Mr Robert Bevan

: Paramedic

: PA30787

: Final Hearing

Date and Time of hearing:10:00 27/11/2017 End: 17:00 30/11/2017

: Cardiff Marriott Hotel, Mill Lane, Cardiff, CF10 1EZ

: Conduct and Competence Committee
: Conditions of Practice

Allegation

Whilst registered as a Paramedic and employed by the Welsh Ambulance Services NHS Trust (‘the Trust’):

 

1)    On or around 10 January 2016, you did not provide adequate care to Patient A, in that:

 

a)    You did not observe and/or record that the patient’s presenting condition was of a psychiatric nature;

b)    You did not obtain Patient A’s medical history from the patient and/or from the patient’s father;

c)    You did not question and/or act upon the empty packet of paracetamol found near the patient;

d)    You did not complete a Patient Clinical Record on the day of the incident;

e)    You did not consider and/or record your consideration of the patient’s capacity to make an informed decision;

f)     You did not question and/or record that you questioned the patient’s father regarding any crisis intervention plans and/or the provision of any support from drug or alcohol rehabilitation teams;

g)    You did not leave a recall card with the patient’s father;

h)    You did not seek support from the Trust’s clinical desk and/or other healthcare professionals;

 

2)    Your actions described at particular 1 constitute misconduct and/or lack of competence;

 

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

Finding

Preliminary matters

1. The Registrant, Mr Robert Bevan, has attended this hearing at which he has been represented by Mr Harris.

2. When invited to respond to the allegations, Mr Harris, on behalf of the Registrant, stated that the following elements of the factual particulars were admitted: 1(b); 1(d); 1(e) (as to recording only); 1(f); 1(g) and 1(h).  However, it was not admitted that any of these amounted to an admission of inadequate care.

3. It is a feature of this case that, notwithstanding that the Registrant was employed at the time as an EMT, he was and is a registered Paramedic.  The Panel decided, and the parties agreed, that it was appropriate and fair to determine the case on the basis that the Registrant was, and is, a registered Paramedic.

Background

4. At the time of the events being considered by the Panel, the Registrant was employed by the Welsh Ambulance Service NHS Trust (“the Trust”).  He has been employed by the Trust since 1986, initially as a patient transport driver.  In 1991 he progressed to a role that would now be described as an Emergency Medical Technician (“EMT”).  In 2009 he qualified as a Paramedic.  However, in late 2015, a short time before the events to this case, he ceased to work as a Paramedic and had returned to work as an EMT.  When he attended Patient A he was working as an EMT.

5. At 13:46 on 9 January 2016 the Trust received information from the police that a 26 year old female was “having some sort of episode” and was in the middle of the road.  On receipt of the information from the police, the matter was assigned the dispatch code “25B06” which is the coding for “Psychiatric/Abnormal Behaviour/Suicide Attempt”.  The response expectation was reflected in the matter being recorded as “AMBER2”, which should have resulted in attendance upon the patient within 20 minutes.  In the event, there was no response from the Trust within that period.  It was not until OO:36 in the early hours of the following morning, approximately 11 hours after the information was initially received, that the call was allocated to the ambulance on which the Registrant was working.  In the meantime, further information had been received, including the information that the patient had not been injured and was waiting with her father.

6. In attending the patient, the Registrant was working alongside another EMT.  They arrived at the patient’s home at 00:59 on 10 January 2016, some 23 minutes after the allocation of the call.  The Registrant took the lead role in that attendance.  At 01:22 it was recorded that the patient had refused treatment.

7. Included in the evidence placed before the Panel was the information that at later stage, Patient A started a fire at the house with tragic consequences.  It should be made clear, however, that in reaching its decisions on the facts the Panel has been careful to exclude from its consideration any element of applying this information in deciding this case.  The Panel’s decisions have been based on matters that were known, or could reasonably have been known, to him at the time.

Decision on Facts

8. The Panel approached its decisions on the facts by acknowledging that the burden of proof rested on the HCPC, the standard of that burden being the balance of probabilities.

