A Queensland paramedic has been reprimanded over several instances of inappropriate patient care – Paramedicine Board of Australia v BML [2026] QCAT 417.  One reason for the light penalty is once again the inordinate delay. The decision of QCAT was delivered on 7 October 2026 after a hearing on 14 May 2026. The alleged misconduct was three incidents that occurred 2019 – ie 7 years ago! The Tribunal said (at [5]-[9]):

Incidents one and two relate to AB. Incident one occurred on 4 August 2019. On 4 August 2019 at 6:28pm, the Respondent and HGA were dispatched to a code 1C (Fall) relating to a 47-year-ol male, Mr AB, who was described as having an “extensive medical [history] [including] HEP C, HIV, Haemochromatosis along with anxiety”. The pair arrived on the scene separately. The patient care officer was HGA. On arrival, the Respondent and HGA were approached by AB’s mother who led them to a bedroom where her son was lying in bed. AB’s mother recalls telling them that she “was concerned about AB’s dehydration and low blood pressure”. She added that “I recall the officers taking AB’s blood pressure and telling me that it was ‘okay now’ which I had been surprised about because when I had helped [him] to the toilet, he had been shaky”. The Respondent undertook a partial vital signs survey which showed that AB had elevated heart and respiratory rates and abnormally low blood pressure…

By his own admission, the Respondent failed to test AB’s blood glucose levels, carry out a 12-lead electrocardiogram, examine AB’s abdomen, and administer treatment by way of IV fluid.

Incident two occurred on 5 August 2019, when HGA and the Respondent were dispatched at 2:55am on 5 August 2019 to AB’s residence under code 1C (Altered loss of consciousness). They were advised of the case at 2:57am by telephone. A central issue in respect of incident two was the timeliness (or lack thereof) of the response by the Respondent and HGA. The ambulance that they used to respond to the incident did not leave the station until about 3:13 am – eighteen minutes after they were dispatched, and fifteen minutes and 40 seconds after they were personally advised of the case by telephone.

Incident three relates to CD. On about 12:15pm on 7 August 2019, CD and her husband were getting lunch ready in their kitchen. While CD’s husband was boiling an egg, CD left to go to an ensuite in their bedroom. After the eggs had finished boiling, he called out to CD but did not receive a response. He went into the bedroom in search of her and found her on the bathroom floor unconscious. He estimates that “from the time she left the kitchen until I found her [was] no more than four minutes”. He called OOO and began performing CPR according to instructions given to him by the operator. At 12:43 pm the Respondent and HGA were dispatched to a code 1A (cardiac arrest) relating to a 70-year-old female, identified as being unconscious and not breathing. Five seconds later, HGA responded to the call by acknowledging the code 1A and telling the operator “we’re gonna have a slight delay. We’re just coming up to the station now. We need to stop and throw some gear in after the last couple of jobs we’ve done, ah and then we’ll continue to respond”. The allegations against the Respondent relate to the timeliness (or lack thereof) of the response, the compliance with mandatory vehicle inspection obligations, the adequacy of treatment, and the accuracy of health records.

At [4] we’re told ‘Both patients died in connection with this conduct, but it is not alleged that his conduct caused their deaths’.

There were clearly further allegations although they are not spelled out. In [12]-[20] there are references to admitted failures to complete a comprehensive examination of AB, a failure to communicate with AB and to explain the significance of his signs and symptoms and the possible consequences of refusing transport to hospital, inadequate management of AB’s airway and ‘failure to effectively manage a cardiac arrest patient’.  There was also an allegation that he, ‘completed (or permitted to be completed by his fellow responding Officer) an inaccurate and/or misleading eARF for Patient AB which omitted details regarding the assessment and management of the patient and rationale for non-transport to hospital on 4 August 2019’ ([27]).

Further, apart from the delay in proceeding to patient CD there is discussion of providing inappropriate treatment at the scene and inadequate record keeping ([21]-[26]).  There were also allegations of false or misleading clinical records with respect to CD ([31]).It was also alleged (at [41]) that

… he managed the call-out inappropriately in that he should have:

(i) been upfront about his need to the use the toilet;

(ii) asked his partner to continue on without him, while he followed in another ambulance; and

(iii) marked himself as Out of Service, due to his lack of sleep and “cognitive issues”.

