Karl Richards

: Paramedic

: PA31707

: Final Hearing

Date and Time of hearing:10:00 04/09/2017 End: 17:00 08/09/2017

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

: Conduct and Competence Committee
: Impaired - no further action

Allegation


Matter 1:


During the course of your employment as a Paramedic with West Midlands Ambulance Service, on 4 February 2014 you attended to Patient A who had suffered a fall and:

1) You did not adequately assess and/or treat Patient A in that:

a) As indicated on your Patient Report Form, you did not offer to· take Patient A to hospital.

b) You inappropriately left Patient A at home, instead of taking Patient A to Hospital.

 

2) The matters set out in paragraph 1 constitute misconduct and/or lack of competence.

 

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

 

Matter 2:

During the course of your employment as a paramedic with West Midlands Ambulance Service, on 4 February 2014 you attended to Patient A who had suffered a fall and:

 
1) you did not adequately assess and/or treat Patient A in that:


a) As indicated on your Patient Report Form, you did not offer to take Patient A to hospital.


b) You inappropriately left Patient A at home, instead of taking Patient A to hospital.

 
During the course of your employment as a paramedic with West Midlands Ambulance Service, between January 2010 and June 2014:

 

2) On 19 January 2014, you attended Patient B who had been suffering from severe epistaxis and you:


a) Told Patient B to ‘calm down and her nose bleed might stop’ or words to that effect

 
b) Acted beyond your scope of practise as a paramedic in that you:

i. Placed folded gauze into the nostril of Patient B

ii. Removed and replaced the gauze in the nostril of Patient B between 2-7 times
 

c) Did not immobilise Patient B for approximately 1 hour and 50 minutes despite the continued epistaxis
 

d) Allowed Patient B to walk to the ambulance for approximately 40 metres in bed socks
 

e) Did not offer Patient B a wheelchair to the ambulance
 

f) Did not put a seatbelt on Patient B prior to the ambulance moving and/or during the journey to the hospital

 

3) On 24 January 2014, you attended Patient C who appeared to be suffering with chest and back pain, and you:

 
a) Asked Patient C to move to another room without first conducting a physical examination and/or clinical observation of the patient
 

b) Responding to Patient C who asked you to take him to the hospital by saying ‘we are not a taxi service’ or words to that effect


c) Left the scene without:

i. Reconciling or attempting to defuse the situation

ii. Taking any safeguarding measures

iii. Advising Patient C and/or the patient’s family what to do if his condition deteriorated
 

4) Your actions described at paragraphs 2 and 3 were inappropriate and/or were not in the best interest of the patient
 

5) The matters set out in paragraphs 1-4 constitute misconduct and/or lack of competence

 
6) By reason of your misconduct and/or lack of competence your fitness to practise is impaired

 

 

Finding

Preliminary Matters

1. There were various preliminary and procedural matters that had to be dealt with by the Panel during the course of the hearing. On each occasion the Panel heard submissions from the representatives, received advice from the Legal Assessor and considered the appropriate Practice Notes.

Amendment of the Particulars of the Allegation

2. Mr Foxsmith applied to amend the Particulars of the Allegation in relation to allegation 2 (b) by changing the spelling of the word “practise” to “practice.”  There was no objection to this suggested amendment by Mr Harries and the Panel had no hesitation in granting the formal amendment.

Proceeding in Private

3. There were periods during the hearing when there were references to the Registrant’s health during which, with the agreement of both parties, the Panel proceeded in private in accordance with Rule 10(1)(a) of the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 (the Rules), which states

“At any hearing—(a) the proceedings shall be held in public unless the Committee is satisfied that, in the interests of justice or for the protection of the private life of the Registrant, the complainant, any person giving evidence or of any patient or client, the public should be excluded from all or part of the hearing;”

4. The Panel was satisfied that it was in the interests of justice or for the protection of the private life of the Registrant to exclude the public from the proceedings and was consistent with Article 6(1) of the European Convention on Human Rights (ECHR), which provides limited exceptions to the need for hearings to be held in public, namely that it was “in the interests of justice or for the protection of the private life of the health professional, the complainant, any person giving evidence or of any patient or client”.

Telephone evidence


5. Further, the Panel, with the consent of the parties, agreed to Patients A and B giving their evidence by telephone.

6. Finally, at the conclusion of the HCPC case, Mr Foxsmith applied to discontinue particular 2 (d) which stated “Did not offer Patient B a wheelchair to the ambulance”.  He asked the Panel to note that Witness 1 had indicated that the ambulance in which the Registrant had attended Patient B’s house on the evening in question did not carry a wheelchair, although it carried a “carry chair”.  Mr Foxsmith conceded that such could not amount to Misconduct or a Lack of Competence since the Registrant could not be criticised for failing to do the impossible.  The application was not opposed by Mr Harries.  

7. In reaching its decision on the application for discontinuance, the Panel noted that it has a duty to make “due inquiry” not least to ensure that there was no “under-prosecution” on the part of the HCPC.  The Panel’s task was to ensure that the HCPC had proper grounds for discontinuing the allegation; had provided an objectively justified explanation for doing so and that the decision not to proceed had been reached either because the HCPC had no realistic prospect of proving the allegation or because there was some other overriding public interest which justified discontinuance.

