Struck Off in order to protect the public

The paramedic, Mr C, whose FTP hearing I attended last week, has been 'struck off' the HPC register in order to protect the public. The report of the panel is published on the HPC website. Had the case been not proven, the HPC would not publish the details. This has the strange consequence of making it appear that all the allegations pursued by the HPC are successful, which is not the case. But that is an issue for another time. What I am interested in here is discovering what it is that the public is being protected from, and what kind of public it is, that is being imagined into existence.

As I mentioned in a previous blog entry, the hearing at the HPC does not appear to be interested in the actual facts of the specific case. They are more concerned with a generalised idea (or ideal) and must rely in great part on what has already been written not in great texts by eminent thinkers in the proper scientific application of their work, but by the Professional Liaison Group set up by the HPC at the start of the process of regulation. This begs lots of questions about science knowledge and management, and calls up the spectre of Galileo.

The case was questioning the actions of Mr C in relation to one patient who he 'paced' due to low heart rate and then gave diazemul (10mg). The case against Mr C was that there was insufficient consent from the patient to 'pace', and that the justification for the diazemul was incorrectly justified (the justification should have been linked to the patient's fitting, not to the patient's stress). Mr C disputes both these allegations, so the case turns around what was said at the moment of the emergency call, and what was said three days later in a management meeting. First Mr C had framed his decision in terms of calming the patient, reducing stress, only later did he articulate it to the patient's history of fitting. It is because of this that the HPC panel were persuaded that Mr C was not of good character and so would undermine the public's confidence should it be discovered that such an inconstant man was included on the register of the HPC.

It is certainly worth considering for a moment the nature of the medication. I, a member of the public, would like to know the nature of the risk that Mr C put his patient to by administering 10mg of Diazemul.

An internet search reveals that Diazemul is a benzodiazepine and that these are used for their sedative and anxiety-relieving effects.

What I happen to know from a few years work in adult acute psychiatry a few years ago, is that this range of medication was contentious because many patients really liked them. The underlying sort of 'common sense' assumption was that people would prefer to be ill in order to enjoy the effects of the drug. A limit to their prescription was therefore encouraged on the ward where I worked as a kind of 'moral' approach to the cure. Is this why Mr C should not have administered the drug to his patient? Has this moral fear made its way into the rules of practice currently consulted by the HPC? Is the fear that the patient would have developed an immoral preference for the medication? I don't know - the knowledge behind the decision was not on show. But it does begin reveal one kind of idea that is taken for granted about 'the public'.

This exclusion of relevant knowledge is something this case shares with the case of Mr U, which I attended the week before and wrote about on this blog. In that case Mr U was accused of verbally and physically assaulting a member of the public, and the impression was that he had done this unprovoked (which was not at all the case). Nevertheless, it was not these facts that led the panel to find the case unproven against him, but that he had been contrite. It was his confession of guilt that allowed the panel to leave that man alone.

In the case of Mr C, however, there was no contrition. In fact, as I mentioned before, there was something approaching its opposite. His representative let it be known that the case was a waste of time, founded on pernicious motives, and which distorted the evidence in its favour.

On the clinical question at the heart of this case - the administration of 10mg of Diazemul - the Panel declared itself uninterested. I quote from their concluding remarks: "The Panel does not consider it necessary to dwell on the issue raised at the hearing as to the proper dose of Diazemuls. This is because the clear finding of the Panel is that no quantity of that drug should have been administered to that patient at that time. However, the Panel should record the fact that it did not find the evidence adduced by the HPC in relation to an acceptable dose to be helpful."

This statement is odd. First it says that it is not relevant to discuss the dosage of the drug, as the use of the drug was prohibited in these circumstances. Second, although the Panel finds the dosage irrelevant, it takes the time to say that the evidence the HPC furnished on the dosing of the drug was not helpful. Third the 'clear evidence' on which the HPC panel makes its decision seems mainly to be the fact that Mr C said something on one occasion, and another three day's later. These utteranes are taken as the bedrock of the case rather than the clinical facts pertaining.

I happened to hear a little of this discussion, so from my position in the public gallery, and on the balance of probabilities, I would guess that quite a bit of time had been taken up on the previous day to the question of how much diazemul was fit for the purpose that day. In fact, the HPC had gone to the trouble of bringing a witness to speak about it. This opens up a can of worms. There is, at the very least, ambiguity about this drug.

There is also some ambiguity about the nature of the public. In this case, the public is a phantom figure who seems likely to drop his trust and run screaming for this hills at the thought that Mr C said one thing on one day (I administered the drug to calm the patient) and another a few days later (not directly reported but that relates to the patient's medical history of fitting).

The other figure of the public in this scenario is that of the patient. The complaint against Mr C did not emanate from this man, nor any member of his family. He remains wholly outside the field of reference of this hearing. Only by implication can anything be deduced about him. Is it that he, a 70 year old man, could not be trusted to receive the medication Diazemul in case he developed a liking for it that Mr C's name must be struck from the register of the HPC?

