that he did not commence CPR until after Colleagues A and B had arrived. The Panel prefers the evidence of the Registrant in this regard as, in the Panel’s view, he had no reason to fabricate this, there is no benefit to him in doing so and this was consistent with his earlier statement to the Trust. In the Panel’s view, if an adequate assessment of the Patient’s cardiac rhythm had been conducted by the Registrant on arrival at the scene, this would have indicated immediate commencement of CPR. Therefore, whilst the Panel accepts that CPR commenced after the arrival of the ambulance crew, in the Panel’s view, this was not timely. The Panel therefore finds the facts of particular 2 proved on the balance of probabilities.
13. The Registrant has admitted the facts of this particular. The Panel has heard from Colleagues A and Colleague B who were both clear in their evidence that when they arrived on the scene, Patient A did not have defibrillation pads attached. The Panel is satisfied that the Registrant’s admission is supported by the evidence of Colleagues A and B and therefore finds this particular proved on the balance of probabilities.
14. The Panel has heard evidence from Colleagues A and B in support of this particular. The Registrant has denied that he was prompted to cannulate the Patient. Whilst both Colleague A and B claimed that the Registrant had been prompted to cannulate the Patient, neither could recall who had provided such a prompt or what form of words were used. The Panel did not find this evidence reliable and preferred the evidence of the Registrant that he had decided to cannulate and that the timing was determined by the cycle of CPR that had commenced. The Panel is therefore not satisfied that the Registrant was prompted to cannulate the Patient and finds this particular is not proved to the requisite standard.
15. The Panel has heard evidence from NT that the start of ALS is measured from the administration of the first drug in the ALS Protocols. The Registrant does not accept that ALS was not performed for a sufficient amount of time. The Panel is satisfied that a period of ALS was performed. It noted the differences in evidence before it as to what constitutes the commencement of ALS ( the first administration of drugs as suggested by NT in her evidence, the act of cannulisation as conceded as a possibility by NT under cross examination or a less well defined point during the transition from ILS to ALS as suggested by the Registrant in his evidence) and carefully considered the various and inconsistent elements of written and oral evidence ( such as between the time line of events drawn up during the Trust’s investigation, the electronic Patient record and the COREPULSE printouts) relating to the timeline of events. The Panel was unable to satisfy itself as to the start time, end time or duration of the period of ALS. Therefore the Panel finds that the HCPC has failed to discharge its burden of proof in respect of this particular and finds it is not proved to the requisite standard.
16. The Panel has heard evidence from Colleague A and B that the Registrant incorrectly administered an initial dose of 150mg of Amioderone when the correct dose was 300mg. Colleague B was less clear about this under cross-examination. The Registrant has denied this. The Panel is not assisted in this regard by the Electronic Patient Record as it is accepted that this has not been accurately completed. The Panel has placed reliance on the written statement of RD, an Emergency Medical Technician who was present on the scene and who prepared the fluids and adrenaline for the Registrant to administer. Given that she was involved in the preparation and verification of the drugs, the Panel prefers her evidence to that of Colleague A who did not draw up the drugs or Colleague B whose position appeared to have shifted during her evidence. The Panel is therefore satisfied that the Patient received an adequate dose of Amioderone.
17. In respect of the dose of adrenaline, the Panel has had regard to both the JRCALC Guidelines and the Trust’s Clinical Manual, both of which indicate that adrenaline should be administered every 3-5 minutes. As found above in relation to Particular 4b, the exact duration of the ALS procedure is not clear. However, the Panel is satisfied that on the balance of probabilities it continued long enough to require more than two doses of adrenaline to be administered. In the Panel’s view, there should have been at least one, and likely more than one, additional dose. In his oral evidence, the Registrant admitted that the patient could have had one more dose of adrenaline. The Panel therefore finds that not only could one more dose of adrenaline have been administered, it should have been administered and, therefore, finds that the facts of particular 4c have been proved to the requisite standard.
Particular 5(a) and 5(b)
18. The Panel has heard evidence from Colleagues A and B as to the comments made by the Registrant in respect of the cannula. The Registrant has admitted the facts of both particulars. The Panel is satisfied that the Registrant’s admissions are supported by the evidence of Colleagues A and B and therefore finds particulars 5a and 5b proved to the requisite standard.