8. The Panel agreed that particular 2 (d) could not be sustained since the Registrant could not be criticised for failing to perform an impossible task and therefore his actions could not amount to Misconduct or a Lack of Competence.  It also agreed that there was no under-prosecution, in particular since the remaining particulars, especially 2 (c), (Allowed Patient B to walk to the ambulance for approximately 40 metres in bed socks) were sufficient to address the alleged mischief in this matter.  Accordingly, taking all these factors into account, the Panel was satisfied that the HCPC had proper grounds for discontinuing allegation 2 (d) and had provided an objectively justified explanation for doing so.  The Panel therefore agreed to discontinue particular 2 (d).


Background

9. The Registrant   joined   the   West   Midlands   Ambulance   Service   Trust   (the Trust) in January/February 2010 as a Paramedic. After completing the required training he became employed as an Advanced Paramedic and was employed as Clinical Team Mentor (CTM) on 4 August 2013. His role involved attending patients on call outs and supervising other clinicians while on calls to ensure that clinicians under his supervision were following Trust Policies and Procedures.

10. On 4 February 2014, the Registrant attended Patient A at his home address together with Witness 2, another Paramedic and BR, a Student Paramedic.  Patient A had suffered from amnesia and could not remember the previous two hours.  It became clear that Patient A had fallen. He had a large bump on his head and was complaining of neck pain and pain in his arms and chest.  Patient A was treated at the scene and discharged. Patient A subsequently visited his GP six days later and was referred to hospital where he was informed that he had broken his neck.  Patient A complained to the Trust and the complaint was referred to Witness 1, Clinical Practice and Governance Manager and Investigating Officer, who investigated the matter on behalf of the Trust.

11. The above matter was referred to the HCPC. As a result of this referral the HCPC requested information from the Trust about other practice concerns regarding the Registrant.  It was at this point the Trust further investigated, and subsequently referred to the HCPC, the concerns in respect of Patient B and Patient C.

12. Patient B was an elderly female patient living alone. On 19 January 2014 she was suffering with a significant nosebleed. The Registrant attended at her home with an Ambulance Technician, Matthew Orchard, but after attempting to stem the bleeding for about 1½ hours, eventually took her to hospital where she was admitted and her nose bleed eventually cauterised.  Patient B subsequently made a telephone complaint in relation to the Registrant on 27 January 2014.  She reported that the Registrant was ‘lovely’ initially but then his demeanour and attitude changed completely. He told her to calm down on a number of occasions and she was not happy with this comment or his attitude towards her as they “made me feel as if I was daft or stupid”.  The Registrant recorded on the Patient Report Form (PRF) that he had used a ‘gauze tampon’ to treat Patient B, which involved using folded gauze up her nose. The Registrant had removed and replaced this on a number of occasions.  It was maintained by the Trust that nasal packing was outside the scope of the practice of a Paramedic and that the UK Ambulance Services Clinical Practice Guidelines for controlling haemorrhage stated that if a patient was bleeding for more than 10 minutes they should be transferred to hospital. Patient B further alleged that the Registrant told her to walk from her house to the ambulance, a distance of 40 metres, in her bed socks and that he did not fasten her seatbelt when she was in the ambulance or during the journey to the hospital.

13. In relation to Patient C, he was a 44 year old man who had been seeing his GP for about six months before the Registrant attended to him on 24 January 2014. During this period he had lost a lot of weight and had reported chest pains. His GP had not prescribed painkillers but treated him instead for anxiety.  However, shortly after the incident he was diagnosed with terminal cancer and died 10 days later.

14. On 24 January 2014, Patient C had been suffering with chest pain, shortness of breath and difficulty of swallowing.  His mother had called for an ambulance for him. It was understood that Patient C’s Mother had initially called Patient C’s GP and had been advised by the surgery to call 999.  Patient C’s mother reported that, upon arrival at the property, the Registrant asked Patient C to move from his bedroom to the nearby living room. It was alleged that he did not conduct any physical examination of Patient C and that when Patient C asked the Registrant to take him to hospital, responded by saying ‘we are not a taxi service’ or words to that effect. As a result of this Patient C’s family (including his mother and sister) became angry and shouted at the Registrant to leave, which he did without advising the family as to what they should do should Patient C deteriorate.

Witnesses


15. The Panel heard evidence from the following witnesses in the case, namely:

- Witness 1, Investigating Officer.  He conducted the Trust’s investigation into the Registrant’s alleged behaviour.

- Witness 2, Paramedic.  She attended to Patient A with the Registrant on 4 February 2014.

- Patient A, who was attended on by the Registrant on 4 February 2014 (by telephone)

- Patient B, who was attended on by the Registrant on 19 January 2014 (by telephone)

- Patient C’s Mother, who was present when the Registrant attended to her son on 24 January 2014.


