The issue of paramedics being disciplined for delaying their response to collect food was the subject of discuss at the recent Australian Paramedics Association (Queensland) conference.  A decision, that may have been the stimulus for that discussion, dealing with that issue has been handed down by the Queensland Civil and Administrative Tribunal (QCAT).  

The decision in Paramedicine Board of Australia and Nursing and Midwifery Board of Australia v JH [2025] QCAT 239 involved a dual registered practitioner, but it was his conduct as a paramedic that was under review.   The delay in responding was only one issue before the Tribunal; there were in fact five allegations. They were identified (at [2]):

Ground 1 is an allegation of inappropriate clinical care.  Ground 2 is an allegation of inappropriate administration of medicine.  Grounds 3 and 4 involve allegations of false and/or misleading information and record keeping.  Ground 5 involved an allegation of breaching appropriate therapeutic boundaries of a patient.  Grounds 1 to 4 all occurred on 8 May 2021.  Ground 5 involved a totally separate incident which occurred on or about 16 May 2021.

At [3] the Tribunal gave some background. It said:

… the respondent had been an ACP with the QAS for over 20 years.  His employment with the QAS was terminated on or about 9 September 2022.  However, the respondent continued to practise as a registered nurse in a prison at Rockhampton.  While practising as a nurse, the respondent has completed a Master of Nursing and has applied to AHPRA for endorsement as a nurse practitioner.  As the Tribunal understands it, the Nursing and Midwifery Board of Australia is awaiting the outcome of these proceedings before deciding that application…

Ground 1

This was the allegation regarding a delay in responding. At [8] the Tribunal said:

It is uncontroversial that on 8 May 2021, the respondent, together with another paramedic, was on a 12-hour shift from 7:00am to 7:00pm.  It is also uncontroversial that the respondent and most likely the other officer had not had any substantial sustenance for about nine and a-half hours when, at or about 4:35pm, they stopped at a Red Rooster restaurant.

Whilst in the restaurant, the respondent and his partner were tasked with responding to a code 1B call for a patient who was at the Etna Creek Correctional Centre (‘ECCC’).  It was alleged that there was ([9(k)]) ‘a three to four minute delay between when the respondent responded to, and accepted, the Code 1B callout and leaving the restaurant to continue to the ECCC’. 

With respect to the timeline the allegation was that the respondent ordered his food after receiving the call.  The Tribunal found, however (at [10]), that ‘the best evidence is that the respondent had, in fact, ordered and paid for his food prior to the emergency call’. They continued ([10]-[11]):

According to the respondent, he said that he needed to eat something as he was feeling dehydrated, lightheaded and nauseous, and that he considered that he could not function properly as an ACP if he did not eat anything.  The respondent also said that the delay was only about one and a-half minutes.  However, he did acknowledge that he should have left immediately, and, in fact, apologised for his delayed action.  It should also be noted that there were no adverse consequences for the patient resulting from any delay and that the patient’s medical history was known to the respondent, and the respondent also knew that the patient was, at the time, under medical supervision at the prison.

The statements of the two employees at the Red Rooster make it clear that the respondent was pushing to have his order dealt with urgently.  The evidence also establishes that as soon as the respondent received his order, he rushed out of the restaurant to the ambulance.  The other paramedic did not provide any probative evidence as to how long the delay might have been.  However, a detailed investigation was carried out which resulted in a written report published in December 2021. Investigation included a review of the CCTV recording of the activities on that day within the restaurant. Leaving aside the error in recording the visit at about 3:36pm instead of 4:36pm, the timeline reveals a delay much more consistent with the respondent’s version.[1] 

That is, the applicants alleged that he ordered his food after receiving the call and that there was a ‘three to four minute’ delay. The respondent said he had ordered and paid for the food before receiving the call and the delay was ‘only about one and a-half minutes’. The Tribunal said that the evidence supported the respondent’s version of events.

With respect to allegation 1, the Tribunal found:

… that having regard to the length of the delay, together with other mitigating factors in favour of the respondent, his conduct ought be characterised as being unprofessional conduct.  Had there been a lengthier delay that had the potential to result in adverse consequence for the patient, absent special circumstances, it would almost inevitably resulted in a finding of professional misconduct.

Had that been the only allegation something less than de-registration might have been expected, but as noted, that was not the only allegation.