19. The Panel has heard evidence from Colleagues A and B as to the comment allegedly made by the Registrant. The Registrant denies this particular, although accepts that he may have said to the patient’s wife that “he may have gone” and that his comment may have been taken out of context. While Colleague A recalls hearing the whole comment being made, Colleague B does not recall hearing the words “we are just doing this for show for the family”, but does recall hearing the words “I hope we don’t get a ROSC because I have already told the wife he is dead”. The Panel is of the view that the second part of the alleged statement would stand out in the memory of both Colleagues A and B, if it had been made, as it would be highly unusual. The fact that Colleague B does not recall the last part of the comment being made, whilst Colleague A does, causes the Panel to adopt a very cautious approach in relation to the totality of the evidence of Colleagues A and B as to what the Registrant said. The Panel is not satisfied on the balance of probabilities that the words alleged in this particular, or words to that effect, were used by the Registrant. Accordingly the Panel finds the facts of particular 6 not proved to the requisite standard.
Decision on Grounds
20. The Panel next considered whether the Registrant’s actions in particulars 1, 2, 3, 4c, 5a and 5b amount to misconduct and/or lack of competence. The Panel is aware that this is a matter for their professional judgement. In reaching its decision, the Panel has considered the submission of both parties, the documentary and oral evidence and has accepted the advice of the Legal Assessor.
21. The Panel considers that the Registrant’s failure to attach defibrillation pads to Patient A does not amount to either a lack of competence or misconduct. The Panel finds that, whilst the Registrant did not attach the pads, he was present when the pads were attached by Colleague B. Prior to Colleague B’s arrival, the Registrant had been following an appropriate course of action to establish a cardiac rhythm through the use of 3-lead ECG. As explained in the findings of fact, he changed his mind, leading to the use of the defibrillator. The Panel does not therefore find that the Registrant’s actions in these circumstances amount to either lack of competence or misconduct.
22. In addition the Panel does not find that the Registrant’s comments in relation to cannulation in particular 5(a) and 5(b) amount to the statutory grounds. The Panel finds that, as the lead clinician, it was appropriate for the Registrant to invite junior colleagues to insert the cannula as a development opportunity, and to offer them the chance to do so under his supervision and “on his ticket”. The Panel therefore finds that this does not amount to either lack of competence or misconduct.
23. The Panel finds that the statutory ground of lack of competence is not made out in respect of particulars 1, 2 and 4(c). This was an isolated incident in an otherwise unblemished career of 13 years and does not represent a fair sample of the Registrant’s work. There is no evidence before the Panel to suggest that the Registrant lacks competence as a paramedic. Instead the issue is that the Registrant chose not to follow the established algorithm for ALS leading to the misconduct found.
24. The Panel finds the Registrant’s actions in failing to establish a cardiac rhythm at the earliest opportunity, failing to commence CPR at the appropriate time and in administering only two doses of adrenaline, when three or more were needed, fell well short of what would be proper in the circumstances. Moreover, the falling short is serious and amounts to misconduct.
25. The Panel is of the view that the Registrant’s actions breached the following standards of the HCPC’s Standards of Conduct, Performance and Ethics in force at the relevant time:
• Standard 1 - You must act in the best interests of service users.
• Standard 13 – You must……… make sure your behaviour does not damage the public’s confidence in you or your profession.
26. The Panel is of the view that the Registrant’s actions also breached the following standards of the HCPC’s Standards of Proficiency for Paramedics in force at the relevant time:
• Standard 4 – You must be able to practise as an autonomous professional, exercising your own professional judgement.
• Standard 4.2 - You must be able to make reasoned decisions to initiate, continue, modify or cease treatment or the use of techniques or procedures...
• Standard 4.4 – You must be able to recognise that you are personally responsible for and must be able to justify your decisions.
27. The Panel is of the opinion that fellow practitioners would be appalled by the Registrant’s misconduct.
Decision on Impairment
28. The Panel next considered whether the Registrant’s current fitness to practise is impaired by that misconduct. Again, the Panel is aware that this is a matter for its professional judgement.
29. The Panel has considered the critically important public policy issues which include the need to maintain confidence in the profession, as well as declaring and upholding proper standards of conduct and behaviour which the public expect. The Panel has found that the first three of the criteria identified by Dame Janet Smith in her fifth Shipman Report were engaged. The Registrant’s actions on the day had placed Patient A at risk of harm as the shortfalls in the care he received did not maximise the chances of achieving ROSC. Such misconduct, the Panel finds, could only act to harm the reputation of the profession in the eyes of the public. Finally, as identified above, the Registrant has breached the fundamental tenets of his profession through not complying with the standards highlighted.
