Mr Lindley J Adams

: Paramedic

: PA05375

: Final Hearing

Date and Time of hearing:10:00 08/01/2018 End: 17:00 09/01/2018

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

: Conduct and Competence Committee
: Struck off

Allegation

During the course of your employment as a Paramedic at South Central
Ambulance Service Foundation Trust you:
1. In relation to incident S1605021533 which took place on or around 2 May 2016:
a. Did not conduct an adequate assessment of Patient A in that you:
i. Did not adequately complete a 12 lead electrocardiogram (ECG)
ii. Did not complete and /or record a second set of observations
iii. Did not consider and / or record any differential diagnoses
b. Did not meet the Clinical Performance Indicators (CPIs) for a cardiac event in respect of:
i. Treatment / care
ii. Recording of pain scores
iii. Recommended medications
c. Did not arrange to convey Patient A to hospital
d. Did not record any clinical justification for leaving Patient A at home

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

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

Finding

Preliminary matters
Service
1. The Panel had sight of a letter dated 14 September 2017, sent to the Registrant at his registered address giving notice of today’s hearing, and determined that service had been complied with in accordance with the Health and Care Professions Council (Conduct and Competence Committee) (Procedure) Rules 2003 (“the Rules”).

Proceeding in absence
2. Ms Shameli applied to proceed in the absence of the Registrant.

3. The Panel accepted the advice of the Legal Assessor, who took the Panel to Rule 11 and to the guidance given in the cases of Tait v The Royal College of Veterinary Surgeons [2003] UKPC 34,   R v Jones (2003) 1 AC 1, and GMC v Adeogba [2016] EWCA Civ 162.

4. The Panel had sight of an HCPC Pre-Hearing Information Form, completed by the Registrant, in which he stated that he had retired from practice and was not planning to attend the hearing. The Panel also had sight of an email sent by the Registrant at a later date, 14 September 2017 in which he stated:

 “I am sure I have informed the HCPC some time ago that a) I would not be attending the hearing b) I will not be represented c) I have no witnesses….”

5. The Panel concluded that the Registrant had chosen not to attend. He had not made an application to adjourn the hearing and the Panel concluded that it was unlikely that he would attend if the hearing were to be adjourned. The HCPC intended to call two witnesses to give evidence today. The Panel concluded that it was in the public interest for the matter to be heard expeditiously and that it would be right for the matter to proceed in the absence of the Registrant.

Application to amend the Allegation
6. Ms Shameli applied to amend the Allegation. The Registrant had been given notice of the amendment in advance of the date of the hearing by a letter dated 14 September 2017 and had not submitted any objection. The Panel concluded that the proposed amendment better reflected the case brought by the HCPC and did not increase the scope of the charge, alter the substance of the case or cause prejudice to the Registrant. Having heard and accepted the advice of the Legal Assessor the Panel decided that it was in the interests of justice to allow the application.

Witnesses
7. The Panel heard from the following live witnesses:
• Witness 1 - Investigations Manager at South Central Ambulance Service NHS Foundation Trust (“the Trust”)
• Witness 2 – Director of International Clinical Quality and Development at ZOLL Medical Corporation.

Background
8. The Registrant joined the Trust in September 1974 and became a Paramedic in 1990 and worked with them until his retirement in May 2016.

9. It was alleged that on 2 May 2016, a 999 call was made in respect of Patient A who was reported to be suffering from chest and back pains. The Registrant attended alone and assessed the patient. He left at 20.56.

10. At 21.20 a second call was made to the emergency services. The Registrant attended as part of a team. Upon arrival Patient A was unconscious. Patient A subsequently died.

11. The Allegation centred on the first emergency call conducted by the Registrant. A number of criticisms were Particularised relating to inadequate care and his failure to transfer Patient A to hospital.