16. The Panel also heard evidence from the Registrant and read a number of statements/interview records/letters including: an agreed report from Jamie Todd, an expert Paramedic; BR, at the relevant time a Student Paramedic; Patient B’s daughter-in-law; Matthew Orchard, at the relevant time an Ambulance Technician; Patient C’s sister; and SG, at the relevant time a Technician.   Such statements were contained in three HCPC bundles (amounting to over 500 pages) and two Registrant’s bundles (amounting to over 670 pages) together with a number of other documents.

Decision on Facts


17. In considering this case the Panel bore in mind that the burden of proving the facts rests upon the HCPC and that the standard of proof is the civil standard of the balance of probabilities. It has taken account of all the evidence presented to it, namely the written and oral evidence of the witnesses, including the Registrant, listed below, together with the documentary evidence provided by the HCPC and by the Registrant. It has also considered the detailed submissions of the representatives, and has accepted the advice of the Legal Assessor.

18. The Panel particularly noted the Legal Assessor’s advice that, notwithstanding that the HCPC’s Procedure Rules do not have a specific provision which indicates that a Panel can find the allegations proved by simply relying upon the Registrant’s admissions of those allegations, there was likewise nothing in the Rules to prevent it from doing so if it was satisfied that the admissions were well-informed, not made for reasons of expediency or duress and had been made with the benefit of legal advice. Consequently, the Panel noted that it would be entitled to treat any informal admissions made by the Registrant during the course of his evidence as determinative of the factual allegations.

Assessment of witness credibility

- Witness 1, Investigating Officer.  He conducted the Trust’s investigation into the Registrant’s alleged behaviour. The Panel found him to be very credible and fair, in that he frequently accepted good points about the Registrant’s practice.

- Witness 2, Paramedic.  She attended to Patient A with the Registrant on 4 February 2014. The Panel found her to be an honest witness who again was willing to make concessions in relation to the Registrant but who was also steadfast and consistent in her evidence.

- Patient A, who was attended on by the Registrant on 4 February 2014 (by telephone). The Panel considered Patient A was very credible, fair and open minded.  The Panel appreciated that he readily admitted to still suffering from amnesia in relation to what had happened to him on 4 February 2014 prior to the arrival of the ambulance, but noted that his evidence in relation to what happened during the attendance of the Registrant at his home was consistent and clear.  He also was steadfast in his evidence whilst willing to make concessions in relation to the Registrant.  The Panel found him to be a compelling witness.  

- Patient C’s Mother, who was present when the Registrant attended to her son on 24 January 2014. The Panel appreciated that she was clearly upset and under pressure when giving her evidence. The Panel treated her evidence with some caution and did not accept all of it, although it did believe her version of what the Registrant said regarding the taxi service.

- Patient B, who was attended on by the Registrant on 19 January 2014 (by telephone). The Panel found her generally to be credible. It believed that she was doing her best to recall the events and, whilst there was some variance in her evidence and contradiction with the evidence of others, on specific key points her evidence was consistent and steadfast under cross-examination.

19. The Panel considered that the Registrant was on the whole credible but his evidence at times was self-serving.  There were occasions when, after being asked to describe what had happened, the Registrant began his replies by saying words such as “I would have done…” instead of “I did…”, which suggested to the Panel that his recall was not as confident as he was attempting to suggest.  The Panel also found that at times his answers were too considered and nuanced, which suggested a lack of spontaneity, empathy and insight.

Decisions on each of the particulars:

During the course of your employment as a paramedic with West Midlands Ambulance Service, on 4 February 2014 you attended to Patient A who had suffered a fall and:

1) you did not adequately assess and/or treat Patient A in that:
a) As indicated on your Patient Report Form, you did not offer to take Patient A to hospital.
b) You inappropriately left Patient A at home, instead of taking Patient A to hospital.

Found Proved in its totality

20. Patient A had called 999. The PRF records that the Registrant together with Witness 2, a Paramedic, and BR, a student Paramedic, arrived at Patient A’s house at 15:55. The call record (CAD) indicates that Patient A had, prior to the arrival of the ambulance at his house, told the call handler that he had ‘left arm pains’, a large lump on his head, ‘neck pains’, and that he was numb down one side. He said that he believed that he might have been having a heart attack.

21. Witness 2 states that on arrival Patient A mentioned that he had fallen earlier in the day and could not remember getting into bed. She went into the kitchen and then outside into his garden and found a 2 foot 2 inch low brick wall with two slabs dislodged and Patient A’s glasses on the ground. When she reported her findings to the Registrant they established that Patient A must have fallen over outside and banged his head. This tallied with the large bump to the left side of this head and a large graze on his leg.  In his statement, Patient A said that he could not recall anything that happened from when he went outside his house at around 14:00 until he woke in his bed in pain at around 15:30. He told the Panel in his evidence that when he woke up he initially called his ex-partner who agreed to come round to his house.  His ex-partner had arrived at the house by the time the ambulance had arrived. After the ambulance crew had been at his house for a while he suddenly remembered a few seconds of falling from a point of about 6 inches from the ground, and parallel to it, thinking ‘this is going to hurt’ and hitting the ground on his left shoulder and head.

