Notice Of Allegation:
1. At all material times you were employed as a paramedic by the Yorkshire Ambulance Service NHS Trust;
2. During the course of that employment, on 11 December 2007, you responded to a call to attend a male patient complaining of chest pains;
3. You attended the scene as the senior officer, with an Emergency Medical Technician (EMT);
4. Upon arrival at the scene, you failed to:
i. adequately attach monitoring equipment to the patient; and
ii. monitor the patient’s rhythms and note that the patient went into ventrical fibrillation (VF) during the 13
minutes that the patient was attached to the monitor;
5. In failing to recognise VF rhythms, you failed to provide the patient with appropriate treatment;
6. You misdiagnosed the patient as suffering from a fit rather than entering into cardiac arrest;
7. As a result, you left the EMT to treat the patient while you drove the ambulance to the hospital;
8. You did not take ultimate responsibility for the patient’s care;
9. After arriving at the hospital, the patient subsequently died.
Committees Finding:
The registrant was neither present nor represented at the hearing. The panel heard an application for Ms Jung on behalf of the Health Professions Council to proceed in the absence of the registrant in terms of Rule 11 of the Health Professions Council (Conduct and Competence) Procedure Rules 2003. The Panel was satisfied that notice of the proceedings was properly served on the registrant in terms of rule 6(1) of the 2003 Rules. Having considered the submission and having balanced the right of the registrant to a fair hearing with the interests of the Health Professions Council and the general public interest, the panel agreed to exercise its discretion to proceed with the hearing in the absence of the registrant.
The panel heard evidence from Mr Paul Webster who was employed as a manager by the Yorkshire Ambulance Trust and who conducted an investigation into the incident of 11th December 2006. Mr Webster’s investigation involved interviews
with the registrant and the Emergency Medical Technician who attended the incident with her and records of the emergency call and clinical incident log from the Life Pack 12 defibrillator and medical records.
Mr Webster explained that at 18.52 hours on 11th December 2006, a category “C” call was received by the communications centre to attend a 28 year old male complaining of chest pains. He advised that at 18.57hours, the call was changed to a category “A” call. He advised that the ambulance arrived at 19.01hours when the patient, who did not speak English, was in his car and complaining of chest pains, sweating and frightened. The crew walked him to the ambulance, gave him oxygen and checked his blood sugars. An attempt was made by the registrant to find a vein and to apply the ECG electrodes. The registrant and the technician had advised in the course of the investigation that as the patient was sweaty, they could not attach the electrodes. However, from the defibrillator printout, it was apparent that leads one, two and three were attached and an adequate reading was obtained and produced in evidence. Mr Webster advised that the patient became rigid shortly after being on the trolley and then became limp. The registrant described this as looking like a fit. The patient’s
breathing decreased and the technician placed an airway into the patient’s mouth and began to ventilate with a bag and mask.
At this point the patient had no pulse. He was given a precordial thump by the technician who then began chest compressions. Neither of the crew saw a rhythm on the defibrillator monitor and were adamant that the electrodes were not attached to the patient. The registrant then drove the ambulance to the hospital under emergency conditions with the technician treating the patient in the back of the ambulance. The patient subsequently died.
The Panel noted that Mr Webster was an experienced paramedic who had also worked as a paramedic assessor. The panel found him to be a credible and reliable witness and accepted his evidence in relation to the incident.
The panel are satisfied that the registrant was employed as a paramedic by the Yorkshire Ambulance Trust and that during the course of that employment on 11th December 2006, the registrant responded to a call to attend a male patient complaining of chest pains and attended the scene as the senior officer with an Emergency Medical Technician. The panel note that these facts were not disputed by the registrant in the course of the trust’s investigation and find that particulars 1, 2 and 3 are proved.
In relation to particulars 4.i, 4.ii and 5, the panel note from the defibrillator printout that only three of
the twelve leads were attached to the patient. However the panel is of the view that there was sufficient time to
properly attach all twelve leads and to comprehensively monitor the patient’s vital signs and as a result of
failing to do so, the registrant did not monitor the patient’s cardiac rhythm and failed to note that the patient went into ventricular fibrillation. Having failed to recognise the VF rhythms, the registrant failed to provide the appropriate treatment which would have been the instigation of a Full Advanced Life Support Protocol. The Panel also note that the defibrillator sounded audible warnings which should have alerted the crew to the deterioration in the patient’s condition. The panel is satisfied that the facts of particulars 4.i, 4.ii and 5 are proved on the balance of probabilities.
In relation to Particular 6, the registrant stated in her interview with the trust that she thought the patient was
suffering from a fit and the panel find that this was a misdiagnosis as all the symptoms indicated a cardiac arrest which was recognised by the technician. The panel also note that it is recorded in the hospital pre alert notes that the patient was in cardiac arrest. The panel is therefore satisfied that this particular is proved.
The panel find that the registrant left the EMT ventilating the patient and doing chest compressions while she drove to hospital and did not take ultimate responsibility for the patient’s care as the senior clinician. The panel also note that on arrival at hospital, the patient subsequently died. The panel note that the registrant did not deny these facts in the course of the trust investigation. The panel therefore find that the facts of particulars 7, 8 and 9 are proved on the balance of probabilities.
The panel considered that the registrant failed to follow the recognised protocols in relation to the treatment of a cardiac arrest presenting in VF, in particular she failed to defibrillate, intubate, cannulate and provide any drug
therapy, all of which are standard procedures. The panel note that the registrant has 21 years experience with the ambulance service, and has been a registered paramedic for 8 years. The Panel finds that her actions amount to a serious clinical failure and amount to misconduct.
The panel find that the registrant’s conduct breaches standards 1,5, 8, 14 and 16 of the Health Professions Council Standards of Conduct Performance and Ethics. As the registrant has not engaged in the process, the panel have no information to demonstrate that she has addressed her failings and the panel therefore finds that her current fitness to practice is impaired.
The panel therefore find that the allegation is well founded.
The panel heard further submissions in relation to sanction and considered the sanctions available to it in
ascending order of severity. The Panel also considered the letter which the registrant submitted to the investigating Panel on 24th September 2007. The Panel note that there has been no contact from the Registrant since that date. The panel also had regard to the wider public interest considerations which include the
deterrent effect to other health professionals; the reputation of the profession concerned and public confidence in the regulatory process. The panel considered that to take no further action or impose a caution would not adequately protect the public or mark the severity of the registrant’s conduct. The panel is of the view that conditions of practice would not be appropriate as there is no evidence of a commitment on the part of the registrant to resolve matters. The panel next considered a suspension and in the absence of the registrant, were not satisfied that there was a realistic prospect that there would be no repetition of the conduct.
Committees Direction:
The Panel has reached the view that the only appropriate sanction would be a striking off order, given the serious failures and lack of insight by the registrant.
The panel is of the view that this is a proportionate sanction and affords the necessary degree of public protection.
Order: The Panel directs the Registrar to strike Pamela Jameson off the Register.
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