Registrant’s submissions
12. Prior to the investigation stage of the HCPC proceedings, the Registrant submitted a document entitled “My version of events”, for the attention of the Investigating Committee, and this was made available to the current Panel. In that document the Registrant expressed his regret regarding the outcome of the incident, but claimed that he had done nothing untoward save for failing to record certain features of the event. He claimed that Patient A had complained to him of upper left arm pain but had not complained of chest pain. He said that he applied a 12 Lead ECG and that he monitored the patient for at least 18 minutes. He claimed that if the ZOLL machine indicated otherwise, this must be because the ZOLL download was corrupt. He added that there had been problems with downloads from the ZOLL in the past. He said that he conducted a second set of observations but accepted that he had not recorded these on the Electronic Patient Record (EPR).

Decision on facts
13. The Panel accepted the advice of the Legal Assessor.

Witnesses
14. The Panel concluded that Witness 1 was reliable, credible and consistent. He was honest in conceding that there were occasions in his witness statement where the wrong exhibit number had been attached to documentation produced by him.

15. The Panel concluded that Witness 2 was reliable, credible, consistent and emphatic in the giving of his evidence.

16. The Panel took into account the representations made by the Registrant both in the course of the Trust’s internal proceedings and in the document that he had provided to the HCPC at the investigation stage. However it gave this evidence less weight than evidence given on oath as it could not be subject to cross examination.

Particular 1(a)(i) – found proved
Did not conduct an adequate assessment of Patient A in that you did not adequately complete a 12-lead electrocardiogram (ECG)
17.  Witness 2 reviewed the information that had been downloaded from the ZOLL cardiac monitor/defibrillator machine on which the relevant ECG procedure had been recorded in relation to Patient A.

18. He informed the Panel that if a patient is suspected of having a cardiac problem, or if it is necessary to rule out a cardiac problem, a 12 lead ECG would ordinarily be carried out. He referred to this as “a basic level of care” for any paramedic to undertake in the circumstances.  He said that this would be done by pressing a button once the leads were attached, at which point a simultaneous reading would be taken and printed out by the “ZOLL” machine. He said that there were a number of “red flags” in place which should have alerted the Registrant to the possibility of a cardiac problem, such as the patient’s age, the pain in Patient A’s upper arm, the complaint allegedly made by Patient A in the 999 call of a pain in his chest, and the fact that Patient A said that he had vomited, was diabetic and was a heavy smoker.

19. He told the Panel that in respect of Patient A, readings had only been obtained from three leads: Lead ii,  the AvF lead and the V5 lead. A complete 12 lead ECG had therefore not been taken. He said that there was no good clinical reason for not using all the leads.

20. Witness 2 said that his analysis indicated that the Registrant had encountered an initial fault with one of the cables which was then rectified. He said that whilst it appeared that the Registrant had scrolled through a number of lead views he did not acquire a complete 12 lead ECG. He gave evidence that the leads reviewed by the Registrant revealed ST segment changes in the ECG which should have indicated the need for a 12 lead ECG even if the clinical signs and symptoms had been unremarkable. He said that even if the Registrant had attempted a 12 lead ECG but had only succeeded with obtaining a view with 3 leads he should have tried again.

21. Witness 2 said in his witness statement that based on the information before him the ZOLL machine had not been faulty; it was extremely unlikely that the download was corrupted. He said that in any event, if there had been a technical issue the Registrant should have made a record to that effect and tried again, and if the problem persisted he should have taken the patient to hospital or called for a replacement device. In giving his oral evidence he said that the “machine was not faulty”.

22. The Panel found this sub-Particular proved. It was clear from the ZOLL machine print out provided to the Panel, in conjunction with the evidence of Witness 2, that only 3 leads had been recorded. The Panel concluded that no complete 12 lead ECG had been recorded. The Panel further concluded that in the absence of a 12 lead ECG this assessment was not adequate, for the reasons set out by Witness 2. In so concluding, the Panel took into account the Registrant’s representations but preferred the evidence given on oath by Witness 2 supported by the documentary evidence. The Panel took into account the fact that the Registrant had not reported any suspected fault to anybody with the equipment at the time of the incident or subsequently. 

Particular 1(a)(ii) – found proved
Did not conduct an adequate assessment of Patient A in that you did not complete and/or record a second set of observations
23.  Witness 1 gave evidence that the EPR did not contain a second set observations. He produced copies of the Trust’s policies which indicated that at least two sets of observations should have been carried out. He informed the Panel that whilst the Registrant claimed to have taken a second set of observations it should be presumed that he had not done so as there was no record of this.