9. The HCPC called a single witness to give evidence before the Panel.  He was Mr TG, an experienced Paramedic employed by the Trust whose work was concerned with safeguarding matters.  Mr TG had conducted an investigation on behalf of the Trust into the Registrant’s involvement with Patient A.  That investigation was in part for a decision to be made as to whether there was a case to answer in relation to an internal Trust disciplinary matter, but also in order to identify learning points.  Mr TG was not tendered as an expert witness, and he did not have any direct knowledge of the relevant events.  The Panel found that Mr TG was a credible witness who sought to assist the Panel in reaching a fair and just decision.  However, in addition to the fact that he had no direct knowledge of the relevant events, there were other factors that operated to limit the extent to which he was able to assist the Panel.  One such was the fact that he worked in a distant geographical area and did not have knowledge of operational limitations that impacted on the Registrant.  Another was that he had access to information that the Registrant did not have when he attended the patient, for example, Mr TG had been able to listen to a recording of the initial report made to the Trust by the Police.

10. In addition to the oral and written evidence of Mr TG, the HCPC relied upon an extensive bundle of documentary exhibits.  These exhibits included not only the Trust’s records relating to the incident, but also records of statements made by people who were not called as witnesses at the hearing.  The Panel received all this information as hearsay evidence.

11. The Registrant gave evidence.  The Panel found him to be a truthful witness who gave consistent evidence.  He was straightforward and did not seek to embroider his account of the events.

12. In approaching the eight sub-particulars of particular 1, the Panel considered the evidence that related to each issue.  The consideration of the evidence included those matters that were admitted by the Registrant at the commencement of the hearing.  Whenever a sub-particular contained more than one limb, the Panel considered each limb separately.  The Panel also considered in respect of each sub-particular, the contention in the stem that the Registrant did not provide adequate care to Patient A.

Particular 1(a).

13. In relation to this issue the Panel first considered what is meant by “the patient’s presenting condition”.  The conclusion of the Panel was that it was not a formal diagnosis, but rather what a reasonable impression would be following attendance by a Paramedic upon a patient. The Panel then considered whether, in relation to the Registrant’s attendance upon Patient A,  the HCPC had proved that the “patient’s presenting condition was of a psychiatric nature”.  The Panel decided that the HCPC had discharged the burden of proving that it was.  This finding was based, in part, upon the fact that the information that had been available to, and seen by, the Registrant on the display in the ambulance.  The Registrant informed the Panel that he understood this information to be stating that the concerns that were causing him to attend the patient were of a psychiatric nature.  The Panel also based its decision that the HCPC had proved that the presenting condition was of a psychiatric condition by taking account of what the Registrant said he had seen when he reached the patient.  This included the fact that the Patient was hiding under the bed covers; was dressed in bed in the early hours of the morning; communicated with him by non-verbal means although she was able to talk; that the room was unkempt; that there was an empty Paracetamol packet in the room; and that he was told by the patient’s father that she had withdrawn from the use of Methadone.

14. As to the contention that the Registrant did not “observe” that the patient’s condition was of a psychiatric nature, the Panel approached this on the basis that, in the context of this allegation, it alleged that the Registrant did not notice or perceive something and register it as being significant.  The Panel found that the Registrant did not observe the presenting condition because he did not recognise during his assessment of Patient A the significance of what he had seen while he had attended the patient.  This was clear because the account he gave to Mr TG within two months of the incident was that he only asked the patient’s father whether his daughter had mental health issues “purely” because of what he had seen on the display terminal in the ambulance cab.  It was not, therefore, because he had come to that conclusion himself.  The Panel does not find that the fact that there was discussion about taking Patient A to hospital reflected his view that she needed hospital treatment.  Furthermore, the assessment of the patient’s mental capacity to make an informed decision does not reflect an acknowledgement of the true presenting condition as the Panel finds it to be, because the assessment of capacity was undertaken solely in relation to the patient’s statement that she did not wish to be taken to hospital.

15. For these reasons the Panel finds that the Registrant did not observe that the patient’s presenting condition was of a psychiatric nature.
16. As no observation was made by the Registrant of the fact that Patient A’s presenting condition was of a psychiatric nature, there was no recording of it.