Grounds 2, 3 and 4

The allegations here related to the treatment of the patient at the ECCC in particular the administration of glyceryl trinitrate (‘GTN’) to the patient in circumstances where that drug was not indicated ([16(a)(i)]). Furthermore, it was alleged ([16]) that the treatment:

(a) …

(ii) was outside the respondent’s scope of practice as an ACP because the administration of GTN by ACP outside the prescribed indications in the QAS protocol was not permitted;

(iii) was undertaken either without the required mandatory approval or with improperly obtained mandatory approval (in that it was obtained on the basis of the respondent’s failure to inform Officer B, Officer C about Patient A’s altered level of consciousness and one-sided weakness and deficit and/or misrepresentations of advice he had been given by Officer B and Officer C); and

(b) was undertaken contrary to the expressed advice and directions of the Consult Line and Senior Operational Supervisor.

It was further alleged ([18]; ground 3) that the respondent had advised the officer on the consult line that other critical care paramedics (‘CCP’s) had authorised the use of GTN even though there was not CCP present. This was alleged to be false and misleading as no such authority had been given.

Ground 4 was ([19]) an ‘allegation of inadequate and false and/or misleading record keeping, the particulars [of which] could be summarised as follows: On 8 May 2021, the respondent created an Electronic Ambulance Record (‘eARF’) for the relevant clinical consultation above with Patient A in which he recorded that, inter alia, he had been given approval to administer GTN by a  CCP (identified incorrectly as ‘Simon’) via the Consult Line at 5:35pm’.

The respondent denied the allegations. That is, he said that Officer B did provide approval for the GTN or, at least that (at [21(b)]) ‘he believed that he had approval from Officer B and there may have been a miscommunication as he was in a moving ambulance with lots of noise from traffic, the patient and general movement’. 

The Tribunal said (at [25]-[27]):

On balance, the Tribunal finds that it is more likely than not that the respondent was not given the necessary authority to administer GTN to the patient.  Even accepting that the respondent might have believed that he had been given authority, his own evidence is that he might have misunderstood what he was being told.  In this regard, reference has already been made to what he referred to in the statement of agreed and disputed facts.

That there could have been a misunderstanding in respect of what the respondent was told was also reflected in the answers given by the respondent during his record of interview.  After listening to the second consult-line recording, the interviewer asked the respondent whether he had any sort of initial statements that he wanted to make in response?  The respondent answered:

yeah, looking back… all I can say for this whole situation is that… I have a poor recollection of what’s happened.  I’m not sure why that is.  I just obviously have – and that I would never give any medication or drugs outside my scope of practice.  I never have in the last 18 years of working.  And I would, as I said – would never give anything [unless] … I thought, and I stress, thought authority had been given, and that’s why I gave it.  If they had said no, not to give it, I would not have given it.

But obviously there was a miscommunication somewhere.  Whether it was traffic noise, the patient, stress of the job, driving to hospital, no backup available, there was a multitude of things that could – but yeah … I would never give a drug without authority. Yeah.  That’s – well – I have a poor recollection of it, and I wish I had a better one, I really do.

[Emphasis in original].

To administer GTN without clear authorisation is a serious breach of the relevant QAS drug therapy protocols.  That is what the respondent did.  It was his professional responsibility to make sure that he had been given approval to administer the drug.  His failure to do so fell substantially below the standard reasonably expected of a registered health practitioner.  In this regard, though, the Tribunal is not prepared to find that the respondent’s conduct involved a course a deliberate and intentional breach of the relevant drug therapeutic protocols.

Another source of stress may have been that the respondent was hungry, noting the evidence (at [10]) ‘that he considered that he could not function properly as an ACP if he did not eat anything’.  This was not discussed or considered by the Tribunal.

Despite submissions from the applicants that the Tribunal should find that the respondent ‘acted in a deliberate manner and deliberately contravened the relevant protocols’ ([28]) the Tribunal found that the evidence did not establish a ‘deliberate and intentional breach of the relevant drug administration protocols’. The Tribunal said (at [30]-[31]):

However, the respondent’s actions of not ensuring that he had the relevant authority resulted in, despite what his belief might have been, him wrongly administering GTN and providing misleading information during his communication on the Consult Line (ground 3) and in him being responsible for inadequately and/or misleading record-keeping (ground 4).  

To put it bluntly, given the seriousness of the situation, the professional obligation or duty of the respondent was not to administer GTN unless he had express and unambiguous authority to do so.  To act in the absence of such authority, the respondent behaved in a way that constitutes professional misconduct.

With respect to the Tribunal that just doesn’t make sense.  If he believed ‘he had express and unambiguous authority’ to administer the drug then he had done what the Tribunal is saying he should do.   There is no suggestion that the respondent was unclear about what authority he had been given so what more was he required to do?  If you believe someone has given you the authority to act then you act on it.  If it turns out you were mistaken saying you had a duty to obtain ‘express and unambiguous authority’ makes no sense if you believed you had done so. 