22. Patient A distinctly remembered the Registrant kneeling on his bed, asking about any pain and examining his chest. Patient A recalls explaining that he had a pain in his arm that ran down his shoulder, and down the outside of his arm to his fingers and thumb which were tingling and numb. He was told later by his consultant that this was ‘a sure sign of neck damage’.

23. In his statement/record of interview on 3 June 2014, BR stated that Patient A presented with amnesia, and that Patient A complained of pain in his left arm, numbness in his arm and tingling in his arm and hand. However, the Registrant did not record any of these symptoms on the PRF and indicated during his evidence that he had not been told by Patient A about these symptoms. Witness 2 in her evidence confirmed that she was concerned about the evidence of retrograde amnesia because Patient A had been unable to recall recent events. She stated that she raised this whilst the Registrant was talking to the patient about staying at home, because she believed Patient A should be taken to hospital. In her evidence she referred to the NICE guidelines which she believed indicated that Patent A should be taken to hospital (particularly those which referred to “any loss of consciousness as a result of the injury” and “Amnesia for events before or after the injury”). Her evidence was the Registrant was happy with his assessment and he told her he was up to date with the NICE guidelines so she trusted his judgement as he was the more advanced paramedic.

24. The Panel also notes that the PRF recorded that the Registrant carried out a full investigation of Patient A’s spine but this was not confirmed by BR who merely confirmed that the Registrant examined the spine when Patient A was in a sitting position and that no examination took place when he was lying down which was also the evidence of Patient A.

25. Patient A was treated at the scene. The Registrant indicated that he and his student had examined Patient A and had found no neck pain after a C-spine examination.

26. The Panel preferred the evidence of Patient A, Witness 2 and the written evidence of BR to that of the Registrant.  Both Patient A and Witness 2had a clearer and more spontaneous recall of the events than the Registrant appeared to have.  In relation to the statement of BR, the Panel notes Mr Harries’ submissions that he was asked about these matters some four months later and that his recall could have been determined by being referred to the documentation such as the CAD and the PRF, but the Panel doubts that he would have confirmed what was alleged to have been said by Patient A regarding his tingling sensations unless he remembered of his own volition.  Although he was a student at the time, he would no doubt have been concentrating since the Registrant was mentoring and observing him. 

27. The Panel therefore does not consider that the Registrant carried out an adequate assessment of Patient A and that he missed the crucial evidence of Patient A suffering from pains down his arm and tingling in his fingers which was corroborated by references to that on the CAD and from BR’s evidence. The Panel also notes Patient A’s evidence about what happened subsequently. He stated that as he was not taken to hospital and because no offer to take him to hospital was made by the Registrant, he thought his injuries were not as serious as they felt. He believed that he should have been taken to hospital because he had loss of memory for around two hours and had clearly banged his head and indeed he still could not recall those two hours. Moreover, he felt pain in his neck, back, shoulder and arm. He stayed in bed for six days before going to see his GP on 10 February 2014 as the pain in his neck was worse. His GP referred him immediately to hospital for an X-ray after which he was informed that he had a broken neck. He had a major operation on his neck on 13 February and had a Halo Frame fitted following which he returned home on 17 February 2014. It had been found that he had multiple fractures to his neck, four of which had to be drilled and pinned in place. One of his neck spine bones was ‘shattered’. He had the Halo Frame applied to his head for a period of eight months following by five months in a neck brace. He has been told that this was an exceptionally long time to remain in a Halo Frame and that due to the severity of his injuries he was at risk of paralysis  every day that he did not receive hospital treatment.  The Panel considers that the severity of this injury makes it all the more inexplicable that the Registrant failed to take proper account of the patients’ head injury, amnesia, numbness and tingling.

28. In relation to particular 1 (a), the Panel does not accept the Registrant’s evidence that he offered to take Patient A to hospital. The Panel found that he had a very good recollection of what happened that day after the ambulance arrived. The Panel notes that he wished to be taken to hospital but this was not offered to him. The Panel is aware of the Registrant’s evidence that he gave Patient A the option to go to hospital whilst at the same time reassuring him about his injuries but the Panel also notes that, notwithstanding that the Registrant indicated he believed he had taken a very detailed record of the visit on the PRF, there is no record that the Registrant offered to take Patient A to hospital. If the Registrant was as meticulous as he said he was about record keeping the Panel believes that he would have made a record about such an offer. The Panel therefore concludes that particular 1 (a) is proved.

29. It therefore follows that 1 (b) is proved since, because crucial evidence and symptoms were missed, Patient A should not have been left at home. The Panel notes that during the visit the Registrant realised that Patient A had a head injury caused by a significant fall and had suffered a period of amnesia. The Panel considered that the NICE guidelines, which the Registrant apparently paid heed to on this occasion, indicated that Patient A should have been taken to hospital. Although the Registrant maintained that Patient A could not recall if he had lost consciousness, this could and should have been deduced from his overall account of falling and the fact that he had almost complete amnesia about the incident. The Panel therefore finds 1 (b) proved.