24. The Panel found this sub-Particular proved. It was clear both from the documentation before the Panel and from the Registrant’s own admission that there was no record of any second set of observations. The Panel concluded further that the Registrant did not in fact complete a second set of observations. The Panel noted that the Registrant had recorded his first set of observations. The fact that there was no record of any observations led the Panel to conclude on the balance of probabilities that none had been completed. The Panel had concluded that there were concerns about the Registrant’s credibility in relation to his submissions made about the malfunctioning of the ZOLL machine; the Panel now had similar concerns regarding his submissions in connection with the completion of a second set of observations. The Panel concluded on the balance of probability that the Registrant had not completed the second set of observations. In those circumstances it could not be said that the assessment was adequate.

Particular 1(a)(iii) – found proved
Did not conduct an adequate assessment of Patient A in that you did not consider and/or record any differential diagnoses
25. Witness 1 informed the Panel that the EPR did not contain a record of any consideration given by the Registrant to any differential diagnoses, and that without such documentation the presumption was that he did not in fact consider any differential diagnoses. He said that differential diagnoses are important in order to establish the type of care to provide for the patient. He said that the Registrant had responded to a cardiac event, and that the process had already been started as a cardiac process with the patient being given aspirin. He therefore needed to put evidence in the EPR that this was not a cardiac event if this was his assessment. An example would be a differential diagnosis such as a muscle injury. However, he failed to record evidence of any differential diagnoses.

26. The Panel found this sub-Particular proved. It was clear that the EPR contained no record of any other potential diagnosis, and the Registrant accepted that he did not document this. In failing to record an alternative diagnosis the assessment was inadequate, and the Panel found this sub-Particular proved on that basis. The Panel did not conclude on the balance of probabilities that the Registrant had not in fact given consideration to a differential diagnosis as it appeared that his decision to leave Patient A was made on the basis that he believed him to be suffering from muscular injury.

Particular 1(b)(i) - found proved
did not meet the Clinical Performance Indicators (CPI’s) in respect of treatment/care
27. Witness 1 informed the Panel that the Registrant did not meet the Clinical Performance Indicators (CPI’s), namely the national guidelines that are required to be followed by paramedics when assisting patients in the course of a cardiac event. Witness 1 did not provide the Panel with documentary support for his evidence but informed the Panel that the relevant CPI’s in the circumstances were:
•  completion of a 12 lead ECG
•  administration of Aspirin
•  administration of glyceryl trinitrate (GTN)
•  administration of analgesia
•  two pain scores.

28. Witness 1 informed the Panel that there was no reason recorded in the first EPR as to why medication was not administered. He said that treatment or care that should have been provided to Patient A in the circumstances, included the giving of aspirin and GTN.

29. The Panel found this sub-Particular proved. The Panel accepted the detail provided by Witness 1 regarding the relevant CPI’s, which had not been challenged by the Registrant in his documentary submissions. The Panel accepted the evidence provided by Witness 1 that whilst it appeared that Patient A had been advised over the telephone to take some aspirin prior to the Registrant’s arrival, the Registrant should have checked the indications for the administration of aspirin and GTN on his arrival. There was no record of this and the presumption therefore was that this was not done. It followed that the Registrant did not meet the CPI for a cardiac event in respect of the treatment and care of Patient A.

Particular 1(b)(ii) – found proved
did not meet the Clinical Performance Indicators (CPI’s) in respect of recording of pain scores
30. Witness 1 informed the Panel that the Registrant did not record, on a scale of 1 to 10, how much pain and discomfort Patient A was suffering. He took the Panel to a Clinical Directive which stated that:

Analgesia must be given to all patients with chest pain and a pain score recorded before and after treatment. This is an important Clinical Performance Indicator and we are measured against other ambulance services on this standard nationally”.

