My visit to London Ambulance Service on 5th May 2015 was a mission to learn more about the organisation's approach to supporting its workforce as its operational staff toil to provide a service in increasingly demanding conditions. With front line staff routinely facing relentless 12-hour shifts without respite, delivering emergency care to the best of their abilities despite skill-sapping fatigue and health-eroding stress, it seemed clear to me that whatever measures were currently in place were insufficient.
An audience with Chief Executive Dr Fionna Moore and Director of Operations Jason Killens gave me the opportunity to learn more about their understanding of the conditions and the measures they were taking to provide relief for their beleaguered ambulance crews. You can read more about their general thoughts and their approach to the challenges in the previous installment of this series, but at the core of the issue was one particular incident which initially alerted me to the LAS dilemma.
News of 30-year veteran LAS paramedic Edmund Daly's dismissal and subsequent suspension of HCPC licence hit the headlines of various media outlets earlier this year and the focus of the coverage was broadly on the fact that he had 'refused to attend a 999 call because he was "tired".'
As I read the reports, it became evident to me that there were more to these circumstances than was featured in the coverage. I read the documentation arising from the HCPC hearing with growing concern. Edmund Daly's case seemed to be a glaring example of the institutional disregard for crew welfare which has become more critical as demand continues to rise and resources become increasingly thin on the ground. At every turn, front line staff are expected to make up for the shortfalls and the inadequacies of the emergency ambulance system and here was a man who had stood up to say 'enough was enough' and had been destroyed for it.
I met with Mr Daly - Eddie - and learned everything he had to tell about his case. His account only compounded my fears, he was every inch the trustworthy professional, a mild-mannered, gentle man who was a credit to his employer and to the paramedic profession, certainly not deserving of such an ignominious end. Furthermore, his reasons for refusing the 999 call seemed justifiable - he was fatigued and unwell with ample evidence to prove it after the fact. Following our meeting, I continued with my research, building a thorough understanding of the entirety of his experience; his career, the night of the 'refusal' incident and the subsequent investigation and multiple hearings.
It just didn't make sense to me that London Ambulance Service would opt to end the career of a loyal, positive and - according to both Dr Fionna Moore and Jason Killens - brilliant clinician in such a way. It was Jason Killens himself who had brought the axe down, so during my interview with him, I resolved to gain an understanding of his part in Eddie's downfall in the hope that it would make more sense.
Seeking An Explanation
|'...caring for the people who visit, live and work in the capital.'|
My initial question, 'It does come down to the precedent set by the Edmund Daly case. What message do you think that that has sent to the people on the front line?' was countered by Jason with another, guarded, question.
'So you tell me what you think about the Edmund Daly case,' he riposted.
There was a long pause as I considered how hard I could push. 'I asked you first,' I chanced.
There was a peel of nervous laughter. The atmosphere remained tense. Jason had the face of a poker player who wasn't going to budge. It looked like I was going to have to lay a card first.
I set about describing Eddie Daly as the 30-year veteran who was highly-regarded by his peers and those in higher stations (a reference to the fact that Fionna Moore herself had provided a character reference in Eddie's defence at his hearing). Every few words I spoke were interrupted by Jason proclaiming his agreement with my statements. An attempt to set me off balance? A knee-jerk need to defend his decision? Or an overbearing attempt to be agreeable? I couldn't be sure.
I then described Eddie’s experiences at the Lakanal House fire in Camberwell in 2009, which left him with some deep-seated issues which permanently undermined his physical and mental well-being, and his ongoing struggles up until the night of his 'misconduct' on 29th May 2013. Killens' interruptions became less frequent and less audible. Dr Moore listened silently throughout.
I highlighted the erosion of his coping mechanisms, the heightened state of fatigue that afflicts PTSD sufferers, and how this would have contributed to his decision on the night of his refusal, finishing with, 'So there you have a man who has done his best for 30 years and to spin forward a year, he's now been sacked for gross misconduct. So how does that come about? What am I missing? What don't I know?'
Jason's response was, 'So, there's probably a whole bunch of things that you don't know that you'll appreciate that I can't talk to you about.'