30. It therefore follows that the stem of allegation 1 is also proved. In missing or not taking sufficient account of a number of symptoms which indicated that Patient A had suffered what turned out to be an extremely serious injury, the Registrant did not adequately assess or treat patient A.

During the course of your employment as a paramedic with West Midlands Ambulance Service, between January 2010 and June 2014:

2) On 19 January 2014, you attended Patient B who had been suffering from severe epistaxis and you:
a) Told Patient B to 'calm down and her nose bleed might stop' or words to that effect

31. Found Proved -The Panel notes that this was admitted by the Registrant during his evidence and on that basis alone finds this particular proved, being satisfied that the Registrant has had the benefit of competent legal advice and that this admission is commensurate of the other evidence before the Panel. 
 

b) Acted beyond your scope of practice as a paramedic in that you:

i. Placed folded gauze into the nostril of Patient B
ii. Removed and replaced the gauze in the nostril of Patient B between 2-7 times

32. Found Not proved in its totality - Although the Registrant admitted (i) and (ii) (the latter on at least two occasions) the Panel did not consider that treating a nosebleed in this way was beyond his scope of practice as a Paramedic. The Panel notes that persistent efforts had been made by both the Registrant and his colleague, Matthew Orchard, who attended with him, to stem the bleeding, such including pinching the bridge of the nose and applying ice cold objects, none of which caused the bleeding to cease completely. The Registrant explained in his evidence that he then rolled up a piece of gauze and placed it in the outer chamber of Patient B’s right nostril in the hope that this would staunch the bleeding. The Panel accepts the expert evidence of Mr Todd that this is not nasal packing but in reality was, as described by Mr Harries, a home remedy applied in the hope that the bleeding would cease. The Panel is not persuaded that this practice is outside the scope of a Paramedic.

c) Allowed Patient B to walk to the ambulance for approximately 40 metres in bed socks.

33. Found Proved - The Panel notes that this was admitted by the Registrant during his evidence and on that basis alone finds this particular proved, being satisfied that the Registrant has had the benefit of competent legal advice and that this admission is commensurate with the other evidence before the Panel about the incident. 


d) Did not offer Patient B a wheelchair to the ambulance (Discontinued)

e) Did not put a seatbelt on Patient B prior to the ambulance moving and/or during the journey to the hospital.

34. Found Proved - The Panel prefers the evidence of Patient B to that of the Registrant. Her evidence was clear that he did not put a seatbelt around her and she described ‘rattling around’ in her seat during the journey and feeling insecure. The Panel also notes that she had a significant recall of the journey, particularly in relation to trying to reach a box of tissues, and that she described a subsequent trip to another hospital later that day when another paramedic expressed incredulity about her not being required to wear a seatbelt in her initial journey to the hospital.  Her recall of what might be termed relatively trivial matters merely indicates to the Panel that Patient B was able to recall parts of her experience with great clarity.  

3) On 24 January 2014, you attended Patient C who appeared to be suffering with chest and back pain, and you:
a) Asked Patient C to move to another room without first conducting a physical examination and/or clinical observation of the patient

Found Proved in relation to not undertaking a physical examination but Not Proved in relation to not undertaking a clinical examination - The Panel notes that the Registrant admitted asking Patient C to move to another room as the room he was in was small and may have made examination difficult and accepts his evidence that before so doing he ascertained from the patient’s demeanour and appearance that he was capable of doing so by undertaking a clinical assessment which did not require any physical contact.  Consequently, the Panel finds the alternative in so far as it relates to not undertaking a clinical examination (which can be carried out by mere observation) Not Proved.  However, the Registrant also accepted that he did not undertake any physical examination of Patient C so on that basis alone finds this particular proved, being satisfied that the Registrant has had the benefit of competent legal advice and that this admission is commensurate with the other evidence before the Panel about the incident.     


b) Responding to Patient C who asked you to take him to the hospital by saying 'we are not a taxi service' or words to that effect

35. Found Proved - The Panel notes that this was admitted by the Registrant during his evidence and on that basis alone finds this particular proved, being satisfied that the Registrant has had the benefit of competent legal advice and that this admission is commensurate with the other evidence before the Panel about the incident.  However, the Panel wishes to record that it prefers Patient C’s mother’s version of what the Registrant is alleged to have said (as outlined in the wording of the particular above) rather than his version and also that it was said abruptly.  Patient C’s mother has been consistent about this and the Registrant’s recollection of his alternative version came somewhat late in the day.