Or was it that the case reveals a wobbly basis for the rule about the use of this medication - an ambiguity that is not resolved on the level of science, truth, or real life practice, but by reference to the pre-determined rules of a centralised State sanctioned committee?

Another day at the HPC FTP hearings.

Today I attended, as a member of public, the second day of Mr C’s hearing. This was chosen at random.

Most of the hearing had happened yesterday, and this morning’s sitting was restricted to a slow and carefully spoken rehearsal of the argument by the lawyer on behalf of the HPC. The timing of her precisely enunciated speech seemed set by the speed at which the panel could write down what she said – she seemed to be dictating them a narrative. This was followed by a rebuttal by the representative of Mr C spoken in real time, if you will, and in a real regional accent. The gist of this rebuttal was that the case was a waste of time and probably pernicious. The legal adviser present then gave the panel a lot of careful guidance on how to structure the conclusion according to a well laid out formula: going through points a, b, and c, and using special forms of phrasing. They then retired for a very long time indeed to consider their conclusion.

Whilst the panel retired to consider their decision, I took the chance to stroll around the park with Mr C. He is a paramedic working in the ambulance service for more that 20 years, and was dismissed by his NHS Trust last year following a complaint made by another member of staff – I won’t say ‘colleague’ as they had never met before. He has been working for a private company ever since. They had written a very warm reference for the HPC to consider and promised him continued employment no matter what the outcome today. Mr C didn’t know how the HPC got hold of his case - the notice came out of the blue – but he speculates that someone at his old place of work found out he had been re-employed and wanted to cause him more trouble. The truth has yet to emerge. I asked him how the original case arose.

“In essence, I was told that I had saved the patient’s life, but that the Trust wanted it saved like this (indicating one hand), not like that (indicating the other)”. In the process of saving the patient’s life, another paramedic arrived and asked Mr C why he had administered the drug in question. Mr C didn’t want to explain right then and asked him to wait till they arrived at the hospital. When they got to the hospital, different circumstances took over and the moment was gone. After trying to pass on the information 4 times (which was no longer interesting to anyone) Mr C went home without writing a full set of notes. The patient lived, the system worked, but the cover story was not constructed. The other member of staff was more aware of the consequence of this: he had been through a hearing before and did not want to leave himself open to the possibility of it happening again. So, in order to protect himself, conjectures Mr C, ‘he put in a complaint against me’.

Many questions arise:
1. The medication in question is contentious – why? At what level? A little of this was discussed in yesterday’s part of the hearing, but without making much impact. This raises questions about science, practice, and what constitutes a ‘professional’. That is, who is entitled to argue about it? Better, whose duty is it to argue about it? It appears that this level of discussion is effectively out of bounds, which immediately throws into question the meaning of the word ‘professional'. It leaves a black hole in place of science.

Instead of practical knowledge it appears that the HPC restricts itself to the question of whether or not Mr C followed a set of pre-written rules (administrative knowledge). So, the legal advice to the panel followed two lines: had Mr C administered the drug because he didn’t know he shouldn’t, in which case he was incompetent; or did he give it knowing that he shouldn’t, in which case it is misconduct. A third possibility was not mentioned: did he administer the drug having weighed up the situation and deployed his professional judgement? However, the decision was framed entirely in terms of pre-written codes of practice and ethics and took for granted that the medication was mis-used. It was up to his representative to remind the panel that there was no evidence whatsoever that the medication should not have been given! The whole thing was turning on a perception of attitude and behaviour rather than the medical facts of the case.

2. How and why does the HPC select a case to pursue? What were the grounds for pursuing this one? Who is the complainant? If these facts are made clear, it might be possible to make a judgement about the nature of the complaint. As it stands we are forced to take it on face value and swallow an awful lot of questions. In their place come a lot of other questions. Why does the HPC act in this way? Is it pursuing the case for its own gain: to give it something to do? to accumulate a set of statistics? For the pleasure of depriving a man of his livlihood? This is where that vacuous statement comes in handy – it is done to ‘protect the public’. But unless it makes plain who is in danger, and what is the nature of that peril, then no-one can make a sound judgement.

3. Why is the context excluded? In his summing up Mr C’s representative posed the question “was the situation as bad as some of the HPC witnesses made out?” he wanted to know why the case had been embellished. It may be that this is sour grapes, but there may be a reason for their sourness. From my point of view in the public benches, the grapes could easily be sour because the climate is not correct. To push the allusion a little, one might want to talk about the sun not being at the centre of this universe. Instead of grounding the evidence in a Copernican paradigm of truth, it is grounded on a committee’s pre-written prescriptions. As it stands, Mr C was being judged on whether or not he could obey previously written administrative rules where the real event was unimportant. Unfortunately, where this becomes the norm it is not unusual to find people willing to dump each other in the pit in order themselves to avoid a ducking. This is not news. It may be an unintended consequence of this new and emerging system, but our rich and brilliant culture bears silent witness to the fact that it cannot be unexpected.