He said that this should be a baseline observation for any paramedic attending to a patient in the context of an emergency call. He said that if information is not recorded on the EPR, then it is to be assumed that the indicators had not been met. He explained the significance of recording information of this type given by a patient suffering from chest pains, it would generate inform the EPR software of the sections of clinical documentation to be completed. He said that it was only after the event that the Registrant stated that the patient had experienced pain on a level of 2/3 out of 10 when he left the scene. However, no pain scores had been recorded.

31. The Registrant in his written representations accepted that he was “not aware of clinical directive number 85” which relates to the general management of high risk non-traumatic chest pain.

32. The Panel found this sub-Particular proved. It was clear both from the documentation placed before the Panel, and from the evidence provided by Witness 1, that the Registrant had not recorded the relevant pain scores and that in so doing, he had not met the CPI’s for a cardiac event.

Particular 1(b)(iii) – found proved
did not meet the Clinical Performance Indicators (CPI’s) in respect of recommended medications
33. Witness 1 informed the Panel that the Registrant did not record any recommendation for pain relief or medication, and therefore did not identify or provide the relevant medication for Patient A, which, according to the relevant guidance, could have consisted of aspirin and or GTN. The indication for morphine administration, was difficult to assess without the patient’s pain scores. He took the Panel to the relevant clinical directive which emphasised the need to give analgesia to all patients with chest pain.

34. The Panel found this sub-Particular proved. It was clear both from the documentation placed before the Panel, and from the evidence provided by Witness 1, that the Registrant had not administered the recommended medications and that in so doing he had not met the CPI’s for a cardiac event. The Panel concluded that without a pain score it was impossible to meet the CPI for a cardiac event in respect of recommended medications in any event.

Particular 1(c) – found proved
did not arrange to convey Patient A to hospital
35. Witness 1 informed the Panel that based on his observations of Patient A, the Registrant decided that it was not necessary to convey Patient A to hospital. Witness 1 produced a copy of the NHS clinical directive on conveying patients suffering from chest pains to hospital. He highlighted that because the patient was suffering from chest pain, there was a presumption he should have been taken to hospital without delay as no differential diagnosis was recorded.

36. Witness 2 gave evidence about the readings obtained from the ECG. He said it is “very clear that there is some abnormality in the ECG”. He said there was a marked ST segment depression in all 3 leads from which readings had been recorded, especially in the V5 lead. He said this indicated “some abnormality in the ECG giving cause for concern” and that there was an “underlying problem with the patient’s heart” which would “require investigation at hospital”. He said there was certainly enough evidence to start “treatment and pre-notify the hospital of the patient’s arrival and condition.”

37. Both Witnesses 1 and 2 stated that the presence of a number of red flag indicators should have led to the patient being conveyed to hospital.

38. The Panel found this sub-Particular proved on the basis of the evidence supplied by Witness 1. The Panel took into account that the Registrant had not disputed that he did not arrange to convey Patient A to hospital.

Particular 1(d) – found proved
did not record any clinical justification for leaving Patient A at home
39. Witness 1 informed the Panel that the Registrant did not record a clinical justification for his decision to leave Patient A at home. Witness 1 said that if he had made such a recording the EPR system would have guided him through more options and would have allowed any practitioner reviewing the EPR to follow his decision-making process.

40. The Panel found this sub-Particular proved on the basis of the evidence supplied by Witness 1. The Panel had sight of the EPR completed by Paramedics after the second 999 call was made in which good use had been made of the “free text” box. By contrast there was no entry made by the Registrant in the free text box or any other area of the EPR to record his clinical justification for leaving Patient A at home following the first visit.

Decision on grounds
41. The Panel accepted the advice of the Legal Assessor who took the Panel to the cases of Roylance  v General Medical Council No 2 [2001] 1 AC and Calhaem  v General Medical Council [2007] EWHC. The Panel was aware that a finding of misconduct and/or lack of competence was a matter for the Panel’s professional judgement.