36. However, the Panel accepts the Registrant’s evidence, corroborated as it is by the statement of SG and what is recorded on the PRF, that prior to the Registrant making this comment, when he asked Patient C what he could do for him, Patient C indicated that he had been waiting for an endoscopy appointment recommended by his GP and that he wanted it “more urgently”, after which he gesticulated by pointing to the Registrant and stating ‘you can take me to hospital’. It was after the Registrant advised the patient that the ambulance was not a ‘taxi service’ that Patient C’s mother started shouting at him to leave their house.  
 

c) Left the scene without:
i. Reconciling or attempting to defuse the situation

37. Found Proved – The Panel considers that as a matter of fact this particular is proved since, by the Registrant’s own admission, the situation had not been reconciled before he left the scene and it accepts that he was not given the opportunity to defuse the situation (although the act of leaving might have resulted in the situation being defused)

ii. Taking any safety measures

38. Found Not Proved – The Panel considers that the HCPC has failed to demonstrate or identify what particular “safety measures” should have been taken.  In any event, it notes that the Registrant had not had an opportunity to undertake a full physical examination of Patient C, who had only asked the Registrant to take him to hospital as he wanted an endoscopy to be carried out as soon as possible, and therefore the Registrant could not have evaluated what safety measures were necessary, especially since his clinical observations did not reveal anything untoward.  Moreover, the Panel notes that he did report what had happened to the Emergency Operations Centre once he had reached his ambulance and that he had left Patient C with members of his family who appeared to have his interests at heart.

iii. Advising Patient C and/or the patient's family what to do if his condition deteriorated

39. Found Proved - The Panel notes that this was admitted by the Registrant during his evidence and on that basis alone finds this particular proved, being satisfied that the Registrant has had the benefit of competent legal advice and that this admission is commensurate with the other evidence before the Panel about the incident.  In passing, the Panel is of the view that the Registrant did not have much of an opportunity to articulate any advice following being told in no uncertain terms to leave the property.


4) Your actions at paragraphs 2 and 3 were inappropriate and/or were not in the best interests of the patient.

Found Proved in relation to particulars:

40. 2 (a) – The Panel accepted the evidence from Patient B that when the Registrant told her to “calm down” (which she denied was accompanied by a friendly hand on the shoulder, which is what the Registrant said he did) his tone was such that she felt diminished and patronised.  The Panel accepts the Registrant’s evidence that he meant well but Patient B’s clear recollection of her reaction indicates to the Panel that his actions did not come across in the way intended and caused Patient B’s unease.  The Panel therefore finds that his actions in respect of this particular were inappropriate and not in Patient B’s best interests.  

41. 2 (c) – The Panel appreciates there is conflicting evidence as to how Patient B came to abandon her attempt to put on her slippers and simply resorted to walking to the ambulance in her bed socks.  There is hearsay evidence from her daughter-in-law and from Mr Orchard that there was an element of choice in what Patient B did, but nevertheless, as the senior clinician present, the Registrant should not have allowed Patient B to undertake such a walk owing to her advanced years and the fact that she was continuing to bleed, which in itself, because of the time that the nosebleed had lasted, may have had a debilitating effect upon her.  The Panel therefore finds that his actions in respect of this particular were inappropriate and not in Patient B’s best interests.    

42. 2 (e) – The Panel considers that, for the same reasons as indicated in the previous paragraph above (her age and the continuing haemorrhaging) as well as simply for safe motoring reasons and the fact that Patient B was under his care, the Registrant should have fastened her seatbelt for Patient B.  The Panel therefore finds that his actions in respect of this particular were inappropriate and not in Patient B’s best interests.    

43. 3 (b) – The Panel notes that the Registrant accepted that, albeit with hindsight, he should not have made any reference to an ambulance being used as a taxi service and that he would not use such terminology again.  This indicates to the Panel that the Registrant himself has come to realise that such actions were inappropriate and not in Patient C’s best interests, irrespective of the Patient C’s and his family’s expectations as to what the Registrant could do for them.  

Found Not Proved in relation to particulars

44. 3 (a) – The Panel considers that the Registrant’s actions, having assessed Patient C’s capacity to do so, in asking Patient C to move to a larger room, were appropriate and in his best interests since the Registrant could better conduct a physical examination of him in a larger space.  The Panel does not accept his mother’s evidence that Patient C was unable to walk to another room but prefers the evidence of the Registrant, corroborated as it is by the statement from SG, who also commented that Patient C complied with the request.

45. 3 (c) (i) and (iii) - The Panel considers that the Registrant’s actions in leaving the scene without reconciling or attempting to defuse the situation, and in not advising Patient C or his family what to do if his condition deteriorated, was, in the circumstances, appropriate.  The Panel accepts the Registrant’s evidence, corroborated as it is by SG, that Patient C’s family started shouting at them and became verbally abusive and aggressive, which necessitated their retreat.  The Panel considers that the Registrant had no alternative but to withdraw.  Moreover, although he did not advise the family what to do if Patient C’s condition deteriorated, his understanding from his clinical examination and observations was that Patient C appeared not to be unwell; Patient C was with members of his family who appeared to be very concerned about him and who had already demonstrated an ability to call for medical assistance; and the Registrant did advise the Emergency Operations Centre of what had happened.  Consequently, the Panel concludes that the Registrant’s actions were appropriate.    

Decision on Grounds

46. Having found the facts proved in this matter, the Panel went on to consider whether the facts found proved, individually or collectively, amounted to misconduct. In relation to misconduct, the Panel noted the advice of the Legal Assessor who referred to the cases of Roylance v General Medical Council [2000] 1 A.C. 311, Cheatle v General Medical Council [2009] EWHC 645 (Admin), Nandi v. General Medical Council [2004] EWHC 2317 and R v. Nursing and Midwifery Council (ex parte Johnson and Maggs) (No 2) [2013] EWHC 2140 (Admin). The Panel noted that misconduct must be serious and amount to a registrant’s conduct falling far below the standards expected of a registered paramedic.