The problem is we are told that these allegations were made, and ultimately accepted by the Tribunal, but nowhere in the judgement are we given any details of what actually happened at scene so we are left to infer what might have happened given those allegations/findings.

Having found that there was professional misconduct and unprofessional conduct the Tribunal had to impose a sanction. It repeated the oft used mantra that the purpose of such a sanction is not to punish but to protect the public (see [53]). At [55] the Tribunal said:

In determining an appropriate sanction for the professional misconduct and unprofessional conduct, the Tribunal is permitted (and required) to have regard to mitigatory factors advanced by the Respondent. As is identified in these reasons below, the Respondent has advanced an argument to the effect that he suffered from significant mental health challenges at the relevant time, and, in essence, his mental health challenges diminish the moral turpitude of the Respondent’s conduct.

At [59]-[62] the Tribunal said:

This Tribunal concludes that the Respondent ought to be reprimanded for the professional misconduct and unprofessional conduct.

The public ought to have confidence that those persons who have been called to the important task of providing emergency healthcare to the public conduct themselves in an upstanding and professional way, that reflects well upon the State’s emergency services. The public are entitled to assume that the State’s ambulance services will respond to emergency calls in a timely way, and provide adequate healthcare when those ambulance officers arrive on the scene.

The Respondent let himself and his colleagues down, and, of course, let down the patients to whom he was charged with providing emergency care, and their grieving families. The Respondent is admonished and reprimanded.

Additionally, the Applicant asked … that this Tribunal cancel the Respondent’s registration.

The Tribunal declined to do so. In proceedings against HGA, the other paramedic working with BML, the Board had asked for a two-year disqualification. That order was not made as HGA had already surrendered his registration. A reprimand was ordered and he was prohibited from providing health services unless he was successful in applying for registration in the future ([62]). (I note that in this judgment they do not give a citation to the decision against HGA nor is it a case that came across my desk, hence it was not reported on this blog even though it was, apparently, decided in 2025).

With respect to BML the Tribunal said (at [65]-[66])

It is the view of the Tribunal that the Respondent is not currently fit to hold registration. This conclusion is reached for two reasons. First, the Respondent’s conduct is egregious enough to arrive at this conclusion. Second, the Respondent’s own admissions about the state of his mental health warrant the conclusion that he is not fit to be registered. As a consequence of these two findings – and notwithstanding the Respondent’s written submissions – the Tribunal concludes that the Respondent’s registration should (if he had been registered as at the date of these orders) have been cancelled. The need for general deterrence against similar professional misconduct would necessitate such a conclusion.

Whilst this Tribunal was minded to make a cancellation order, such an order would now lack a jurisdictional foundation. After the Applicant filed its outline of submissions on 31 October 2025, the Respondent elected to surrender his registration on 20 November 2025, prior to the hearing of this Referral. Consequently, the Applicant no longer seeks the making of a cancellation order.

For reasons that are not explained here (but see Paramedicine Board of Australia v BML [2024] QCAT 427) the Tribunal also made a non-publication order that is

… publication of:

(a) the contents of a document or other thing filed in or produced by the Tribunal;

(b) evidence given before the Tribunal; and

(c) any order made or reasons given by the Tribunal.

is prohibited to the extent that it could identify or lead to the identification of the Respondent, save as provided for by the terms of this order, and save as is necessary for the parties to engage in and progress this proceeding or any appeal or review arising from this proceeding, and for the Applicant or the Australian Health Practitioner Regulation Agency to carry out their statutory functions under the National Law.

Presumably that doesn’t apply to the judgment itself given it has been published for all the world to see – see

Discussion

The desire to protect BML’s identity, and the identity of the patients, may well explain why so little detail is given as to what happened at the scene of each incident.

It is interesting as decisions to de-identify the respondent is not usual. in Alpert v Commonwealth of Australia (Department of Defence) [2023] FCA 784 Snaden J said (citations omitted):

In R v Davis (Wilcox, Burchett and Hill JJ), this court observed (at 514):

Whatever their motives in reporting, [the media’s] opportunity to do so arises out of a principle that is fundamental to our society and method of government: except in extraordinary circumstances, the courts of the land are open to the public. This principle arises out of the belief that exposure to public scrutiny is the surest safeguard against any risk of the courts abusing their considerable powers. As few members of the public have the time, or even the inclination, to attend courts in person, in a practical sense this principle demands that the media be free to report what goes on in them.