17. The Panel is satisfied that these findings resulted in the Registrant failing to provide an adequate level of care to Patient A as it stopped further consideration of Patient A’s presenting condition.

18. Particular 1(a) is proved.

Particular 1(b).

19. The Registrant’s admission that he did not obtain Patient A’s medical history either from herself or from her father accords with the other evidence received by the Panel, and is accepted.  However, he did not admit that this amounted to inadequate care.

20. The Panel does not find that the stem contention relating to inadequate care is made out in relation the fact that the medical history was not obtained from the patient herself.  On the available evidence, the Panel finds that the Registrant could not have obtained that history from her whatever efforts he might have made to obtain it.  The Panel does, however, find that the stem is made out in relation to the failure to obtain a medical history from the father.  Had a medical history been obtained from the father, further investigations might have been suggested.

21. Particular 1(b) is proved.

Particular 1(c).

22. Although denied at the outset of the hearing, by his closing submissions, Mr Harris stated that the Registrant now accepted that he did not question or act upon the empty packet of paracetamol found in Patient A’s bedroom.  The Panel accepts that admission, finding that it was a matter of potential significance as already recorded in relation to its findings under particular 1(a).

23. The Panel finds that the stem is also made out in relation to this particular, it clearly being a relevant feature in the light of the presenting condition.
24. Particular 1(c) is proved.

Particular 1(d).

25. The Panel accepted the Registrant’s admission that he did not complete a Patient Clinical Record on the day of the incident, and notes that he did not admit this amounted to inadequate care.

26. The Panel also finds that the stem allegation is proved by the failure to complete a Patient Clinical Record.  A Patient Clinical Record is a basic aspect of record keeping required by all HCPC registrants.  A significant element of the requirement that adequate records are kept is that there is scope for patient safety to be compromised if there is no record of how health professionals have interacted with patients and the relevant findings.

27. Particular 1(d) is proved.

Particular 1(e).

28. The Panel accepted the evidence of the Registrant that he did consider Patient A’s capacity to make an informed decision.  Accordingly, that limb of the allegation is not proved.

29. The Panel accepted the Registrant’s admission that there was no record made by him of his consideration of the patient’s capacity to make an informed decision, and that contention is proved, although the Panel noted that he did not admit this amounted to inadequate care.

30. For the reasons already explained in relation to the Patient Clinical Record, the Panel finds that the stem contention is proved in relation to the failure to record the assessment of capacity.

31. Accordingly, particular 1(e) is proved in relation to the failure to record.

Particular 1(f).

32. The Panel accepts the Registrant’s admission that he did not question the patient’s father regarding any crisis intervention plans and/or the provision of any support from drug or alcohol rehabilitation teams.  As there was no questioning in this regard, there was no recording of the matter.  The Panel noted that the Registrant did not admit that this amounted to inadequate care.

33. For the reasons explained in relation to particular 1(b) (medical history), the stem contention is made out in relation to this failure.

34. Particular 1(f) is proved.

Particular 1(g).

35. The Panel accepts the Registrant’s admission that he did not leave a recall card with the patient’s father, and noted that he did not admit that this amounted to inadequate patient care.

36. The Panel does not find that the stem contention that the Registrant did not provide adequate care to the patient is made out.  This is because the Panel accepts the evidence of the Registrant that there were no recall cards available to him that he could have left with the father.  The Panel notes that that the absence of the card was ameliorated by information the Registrant gave orally to the father.

37. Particular 1(g) is proved only to the extent that a recall card was not left with the patient’s father.

Patient 1(h).

38. The Panel accepts the Registrant’s admission that he did not seek support from the Trust’s clinical desk and/or other healthcare professionals; and the Panel noted that he did not admit that this amounted to inadequate patient care.    The Panel acknowledged the communication difficulties that might have been presented to the Registrant had he attempted to seek such support.  However, the Panel finds that the reason why he did not seek the support was because he did not think it was necessary.  The Panel finds that if he had determined that it was necessary to obtain such support, he could have tried to obtain it.