47. The Panel noted the submissions of Mr Foxsmith and Mr Harries.  The Panel was aware that this was a matter for its own individual judgment.  The Panel further noted Mr Foxsmith’s submissions that a number of standards in both the HCPC’s Standards of conduct, performance and ethics and in the Standards of Proficiency for Paramedics, had potentially been breached.

48. The Panel also finds that the Registrant is in breach of the following paragraphs of the HCPC Standards of conduct, performance and ethics:

1 - You must act in the best interests of service users.
7 - You must communicate properly and effectively with service users and other practitioners.
10 - You must keep accurate records.
49. The Panel finds that the Registrant is in breach of the following paragraphs of the HCPC Standards of proficiency: Paramedics:

1a.1 - be able to practise within the legal and ethical boundaries of their profession.
– understand the need to act in the best interests of service users at all times

1a.5 - be able to exercise a professional duty of care
1a.6 - be able to practise as an autonomous professional, exercising their own professional judgement

– be able to assess a situation, determine the nature and severity of the problem and call upon the required knowledge and experience to deal with the problem

1b.4 -  understand the need for effective communication throughout the care of the service user

2a.2 - be able to select and use appropriate assessment techniques
– be able to undertake and record a thorough, sensitive and detailed assessment, using appropriate techniques and equipment

2a.4 - be able to analyse and critically evaluate the information collected


50. The Panel reminded itself that it had found proved the following particulars: 1 (a) and (b), 2 (a), 2 (c), 2 (e), 3 (a) in part, 3 (b), 3 (c) (i) and (iii), and 4 insofar as it related to 2 (a), 2 (c), 2 (e) and 3 (b).
51. In relation to particulars 3 (a) and 3 (c) (i) and (iii) the Panel accepts the Legal Assessor’s advice that, having found that such actions were not inappropriate and were in the best interests of the patient concerned, such could not constitute Misconduct on their own since they had failed even to reach such a modest threshold of allegedly poor practice.  The Panel therefore finds that these allegations are not sufficiently serious as to amount to Misconduct let alone to a falling short of the standards expected.
52. In relation to all the remaining matters found proved, save for those in respect of particulars 1 (a) and (b), the Panel, whilst finding that they amounted to poor practice, none of them, either individually or collectively, amounted to such a falling far short as to constitute Misconduct.


53. However, in relation to particular 1 in its entirety, the Panel does find, notwithstanding that this was an isolated incident in an otherwise (up to these allegations) blemish-free practice, and which fortunately did not have a more serious outcome, that the Registrant’s failure to pay sufficient heed to what Patient A was telling him about the pain and tingling in his left arm and the failure to make further enquiry into Patient A’s fall and subsequent amnesia does amount to a serious falling far short of the standards expected such as would be considered deplorable by other practitioners. 


54. Consequently, the Panel considers that although this was a single incident the failure to take proper care of Patient A makes it particularly grave and amounts to Misconduct.       

55. Finally, the Panel does not consider that any of the matters found proved amount to a lack of competence since a fair sample of the Registrant’s work has not been taken.  The matters found proved relate to three separate and isolated incidents during a three week period.

Decision on Impairment 


56. In reaching its decision on impairment, the Panel took account of the submissions of the representatives, the documentary and oral evidence given during the hearing, and the advice of the Legal Assessor. It also took account of the HCPC Practice Notes “Finding that Fitness to Practise is “Impaired” and “Fitness to Practise – What does it Mean?”.

57. The Panel was aware that, in determining whether fitness to practise is impaired, it must take account of a range of issues which, in essence, comprise two components, namely the ‘personal’ component (the current competence and behaviour of the individual Registrant) and the ‘public’ component (the need to protect service users, declare and uphold proper standards of behaviour and maintain public confidence in the profession). The Panel was aware that not every finding of misconduct would result in a finding that fitness to practise is impaired.

58. The Panel notes that the incident involving Patient A took place over three years ago, since when (and indeed beforehand, from 2010 up to the end of 2013) the Registrant has practised without any other concerns being raised about him.  He has presented an impressive set of testimonials, including positive patient feedback forms, and the Panel also notes that Witness 1 spoke highly of his competence, skills and commitment, which resulted in the Registrant being appointed as a Clinical Team Mentor in August 2013.

59. In addition, the Panel notes the Registrant’s continuing commitment to CPD and the numerous courses attended and research undertaken since 2014 (including a case study in relation to head injuries) all of which demonstrates to the Panel that he is motivated to improve his performance and skills as a paramedic.  His current employers and colleagues speak highly of him.  The Panel noted that even though the Registrant had denied that he acted in the way found by the Panel with regard to Patient A, he still addressed that area of his practice notwithstanding that he did not at the time apparently consider that he had been at fault.  Accordingly, the Panel considers that the Registrant has remedied the specific failings in his practice with respect to head injuries and amnesia as indicated by Patient A’s case and is satisfied that the chances of repetition are low.  On that basis the Panel concludes that the Registrant is currently competent and that the personal component of his practice is not impaired.