42. In reaching its conclusion, the Panel concluded that the following HCPC Standards of Conduct, Performance and Ethics (2016) had been breached:
Standard 3 – Work within the limits of your knowledge and skills
Standard 6 – Manage risk
Standard 10 – Keep records of your work

43. The Panel also concluded that the following HCPC Standards of Proficiency for Paramedics (2014) had been breached:

Standard 1 – Be able to practise safely and effectively within their scope of practice
Standard 1.3 – be able to use a range of integrated skills and self-awareness to manage clinical challenges independently and effectively in unfamiliar and unpredictable circumstances or situations
Standard 1.4 – be able to work safely in challenging and unpredictable environments, including being able to take appropriate action to assess and manage risk

Standard 2 – Be able to practise within  the legal and ethical boundaries of their profession
Standard 2.1 – understand the need to act in the best interests of service users at all times
Standard 2.2 – understand what is required of them by the Health and Care Professions Council
Standard 2.8 – be able to exercise a professional duty of care

Standard 3 – Be able to maintain fitness to practise
Standard 3.1 – understand the need to maintain high standards of personal and professional conduct
Standard 3.3 – understand both the need to keep skills and knowledge up to date and the importance of career-long learning

Standard 4 – Be able to practise as an autonomous professional exercising their own professional judgement
Standard 4.1 – be able to assess a professional situation, determine the nature and severity of the problem and call upon the required knowledge and experience to deal with the problem
Standard 4.2 – be able to make reasoned decisions to initiate, continue, modify or cease treatment or the use of techniques or procedures, and record the decisions and reasoning appropriately
Standard 4.4 – recognise that they are personally responsible for and must be able to justify their decisions
Standard 4.5 – be able to use a range of integrated skills and self-awareness to manage clinical challenges effectively in unfamiliar and unpredictable circumstances or situations
Standard 4.8   be able to make a decision about the most appropriate care pathway for a patient and refer patients appropriately

Standard 8 – Being able to communicate effectively
Standard 8.7 – understand the need to provide service users or people acting on their behalf with the information necessary to enable them to make informed decisions

Standard 10 – Being able to maintain record appropriately
Standard 10.1 – be able to keep accurate, comprehensive and comprehensible records in accordance with applicable legislation, protocols and guidelines
Standard 10.2 – recognise the need to manage records and all other information in accordance with applicable legislation, protocols and guidelines

Standard 14 – Being able to draw on appropriate knowledge and skills to inform practice
Standard 14.3 – be able to conduct appropriate diagnostic or monitoring procedures, treatment, therapy or other actions safely and effectively
Standard 14.9 – be able to gather appropriate information
Standard 14.10 – be able to select and use appropriate assessment techniques
Standard 14.11 – be able to undertake and record a thorough, sensitive and detailed assessment, using appropriate techniques and equipment
Standard 14.12 – be able to conduct a thorough and detailed physical examination of the patient using appropriate skills to inform clinical reasoning and guide the formulation of a differential diagnosis across all age ranges
Standard 14.15 – be able to undertake or arrange investigations as appropriate
Standard 14.16 – be able to analyse and critically evaluate the information collected
Standard 14.17 – be able to demonstrate a logical and systematic approach to problem solving

Standard 15 – Understand the need to establish and maintain a safe practice environment
Standard 15.1 – understand the need to maintain the safety of both service users and those involved in their care

44. It was the judgement of the Panel that the Registrant’s behaviour had fallen seriously below the standards expected of a Paramedic acting in the circumstances faced by the Registrant at the time, and that the Particulars found proved amounted to misconduct. In particular, it was clear that the Registrant should have, but did not, take a complete 12 lead ECG, which, on the basis of the evidence presented to the Panel, was crucial in the circumstances.

45. The Panel concluded that lack of competence on the Registrant’s part had not been made out. The Panel had not been provided with a fair proportion of the Registrant’s work over a reasonable period of time and was not in a position to conclude that the Registrant lacked the requisite skills, or that he was incapable of meeting the standards required of him.

46. Accordingly, the Panel found Particular 2 proved on the basis of misconduct.

Decision on impairment
47. The Panel accepted the advice of the Legal Assessor who addressed the Panel on the meaning of impairment and referred to the case of Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery council (2) Paula Grant [2011] EWHC 927.