Ground 5

This allegation dealt with a different patient on a different day.  The allegation was that he got too close to a patient and inappropriately touched her.  The respondent’s case was that he had to get close to her to hear her and to allow her to speak without being overheard. The Tribunal said (at [39]) ‘During his interview, [the respondent] confirmed that he had placed his arm on either side of the patient and leaned close to her to get her attention, given the chaotic nature of the surrounding environment.  And in hindsight, he may have been “possibly a little bit close.”   The Tribunal found (at [40]):

On balance, supported by the evidence of the patient, the Tribunal prefers the evidence of the respondent as to his actual physical conduct on that day.  The Tribunal also accepts that at all times, he was acting in a manner designed to engage with and reassure a clearly distressed and probably very embarrassed young woman.  During closing submissions, Mr Bowman said, ‘if looked at on its own, ground 5, if proven, constitutes unsatisfactory professional conduct.  The Tribunal agrees and considers it appropriate to look at this ground in isolation as it is an entirely different course of conduct separated from the other grounds, not only in time and place but also because of its nature and characterisation.

Penalties

The applicant Boards sought orders that the practitioner was guilty of professional misconduct and his registration as both a paramedic and nurse should be cancelled, and he be disqualified from registration or providing health services for two years.  At the time of hearing, they no longer pushed for cancellation of his paramedic registration ‘as the respondent let his registration lapse on 1 January 2025’.  

The Tribunal noted that the respondent had been unable to practice as a paramedic for the last three years [41].  They said that the findings with respect to ground 1 did not require any further period away from the profession.  Grounds 2, 3 and 4 however ‘result in a serious example of professional misconduct.  The cumulative effect of each of the grounds alleged against the respondent warrants an order that the respondent be reprimanded and disqualified from re-applying for registration as a paramedic for a period of six months’.

The Tribunal noted that the respondent was dual registered.  Although the conduct as a paramedic may affect his status as a nurse they noted that he had continued to practice as a nurse without any complaint.  There was no need to make orders to restrict his ongoing practice as a nurse. 

The outcome was that Tribunal found that the respondent’s conduct with respect to allegation 1 was unprofessional conduct and with respect to grounds 2, 3 and 4 it was professional misconduct.  Ground 5 represented unsatisfactory professional performance. The respondent was reprimanded and disqualified from applying for registration as a paramedic for six months. His registration as a nurse continues.

Discussion

The Health Practitioner Regulation National Law (Queensland) provides for different levels of ‘misbehaviour’.  There is ‘unsatisfactory professional performance’, ‘unprofessional conduct’ and ‘professional misconduct’.  Professional misconduct is the most serious allegation.  There are also two types of disciplinary tribunals.  A health and professional standards panel can determine whether a practitioner’s conduct ‘constitutes unsatisfactory professional performance [or] … unprofessional conduct’ (s 191(1)(b)).  The panel can take a number of actions in respect of proved unsatisfactory professional performance or unprofessional conduct, but it cannot suspend or cancel the practitioner’s registration (s 191(3)).  Only the ‘relevant tribunal’, which in Queensland is QCAT, can take that action (ss 196(2)(d) and (e)). This matter proceeded before QCAT rather than a panel because the Boards were pushing for the respondent’s de-registration.  

What I find unsatisfactory about the Tribunal’s reasoning is the assertion that he had to have clear and unambiguous authority to administer GTN if that is what he believed he had.  If the legal threshold for action is ‘x is true’; and you do believe ‘x’ is true then you have met the legal threshold even if it turns out that you were wrong.  In criminal law there is a defence of an honest and reasonable belief in facts that if true would make the act innocent (Proudman v Dayman [1941] HCA 28). If your actions are innocent if ‘x’ is true and you honestly and reasonably believe that x is true, then there is no crime.  

Here, we are told, the respondent believed he had received the authority that he reported on the clinical line and in the patient record. The evidence of Officer B was not that he did not give the authority rather that he could not remember the incident, but he said he would not have given the authority. The Tribunal said (at [22]):

Officer B referred to by the respondent is a critical care paramedic who has been employed by the QAS since January 1990. Officer B was interviewed on 5 October 2021. Given the passage of time and the fact that there was a very heavy workload on 8 May 2021, it was not surprising that he had only a ‘very limited’ recollection of the events of that day. Notwithstanding his limited recollection of the actual events on that day, Officer B was adamant that, in the circumstances of the situation as described to him, he would not have given the respondent authority to administer GTN to the patient. There was no challenge by the respondent to any of the contents of the record of interview of Officer B.