39. So far as the stem allegation that this failure resulted in the Registrant not providing an adequate level of care to Patient A, the Panel finds the matter proved.  The fact that the Registrant used Google to search for symptoms of methadone withdrawal demonstrated that he had concerns about what he found.  In the judgement of the Panel, this should have triggered the seeking support of the type identified in the particular.

40. Particular 1(h) is proved.

The stem allegation that the Registrant did not provide adequate care to Patient A.

41. Having regard to the Panel’s findings on each sub-particular about the provision of adequate care to Patient A, the Panel finds overall that particular 1 is proved.

Decision on Grounds

42. After the Panel announced its decisions on the facts, the Registrant gave further evidence directed to the issue of current impairment of fitness to practise.  During the course of his evidence the Registrant stated that he accepted that the Panel’s findings should result in a finding of misconduct.  Following the Registrant’s evidence the Presenting Officer made submissions on the statutory grounds and impairment.  Mr Harris then made submissions on the same issues.

43. Notwithstanding the Registrant’s acceptance of misconduct, the Panel was of the clear view that it was required to make its own decision on the statutory grounds.  The Panel approached its decision on this issue on the basis that the determination was to be confined only to those facts found proved that had contributed to the finding that the Registrant did not provide adequate care to Patient A.

44. The Panel first considered whether these facts amounted to a lack of competence being made out.  The conclusion of the Panel was that, as the facts represented a single incident, they did not represent a fair sample of the Registrant’s work.  The Panel also determined that the findings, although serious by themselves, were insufficient to cross the threshold of not being based on a fair sample.  Accordingly, the Panel concluded that the lack of competence was not established.

45. The Panel next considered whether the findings being considered should properly result in a finding of misconduct.  The conclusion of the Panel was that the findings were of significant failings that resulted in breaches of the standards established by the HCPC.  In particular the Panel found that the Registrant breached the following requirements of the Standards of conduct, performance and ethics, namely: standard 1 (“You must act in the best interests of service users”), standard 5 (“You must keep your professional knowledge and skills up to date”) and standard 10 (“You must keep accurate records”).  Furthermore, the standard of performance demonstrated by the Registrant on the relevant occasion resulted in him not discharging the requirements of a number of the Standards of proficiency for Paramedics.  The conclusion of the Panel was that the Registrant’s failure to bring together the various strands of information that were available to him led to him not providing adequate care to the patient.  This represented a significant falling short of what was expected.  Even though it flowed from a single incident, it was sufficiently serious properly to be categorised as misconduct.

46. For these reasons the Panel found that the statutory ground of misconduct was made out.

Decision on Impairment 

47. The finding that misconduct was made out required the Panel to consider whether, in the light of the nature of that misconduct, the Registrant’s fitness to practise as a Paramedic is currently impaired.

48. The Panel is satisfied that the shortcomings identified by its findings are of a nature that are potentially capable of being remedied.  It is also satisfied that the Registrant has expressed genuine remorse for the fact that they occurred.  However, when the Panel turned to consider whether the Registrant had remedied the shortcomings, it concluded that, although the Registrant had started to develop insight into his failings, this was very recent; and that he still has rather limited insight.  Equally, although the Registrant has taken some steps towards remediating the deficiencies, he has not fully remediated them.  It follows from this that there remains a risk of a repetition of the Registrant failing to offer a patient an adequate level of care.  This conclusion necessitates a finding that the Registrant’s fitness to practise is currently impaired upon consideration of the personal component.

49. Furthermore, the Panel considers that the public component is also made out.  There would undoubtedly be concern on the part of members of the public at the prospect of the Registrant returning to work wholly unrestricted.  This is because he still presents a risk of repeating behaviour that would result in an inadequate level of care being offered to patients.

50. For these reasons the Panel finds that there is current impairment of fitness to practise with the consequence that the Panel must go on to consider the issue of sanction.

Decision on Sanction

51. On behalf of the HCPC the Presenting Officer submitted that the Panel should have regard to the HCPC’s Indicative Sanctions Policy when considering the issue of sanction.  She did not urge the Panel to apply any particular sanction.