48. The Panel concluded that the Registrant had put Patient A at unwarranted risk of harm, had breached one of the fundamental tenets of the profession and had brought the profession into disrepute. The Panel accepted that this was an isolated incident. However, the Panel had not been provided with any information about the Registrant’s current position other than that he no longer wished to work as a Paramedic and had retired. Whilst the Registrant’s failings are capable of remediation, the Panel had not been provided with any evidence of steps taken to remediate his shortcomings. Furthermore whilst the Registrant had expressed remorse for the consequences of what happened, he had not provided any insight into his own failings. The Panel concluded that there was therefore an ongoing risk that he could repeat his misconduct. The Panel also concluded that confidence in the profession, and in its regulator, would be undermined if a finding of impairment were not to be made given the risk to the public from a repetition of his misconduct.
 
49. Accordingly, the Panel found the Registrant’s fitness to practise to be currently impaired.

Decision on sanction
50. The Panel was provided, for the purpose of sanction, with details of a finding of misconduct that had been made in relation to the Registrant by the Conduct and Competence Committee of the HCPC at a final hearing held on 12 May 2014 relating to events that took place in May 2012. No finding of impairment was made on that occasion. The case concerned a finding that in the course of his employment as a Paramedic with South Central Ambulance Service on 02 May 2012 the Registrant had:
• delayed a response to an emergency call
• dishonestly misled his employers as to the reasons for his late response.

51. The facts behind that Allegation were that the Registrant delayed attending an emergency call for a patient who had fallen and sustained a broken hip and required emergency admission to hospital, and persuaded a colleague to lie about the reason for his absence. He did not attend the hearing. The facts were found proved in his absence by reason of his admissions prior to the hearing. The Panel concluded that misconduct but not current impairment was made out.

52. In relation to the matter before this Panel, in considering what sanction, if any, to impose, the Panel accepted the advice of the Legal Assessor and referred to the Indicative Sanctions Policy.

53. The Panel bore in mind that its purpose was not to be punitive, but to protect the public interest. It understood that it must act proportionately, balancing the interests of the Registrant with those of the public. It considered the range of available sanctions in ascending order of seriousness, starting with the option of taking no action.

54. The Panel found, by way of aggravating factors, that the incident had involved a clear risk of serious harm, the Registrant had demonstrated remorse but no insight, the Registrant had been a team leader of many years’ experience, and this was a second finding of misconduct in the past four years.

55. The Panel found by way of mitigation that the Registrant had made some admissions albeit limited and had expressed remorse for the consequence of his actions.

56. In view of the seriousness of the case, to take no further action or to impose a Caution Order would not be sufficient to protect the public or the public interest.

57. The Panel concluded that conditions of practice would be unworkable in light of the Registrant’s declared intention not to work as a paramedic, his lack of attendance, lack of insight and denial of the Allegation.

58. The Panel gave careful consideration to a Suspension Order. However, the Registrant has not fully engaged with this hearing and has not provided any evidence of remediation or insight. His misconduct had been serious. He had appeared before the Conduct and Competence Committee in 2014, and yet has not demonstrated that he has learnt from that experience or understood the seriousness of the position he now faced, including the importance of appearing before his regulator to provide evidence of remediation and insight. His stated intention not to work again as a paramedic is demonstrative of an unwillingness to resolve matters and suggests that any sanction lower than a Striking Off Order is inappropriate. Furthermore, in light of the seriousness of the current Allegation and the existence of a recent finding of misconduct, the Panel concluded that any lesser sanction would undermine confidence in the profession and the regulatory process.

59. In those circumstances the Panel concluded that a Striking Off Order was the only appropriate order. Such an order was necessary due to the seriousness of the misconduct, the lack of adequate remediation and insight, the risk of repetition in light of the lack of insight, and the fact that any lesser sanction would undermine confidence in the profession and the regulatory process for the reasons set out above.

Order

That the Registrar is directed to strike the name of Mr J Adams from the Register on the date this order comes into effect. 

Notes

No notes available

Hearing history

History of Hearings for Mr Lindley J Adams

Date Panel Hearing type Outcomes / Status
08/01/2018 Conduct and Competence Committee Final Hearing Struck off