60. The Panel went on to consider the wider public interest in maintaining confidence in the profession and declaring and upholding proper standards of conduct and behaviour. It concluded that, for the reasons outlined above, that the Registrant’s misconduct sufficiently serous that it is necessary to mark its unacceptability.

61. The Panel therefore finds that the Registrant’s fitness to practise is currently impaired on the ground of public confidence in the profession and the wider public interest.

Decision on sanction

63. In reaching its decision on sanction the Panel took account of the submissions of the parties, the Indicative Sanctions Policy (“ISP”) document and the advice of the Legal Assessor, which it accepted.  It noted the case of Professional Standards Authority v (1) GMC & (2) Uppal [2015] EWHC 1304 Admin which indicated that “Professional standards have been upheld, and public confidence in the profession maintained, by the fact that Dr Uppal has undergone a rigorous disciplinary assessment of her fitness to practise, resulting in a finding of misconduct on her record, with the option of a warning, by way of sanction”.  The Legal Assessor pointed out that in this current case, the Panel had gone one step beyond the Tribunal in the case of Uppal by finding not just Misconduct but also Impairment on public policy grounds.

64. Mr Harries submitted that the Registrant’s case fell within the ambit of Uppal and it was appropriate for it to be dealt with by the Panel taking no further action.  He pointed to the Panel’s reasons for finding that the Registrant was not impaired in relation to the personal component; to the Registrant having already addressed those parts of his practice that had been found wanting by the Panel in relation to Patient A; and he reported that the Panel’s finding of impairment had “devastated” him.

65. The Panel was mindful that the purpose of sanctions is not to be punitive, although they may have that effect. It appreciated that the primary purpose of any sanction is to address public safety from the perspective of the risk which the registrant concerned may pose to those who use or need his services. It noted, however, that in reaching its decision, panels must also give appropriate weight to the wider public interest, which includes: the deterrent effect to other registrants; the reputation of the profession concerned; and public confidence in the regulatory process. In addition, the Panel noted that it must act proportionately, which requires it to strike a balance between the interests of the public and those of the Registrant.

Mitigating and Aggravating factors

66. The Panel took account of the various mitigating factors namely:
 
• The Registrant’s previous good character and service for 4 years up to this incident and in the 3 years since;  
• This matter was one isolated incident;
• This appears to be an uncharacteristic which was not reflective of the Registrant’s  general practice; 
• The Registrant had supplied a significant number of testimonials indicating that he is regarded as a dedicated and skilful Paramedic;
• The Panel was satisfied that the HCPCT’s proceedings in themselves would likely have a significant effect upon the Registrant and had little doubt that they would cause him to reflect even further on his practice; he thus had insight into his failings;
• The Registrant was found to be not impaired in relation to the personal component and thus is a safe and competent practitioner who does not pose a risk to patients or the public.
 
67. The Panel noted the following aggravating features:
 
• The delay caused by the Registrant’s failings did cause Patient A unnecessary pain and concern;
• The delay had the potential to cause additional and serious harm to Patient A (although it did not);
 
Consideration of Taking No Action

68. The Panel took the view that this was a case that could be appropriately dealt with without a sanction.  For the reasons already stated in its determination on Misconduct and Impairment, the Panel is satisfied that this is one of those cases where a finding of impairment on public policy grounds is sufficient to mark the seriousness of the matter and will be a constant reminder to this Registrant, whom the Panel considered had perhaps over prided himself on his practice, that such failings as he demonstrated in relation to Patient A were unacceptable.

69. The Panel did consider whether a minimal sanction, such as the imposition of a caution, might be a preferable alternative and noted that it was considered appropriate:

“where the lapse is isolated, limited or relatively minor in nature, there is a low risk of recurrence, the registrant has shown insight and taken appropriate remedial action. A caution order should also be considered in cases where the nature of the allegation means that meaningful practice restrictions cannot be imposed but where the registrant has shown insight, the conduct concerned is out of character, the risk of repetition is low and thus suspension from practice would be disproportionate. A caution order is unlikely to be appropriate in cases where the registrant lacks insight.”

70. However, although the Registrant’s case mirrored some of the factors mentioned above, the Panel concluded that the imposition of a caution was unnecessary due to the likely adverse effect upon the Registrant of the Panel’s findings.  In those circumstances the Panel did not see any additional advantage in imposing any formal sanction over and above its finding of impairment which it considered was sufficient in the particular circumstances of this case, to mark the seriousness of the matter and to remind the Registrant of the unacceptability of his actions. The Panel therefore finds that taking no further action is the proportionate outcome. 

Order

No information currently available

Notes

 

Hearing history

History of Hearings for Karl Richards

Date Panel Hearing type Outcomes / Status
04/09/2017 Conduct and Competence Committee Final Hearing Impaired - no further action