52. On behalf of the Registrant, Mr Harris requested that the Panel should consider imposing a caution order.  He further submitted that if the Panel did not consider that the making of a caution order was appropriate, then a conditions of practice order, focused on training rather than restriction, should be considered.

53. The Panel did not determine that there were aggravating features of the case beyond those which resulted in the Panel determining that the Registrant’s fitness to practise is still impaired.  As to mitigating factors, the Panel took into account the fact the incident was a single, isolated event; the Registrant had expressed remorse; had not sought to apportion blame to others; had fully engaged in the regulatory process; and had been open and honest throughout.  The Panel also acknowledged the positive testimonials presented by the Registrant.

54. The Panel first considered whether a sanction was required.  The conclusion of the Panel was that a sanction is required in this case as the circumstances were too serious to result in no further action being taken.  This is not a case in which mediation would be appropriate.  A caution order would not provide a suitable degree of protection for the public, because it would not allow for there to be any restrictions on the Registrant’s practice and it would not enable a future review to assess whether he had fully remediated his shortcomings.

55. The Panel then considering making a conditions of practice order.  The Panel concluded that it was necessary to impose an order combining restriction and practice development. This would address the Registrant’s knowledge and skills shortcomings and provide the necessary degree of public protection.  To that extent it would be a proportionate response to the allegations.  The Panel does not consider that it is necessary to repeat in this narrative explanation the conditions appearing in the Order, save to state that it considered the sufficient and appropriate length of the order to be 12 months, at the end of which it will be reviewed by a panel.  That panel would be assisted in its review by receiving from the Registrant all the reports required by the conditions together with any professional references from any employer and any relevant testimonials that the Registrant might wish to provide.

56. The Panel tested its tentative view that a conditions of practice order is the appropriate order to be made in this case by considering whether a suspension order should be made.  It concluded that the suspension of the Registrant’s registration would be a disproportionately severe response in circumstances where an adequate degree of protection could be provided by the implementation of conditions of practice.

Order

The Registrar is directed to annotate the Register to show that, for a period of 12 months from the date that this Order comes into effect (“the Operative Date”), you, Mr Robert Bevan, must comply with the following conditions of practice:

1. You must not work as a Paramedic alone.

2. You must only work as a Paramedic when working alongside another Paramedic who does not have current restrictions imposed on his or her HCPC registration.

3. Within three months of the commencement of this Order you must identify a Paramedic who does not have current restrictions imposed on his or her HCPC registration with whom you must work to formulate a Personal Development Plan (“PDP”) to address the following areas of your practice:

(1) Accurate and complete record keeping.
(2) How you should focus your Continuing Professional Development moving forward.
(3) Mental health assessments with particular regard to the link between red flags and formulating a working diagnosis.

4. You must within three months of the commencement of this Order inform the HCPC of the identity of the Paramedic with whom you are proposing to work in compliance with condition 3.

5. You must allow the Paramedic identified by you to the HCPC in compliance with condition 4 to provide information to the HCPC with regard to your progress towards achieving the aims set out in your Personal Development Plan.

6. You must obtain from the Paramedic with whom you are working in connection with your PDP up-to-date reports on your development, implementation and progress with regard to the PDP and submit them to the HCPC:

(a) No later than 5 months after the commencement of this Order; and,
(b) No later than 28 days before the date scheduled for the review of this Order.

7. You will be responsible for meeting any and all costs associated with complying with these conditions.

8. Any condition requiring you to provide information or reports to the HCPC is to be met by you sending the information to the HCPC identifying your FTP number and marked for the attention of the Fitness to Practise department.

9. You must promptly inform the HCPC of any disciplinary proceedings taken against you by your employer.

10. You must inform the following parties that your registration is subject to these conditions:

(a) any organisation or person employing or contracting with you to undertake professional work;
(b) any agency you are registered with or apply to be registered with (at the time of application); and,
(c) any prospective employer (at the time of your application).

Notes

This order will be reviewed again before its expiry.

Hearing history

History of Hearings for Mr Robert Bevan

Date Panel Hearing type Outcomes / Status
27/11/2017 Conduct and Competence Committee Final Hearing Conditions of Practice