The exclusion of public access to the processes with which a court deals is only to be effected in exceptional cases… In John Fairfax Group Pty Ltd (Receivers and Managers Appointed) v Local Court (NSW), Kirby P (in dissent but not on this issue) said (at 142-143):

It has often been acknowledged that an unfortunate incident of the open administration of justice is that embarrassing, damaging and even dangerous facts occasionally come to light. Such considerations have never been regarded as a reason for the closure of courts, or the issue of suppression orders in their various alternative forms… A significant reason for adhering to a stringent principle, despite sympathy for those who suffer embarrassment, invasions of privacy or even damage by publicity of their proceedings is that such interests must be sacrificed to the greater public interest in adhering to an open system of justice. Otherwise, powerful litigants may come to think that they can extract from courts or prosecuting authorities protection greater than that enjoyed by ordinary parties whose problems come before the courts and may be openly reported.

It is well accepted that “…mere embarrassment, inconvenience or annoyance will not suffice to ground an application for suppression or non-publication”, It is a feature of open justice that those to whom court processes refer may thereby suffer embarrassment or distress; but “…that is a price the community has to pay for the undoubted benefit of court proceedings being, except in very exceptional circumstances, conducted in public”…

Open access to decisions is part of the principle that ‘not only must justice be done, it must be seen to be done’.  Importantly too the law is meant to have an educative effect. When a Commission or a court makes a ruling, it sets out the law, what facts have been established and what the legal consequences are. That is meant to guide others so that they can see what the implications are and then take steps to avoid consequences they would rather avoid. This decision lacks some of that educational benefit as we really don’t know what happened but we may be grateful that the Tribunal was willing to take some action to mitigate the impact of the public nature of proceedings on this respondent. They must have accepted that in this case the impact would be more than ‘…mere embarrassment, inconvenience or annoyance’. Even so, as noted the judgement has been published and now noted here. No doubt there maybe some QAS paramedics who will know who the respondent is; but they should keep that to themselves.

What is not explained, and perhaps again because of a desire not to identify the respondent, is why given what sounds like an egregious list of errors, there was no prohibition on care or on providing health services in the future. The reasoning can be inferred but is not explicit. The Respondent argued (at [63]) and it may be inferred that the Tribunal accepted that …

(d) … [BML] has shown consistent and genuine insight and remorse. He has undertaken significant additional training and extensive/ongoing Rehabilitation for his condition/illness. The strength of his insight is revealed through his candid acknowledgment that the sequelae of his occupational trauma render him presently unable to resume practice.

Further

(e) …the cause of the misconduct was not negligence, reckless disregard for professional obligations or even a failure to understand professional obligations. The behaviour did not involve dishonesty or self-interest.  Rather, it was the product of mental illness. The unusual features of this case mean it is an inapt vehicle for general deterrence considerations.

And

(f) …  there is no risk that [BML] will resume practising (within the meaning of the law) without obtaining registration and thus no risk to the public. Any board will need to consider any such application on its merits if ever made.  As accepted by the Board, [BML] is less culpable than [HGA] and a less severe sanction in the Respondents case than in [HGA’s] case (and there is no need for a disqualification order and it naturally follows there is no need for a prohibition order.

As the Tribunal said, the application for a cancellation order was not pressed as BML had surrendered his registration. The Tribunal did not formally address the need for, or why there was no need for, a prohibition order.

The case is therefore somewhat lacking as an instrument of education for other paramedics but that was the position of the respondent that is ‘this case … is an inapt vehicle for general deterrence considerations’ ie the facts were unique to BML and there is not a wider lesson here for others.  What others may infer is that failure to be upfront and honest – whether it’s about the need to use the toilet, the impact of practice on one’s mental health, or what happened at the scene – can compound or make worse poor patient decisions.  It may also serve as an example that in the right circumstances a Tribunal can acknowledge and take into account the well-known impact that being a first responder can have on the mental health of those responders.

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.