'A Very Stupid Decision'
|Jason Killens, LAS Director of Operations|
‘So what you know is what you know. What I would say, what I would say - and of course you know I'm the bloke who dismissed him - so it was my decision and my decision alone. A dismissal decision is the most difficult thing I have to do in this place. Thankfully, they're rare. Very rare. But it's life-changing for the individual. I recognise that. It's life-changing for them because they lose the job that they love. In most cases. In most cases when people get dismissed it's because they do something so serious, in the spur of the moment, that you can't step back from it. And that's the case, that's what happened here. Eddie... I've known Eddie for a long time, he's a nice bloke as you described at the top. He was a good paramedic, he was well-respected by staff, he was a good team leader, he had a good rapport with patients, he was brilliant clinically. But he made a stupid decision. A very, very stupid or bad decision, whatever you want to call it.'
'Which you're prone to do when you're tired,' I replied. 'Better to make it on the radio rather than when he's trying to administer drugs.'
'As I say, there are some things that I probably know that you might not, which informed my decision at the time. He went through... it was a 12-hour hearing that we had in the end, so it wasn't a quick thing by any stretch. That is very unusual. Very unusual for a dismissal hearing, they would normally go three, four hours. Very unusual to go that long. We went that long because there were a number of things we needed to consider, not least Eddie's career and what happened leading up to the day and what happened on the day and what happened subsequently to the day. But in the end, having considered everything that came forward, the nub of it was that there was a refusal to respond to a call. That's the nub of it, yeah? He refused to go to a job when he should have gone to a job. He was in his shift time, yes? And he refused to go to that call, and on that basis, having struck right at the heart of what we're all here to do: respond to patients, help people.'
Are Patients more Valuable than Staff?
|How many unwell people are in this picture?|
Jason replied, 'So, he was in his shift time. He was in his shift time and he had not said he was unwell and not able to continue and he refused to go to that call. And being in a position of responsibility, which he was - he was a role model for people, he was a team leader, yeah? That made it worse. And having got to that point, because of what he did on that day, not what happened in the previous thirty years, what he did on that day was so serious that we had no choice but to do what we did. What is easy? No. Was it something that was a split second decision? No. Did I reflect on it and decide whether this was the right thing to do? Yeah, long and hard.'
He went on to use the HCPC decision to suspend Eddie's paramedic licence as further vindication of his decision. The HCPC hearing was unopposed, Eddie had not attended to defend himself, and the evidence and witnesses used were provided by LAS, the same as those used by Jason in the hearing. Jason also pointed out that Eddie had chosen not to dispute the decision at industrial tribunal, apparently unaware that the £40,000 cost of doing so had been an insurmountable barrier for Eddie.
Jason was unrepentant. 'He chose not to represent himself at the HCPC hearing. They're Eddie's choices, not mine, yes? All I'm saying to you is it was not an easy decision. It was not an easy decision. They never are, but in this case it was particularly difficult because of who it was and what he was like as a person here. One of our people. But, because of what he did, I believe it was the right thing to do and I stand by that decision now and I'd do it again.'
What is 'Fitness to Practise?'
I asked, 'Is this indicative of a general management failure to understand what impact ambulance work at the present level of demand has on their operational staff?'
'No. It's not! I can't have...', Jason began, but tailed off as I laboured my point.
|Does 'lack of competence' include fatigue or ill health?|
At this juncture, Anna Macarthur tried to reign in the increasingly combative nature of our discussion, but Jason had a point to make, stating firmly, 'But that's not what he said!'
There was a brief exchange about the words Eddie used on the night. Eddie maintains that he said 'I don't feel right', Jason disputed this. In the final dismissal documentation issued by Jason (which I checked after the interview), the most similar phrase taken from recordings of the conversation on the night quote Eddie as saying 'I don't feel this is right'. This gives weight to Jason's assertions that Eddie was standing for a principle rather than claiming he was ill. As inconsequential as those two words may sound, it seems that this more than any other single fact was the final nail in the coffin for Eddie's career.
The Weight of Responsibility
|Andrew Lansley visits the LAS control room in 2012|
Jason claimed he couldn't recall the nature of the 999 call in question. I reminded him that it was to a 43-year-old female with nausea and vomiting. He also couldn't remember how long the call was held for. I pointed out that HCPC records indicated that it was 90 minutes.
