In Paramedicine Board of Australia v Clark [2023] VCAT 1192, the Victorian Civil and Administrative Tribunal ordered that Mr Clark cannot apply for registration as a paramedic, and cannot work in any health service ‘involving the provision of care to a person, including, without limitation, by way of first aid or in any aged care or disability care setting’, until 26 October 2028.

Mr Clark agreed ([7]) that he was guilty of professional misconduct and that penalties were appropriate. He had not sought to renew his registration since November 2020 and and lost his employment with Ambulance Victoria ([6]).

The Facts

In July 2020 Mr Clark and his partner were called to a female patient who had collapsed. They arrived at 10:57am to find the patient ‘conscious and responsive, although she was making incomprehensible sounds’ ([2]).  At 11:25am she suffered a cardiac arrest.  Mr Clarke said that the patient was in asystole and there was no value in performing CPR.  Another paramedic on the scene ‘said it ‘did not feel right’’ but these concerns were ignored.  Further ([4]):

… while he spoke to a clinician at Ambulance Victoria (‘AV Clinician’), he told the clinician that SST had been in asystole and they had withheld resuscitation (rather than seeking advice as to the appropriate course).

Without CPR, the patient died. A clinical review of the case led to allegations that:

  • Mr Clark failed to provide adequate clinical care when making the decision to withhold resuscitation;
  • He failed to communicate effectively with the other team members; and
  • He provided misleading information about the events in question ‘particularly indicating in the Patient’s records (and subsequent discussions) that she was in asystole, contrary to the data from the electrocardiogram (‘ECG’) monitor which indicated that [she] was in bradycardia (i.e. had a slower than normal heart rate) at the time.

At [10]-[13] the Tribunal said:

While the provision of cardiopulmonary resuscitation (‘CPR’) may or may not have resulted in SST surviving her cardiac arrest, Mr Clark’s decision not to commence resuscitation deprived her of any chance of survival, was inconsistent with relevant guidelines and was substantially below the standards expected of a paramedic of an equivalent level of training and experience. 

Further, despite the presence of other colleagues and the ability to seek advice from the AV Clinician, Mr Clark pressed on with his decision, contrary to the Code of Conduct (interim) for Paramedics from June 2018 (‘Code of Conduct’) which, among other things, requires paramedics to consult and take advice from colleagues when appropriate, which was clearly the case in this situation.

Lastly, the information that Mr Clark provided to his colleagues (i.e., that SST was asystolic) was clearly false and his subsequent reporting of the events in SST’s personal care record (‘PCR’) – suggesting that the AV Clinician ‘did not question this nor raise any concerns’ and that ‘all on scene agreed to withhold resuscitation’ – is inconsistent with the accounts of his colleagues and therefore was misleading.

While mistakes can of course be made in the hectic and stressful situations that confront paramedics, often on a daily basis, Mr Clark’s lack of self-awareness and professional humility meant that critical opportunities to remedy the situation were lost.  The events have effectively brought a premature end to Mr Clark’s career as a paramedic.

With respect to allegation 2 and failure to communicate with colleagues, the Tribunal pointed to the Code of Conduct which said that good paramedic practice required ‘‘communicating clearly, effectively, respectively and promptly with colleagues’ ([20]).  Mr Clark was said to have failed in that regard as he failed to take into account Paramedic B’s concerns and Paramedic A’s ‘silence’.  This case was, of course, about Mr Clark and we don’t know if there were any consequences for paramedics A and B but one might think that if those paramedics failed to clearly articulate any concerns or suggest alternative assessments then may also raise questions about their conduct.

Of particular concern was Mr Clark’s communication with the AV clinician who could only go on what they were told, that is they were not there to form their own opinion.  As the Tribunal said (at [21]):

… by conveying to the AV Clinician that the Patient was ‘brady[cardia] into asystole’ and that they had ‘exhausted any other management’ (despite never commencing CPR), Mr Clark influenced the AV Clinician’s ‘interpretation of what had transpired at the scene’;[27] and

And with respect to the allegation that Mr Clark entered misleading information into the Patient Care Record the Tribunal said (at [31]):

… the second statement is misleading to the extent it suggests that Mr Clark sought the AV Clinician’s views on a proposed course of action.  Rather, the matter was presented to the AV Clinician as a fait accompli, and was based on information that was itself false (i.e., that SST was asystolic) or misleading (i.e., that there was consensus between the team members).

Having determined that the allegations were established, the Tribuanl had to determine the appropriate order. The Paramedicine Board submitted (at [48]) that:

… given the objective seriousness of [Mr Clark’s] conduct, his lack of insight and remorse and to ensure that general deterrence, specific deterrence and the protection of the community and maintenance of the reputation of the profession are achieved.

With respect to the need to protect the public the Board submitted ([49]):

… there is an obvious need to protect the public given the nature of his conduct, his limited insight and his unwillingness to accept that his conduct on 20 July 2020 was wrong. The Respondent has stated that if he were confronted with the same patient again, he would make the same decision.  The Respondent has provided no evidence of an understanding that his actions were wrong, his remorse, and steps taken to minimise the risk of such conduct occurring in the future. Accordingly, the Tribunal can have no confidence that the Respondent is a fit and proper person to hold registration as a paramedic and that he is able to practice the profession of paramedicine competently and safely.

It was also submitted that ‘An order for disqualification and prohibition [would] … send a strong message to the community and the profession, that paramedics who engage in this type of conduct will be the subject of meaningful disciplinary action’.

The Tribunal agreed with the Board’s submissions and imposed the disqualification for five years. The Board had also suggested that Mr Clark be prohibited from working in any health service for that period. The Tribunal thought that went too far. They said (at [66]-[67]):

The definition of health service in the National Law is extremely broad.  In our view, it is inconsistent with the principle found in section 3A(2)(c) of the National Law (see [45]) to impose a prohibition order that applies to all health services, as opposed to that subset of health services which the allegations demonstrate must be prohibited in order to protect the public and ensure the safety and quality of services.  There may be circumstances where ‘transferable skills’ can still be used, without posing a risk.

We have modified the proposed form or order to limit the prohibited health services to those involving the provision of care to persons, with specific inclusions based on the areas of concern identified by the Board.

For media reporting on this case, see

The references to ‘bird poo’ come from a statement Mr Clark made to AV during their investigation. The detailed allegations are set out as an annexure to the judgment and there it is alleged that apart from failing to accurately diagnose that the patient was not in asystole,

Mr Clark identified contradictory factors as the rational[e] for his assessment for withholding resuscitation. During the interview conducted by Ambulance Victoria for the In Depth Case Review, Mr Clark told Ambulance Victoria the following rationales were considered, namely;

(i) [The patient’s] unknown COVID-19 status;

(ii) [The patient’s] size and weight as a reason he was unable to relocate 2 metres away to a path for patient management to commence resuscitation (100 kg, weight and 168 cm, height);

(iii) water-soaked ground;

(iv) bird faeces on the ground; and

(v) close proximity to water’s edge;

The Tribunal accepted (at [16]) that none of these were valid reasons to withhold resuscitation.

This blog is made possible with generous financial support from the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.