30. The Panel has also considered the personal element of the Registrant’s conduct. The Panel considered the issue of insight and remorse. While it is recognised some indications of insight, such as the Registrant’s admission that a further dose of adrenaline might have been appropriate, this was not enough. There was no evidence before the Panel to satisfy it that the Registrant had undertaken the necessary reflection and fully accepted what he had done wrong. There was no evidence before the Panel to suggest remorse.
31. The Panel next considered the risk of repetition. Whilst the Registrant’s misconduct was, in theory, capable of remediation, there was no evidence, especially without the necessary insight, to suggest that this had been achieved. Therefore, the Panel could not rule out the risk of repetition.
32. Looking forward, the Panel finds that there remains a risk, through repetition, to the public and to the reputation of the profession. Moreover, the Panel also finds that there is a need to uphold proper standards of conduct and professionalism and to send a clear message to the profession about the unacceptability of the Registrant’s misconduct. For these reasons the Panel finds that the Registrant’s current fitness to practise is impaired on the grounds of public protection and the wider public interest as well as on the personal component, given the lack of insight and remediation. The allegation is therefore well founded.
Decision on Sanction
33. The Panel has heard submissions from Ms Sheridan and Ms Wilson on the issue of sanction. The Panel has also accepted the advice of the Legal Assessor and had regard to the HCPTS Indicative Sanctions Policy.
34. The Panel is aware that the purpose of sanction is not to be punitive. The primary function of any sanction is to address public safety from the perspective of the risk the Registrant may pose to those using or needing his services in the future and to determine what degree of public protection is required. The Panel must also give appropriate weight to the wider public interest considerations which include the reputation of the profession, the deterrent effect on other registrants and public confidence in the regulatory process.
35. The Panel considered the following mitigating factors: this was an isolated incident in an otherwise unblemished career spanning 13 years; the Registrant has made partial factual admissions; the Registrant has attended the hearing and fully engaged in the process; the Registrant has produced positive testimonials and character evidence.
36. The Panel also considered the following aggravating factors: the Registrant’s lack of insight and the seriousness of the misconduct found proved.
37. The Panel considered the sanctions available to it in ascending order of severity. The Panel considered that to take no action or to impose a Caution Order would not be appropriate, given that neither would restrict the Registrant’s practice and the Panel has identified a risk of repetition. The Panel is of the view that the misconduct is not minor and there are significant shortfalls in the Registrant’s level of insight. In addition, the Panel is of the view that to take no action or impose a Caution would not be sufficient to address the wider public interest considerations.
38. The Panel next considered a Conditions of Practice Order. The Panel has not found any lack of competence on the part of the Registrant. Indeed the Panel was confident that he was capable of effective practice. The Panel did not consider that it was possible to formulate workable, verifiable and relevant conditions of practice in the circumstances of this case that would serve any useful purpose. Here, the Registrant was aware of the appropriate procedure and chose not to follow it.
39. The Panel next considered a Suspension Order. The Panel is of the view that a Suspension Order would afford the Registrant an opportunity to reflect on his misconduct and develop full insight. It would also provide a clear marker to the wider profession that such misconduct was unacceptable, whilst acting similarly to protect the reputation of the profession. The Panel has therefore determined that in the circumstances of this case, a Suspension Order is the appropriate and proportionate sanction.
40. The Panel next considered the length of the Suspension Order and concluded that a period of six months was the minimum necessary to achieve the aims set out above.
41. For completeness, the Panel considered the imposition of a Striking Off Order, concluding that it would be disproportionate as the Registrant’s misconduct is not fundamentally incompatible with remaining on the Register.
42. This Order will be reviewed prior to its expiry. The Panel conducting that review may be assisted by the following:
• The Registrant’s attendance at that hearing.
• A reflective piece demonstrating the necessary level of insight and acceptance, and exploring the boundaries of autonomous practice relative to adherence to evidence-based guidelines.
• Evidence of CPD undertaken by the Registrant in order to maintain and develop his professional skills, especially in the delivery of ALS.
• Any other evidence which the Registrant considers might assist that Panel.
ORDER: That the Registrar is directed to suspend the registration of Mr Laurence P Milton for a period of six months from the date this order comes into effect.
The order imposed today will apply from 10 August 2017 (the operative date)
This order will be reviewed again before its expiry on 14 February 2018.
History of Hearings for Mr Laurence P Milton
|Date||Panel||Hearing type||Outcomes / Status|
|04/07/2018||Conduct and Competence Committee||Review Hearing||Conditions of Practice|
|04/01/2018||Conduct and Competence Committee||Review Hearing||Conditions of Practice|
|10/07/2017||Conduct and Competence Committee||Final Hearing||Suspended|