And (at [29]):

As the Tribunal understands it, that submission [that the respondent had acted in a deliberate manner and deliberately contravened the relevant protocols, and that this was not an instance of mistaken belief on the part of the respondent] relied heavily on the evidence of Officer B, the effect that in relevant circumstances, ‘there is no way that I would have suggested that he should.’ That evidence has to be seen for what it is. That is, with no disrespect to Officer B at all, it is evidence about what he would have expected his response to be. It is not exact evidence of what actually did occur on that day, of which he had only a very limited recollection of. Also, and perhaps more importantly, it does not provide probative evidence about what the respondent may or may not have heard or thought he heard at the other end of the telephone call. On balance, the Tribunal is not sufficiently satisfied that the respondent’s course of conduct involved a deliberate and intentional breach of the relevant drug administration protocols.

So, the respondent gave evidence that he believed Officer B authorised the use of GTN and Officer B gave evidence that he did not recall the particular incident, but he did not think he would have given that authority. There was no evidence that on this occasion Officer B did not give that authority or given the conversation there were no reasonable grounds for the respondent to believe Officer B had given the necessary authority. And if the respondent believed that he had the authority a ruling that he had to have authority is unhelpful.  

At worst this case is a case of mistake; and everyone makes mistakes.  The respondent hadn’t had any ‘substantial sustenance’ for 9.5 hours.  He attended a job and thought he had authority to administer GTN from a paramedic who now cannot recall the event but thinks he would not have given that authority.  The tribunal has said that it was incumbent upon the respondent to have ‘express and unambiguous authority to do so’ but he thought he did. And now years after the event memories are unclear, recorded conversations can be replayed, and people are asked to say what they would have done some time ago if the facts now presented (which may not have been the facts as presented at the time) we put before them.  It seems reasonable to make a concession that there may have been a misunderstanding.   And that makes sense – if the respondent says ‘I thought you gave authority’ and officer B says ‘I don’t think I would have’ and both say ‘but I cannot really recall’ then accepting that there may have been a miscommunication rather than anyone is lying is a gentle concession but one which has been held, in this case, against the respondent.  One might infer that the Tribunal thinks the respondent was  meant to identify at the time, the possibility of a miscommunication even though there is no indication why that should have crossed his mind until he later learned that Officer B did not recall giving the authority.

In my respectful opinion this does not appear as a case of professional misconduct by a paramedic but a clear systems failure. The system did not ensure that over a 12 hour shift the paramedics were given time to attend to bodily needs such as getting sustenance (and what if they need to use a toilet?).  The system allowed for a CCP to give authority to an ACP but did not have a process by which that was to be recorded other than as it was, by the ACP putting a note in the patient record.  If ‘express and unambiguous authority’ is required to be documented then a process of secure communications where that communication is recorded is required, or perhaps a process where the CCP has to make a note of the conversation and their response and then text or email that to the treating paramedic so the treating paramedic can see that the CCP got the correct clinical picture and the authority is recorded.  Building such a system will have implications however for time critical treatment.  Failing that requiring a person to have ‘express and unambiguous authority’ requires only that they believe – perhaps on reasonable grounds – that they have that authority.  But if that’s the test then it appears the respondent met that test.

In his book The Field Guide to Understanding ‘Human Error’, Sidney Dekker says words to the effect of no-one goes to work to make a mistake, so the decisions they made, made sense at the time. To avoid human error one needs to understand why those decisions made sense and the systemic issues in play rather than blame the individual.  In this case the decision to wait for food made sense because this experienced paramedic knew he hadn’t eaten for 9 hours so there were conflicting demands – he needed to respond to the patient but he also needed to eat something to be able to function (though we don’t know if he at en route). The delay would be minimal and the patient they were called to was under medical supervision. In fact, his decision didmake sense as there was no impact on the patient, it was just a breach of a rule.  And the decision to administer GTN made sense if he believed he had what the tribunal said he had to have, clear and unambiguous authority. 

Conclusion

I find this case quite unsatisfactory. It is punitive (despite Tribunals always saying they are not punitive) and does not reflect a just culture or a recognition of systemic issues that led to these outcomes. 

It is, however, what it is and if we are to try and draw lessons from QAS paramedics it is you cannot delay for even a minute a response (so what happens if you’re in the bathroom I don’t know) and you must not only believe you have authority to act you must actually have that authority and so a honest and reasonable belief in facts which if true would justify your actions does not seem sufficient.

This blog is a general discussion of legal principles only.  It is not legal advice. Do not rely on the information here to make decisions regarding your legal position or to make decisions that affect your legal rights or responsibilities. For advice on your particular circumstances always consult an admitted legal practitioner in your state or territory.