His response, 'So, you heard me say earlier, you know we've got a real pressure of work problem here. We accept that. We've got the highest standard of utilisation in the country. We accept that, we know that. Our commissioners know that and the HSE know that. That's why we've come together this year to tackle it. With a big investment chunk again, we'll bring utilisation down. So it is understood that there is... there are calls which wait longer than we would want. We understand that, we know that.'
Fionna Moore backed him up, 'That's gone on over the last year. Even worse than it was back in 2009. So in the last year, we believe that we have continued to deliver a safe service on the basis of our response to Red 1s and Red 2s. We haven't hit our targets, but we believe we've still provided a safe response and we can evidence that by an internal review and indeed an external clinical review, but the quality of our service that we have provided has been poorer than we would have aspired to and that means that inevitably that C1s and C2s are waiting for a long time.'
Fionna repeated her claim that they were focused on providing a 'safe service' despite the extraordinary demand and lack of resources which sees LAS routinely in a state of 'surge red' with frequent escalations to 'surge purple' (usually reserved for major incidents).
'But safe for who[m] though?' I asked, 'Because in Eddie Daly's case, had he towed the line and gone and done the job, if he was as unwell as I believe he was, then would that have been safe for him to go and respond to a call?'
Her explanation saw her reinforce Jason's position, 'So if Eddie was unwell then he would have told us he was unwell. The evidence that we heard and that the HCPC heard was that if he had said that he was unwell and not able to continue his shift or respond to the call because he was unwell, then the conversation and the outcome would have been entirely different.'
'An Element of Control'
Fionna stated, 'But then Eddie is not inarticulate. I'm sure, had he said 'I'm sorry, I'm not well' he'd still be here.'
Jason said, 'What I can't do... so, what I'm desperately trying to do through the restructure of management and put the right leadership across the organisation is empower everyone at the lowest possible level to make decisions and be autonomous in what they do, within boundaries. So everyone has to get paid the same, everyone has to wear the same uniform, that kind of stuff. But around that, I want people locally, the local teams to decide how they go about delivering service, within the rules that we have to set and are given to us through the regulations, statutes and so on. What I can't have people doing, is picking and choosing what they do. And the Eddie Daly example is a good one here. I can't have people deciding when they will and won't go to calls. There has to be doesn't there - you surely must see this - there has to be an element of control.'
Jason went on to suggest that there were other elements to the Eddie Daly case of which I wasn't aware but which 'informed' his decision. I was less than convinced, especially after having read through outcome documentation he referenced which I hadn't seen at the time of this interview, but that he insisted was vital and might change my understanding. It didn't. If anything it underlined to me that his decision was made entirely on the basis of Jason's inflexible belief that a rule had been broken and that the details were of no real consequence. As Jason himself had said earlier, ‘It was my decision and my decision alone’. This was apparent.
I wouldn't go as far as to say that the investigations and the disciplinary hearings were a charade, but there is certainly plenty of evidence to suggest that the process was deeply flawed, from a weak investigation to witheld evidence, suspect reports and precedents which were dismissed (the paramedic officer who refused a 999 call but kept his job and got a 'reflective practise' verdict from the HCPC). Most worryingly, it suggested an absolute disregard for Eddie’s welfare and the clear systemic collusion to disprove that as a factor relevant to the case.
Faith in the Process
|'...improving the working lives of staff.'|
This seemed unfair on Eddie, he was very much a stunned passenger in the whole process. I said, 'I spoke to him about that particular point yesterday and he said that it was a... he opted for the lesser of two evils. He just wanted it over. It had been a torturous experience for him up until then. So he was presented with a choice of prolonging the agony further, or proceeding that day when it probably wasn't in the best interests of his case. So he was damned if he did and damned if he didn't.'
Jason considered this, arriving at, 'I think that's a fair assessment. This issue wasn't going to go away and it needed to be brought to a conclusion one way or another. And the choice for Eddie on the day was: do you deal with it today or do we put it off and postponed it for another day. Because it was not going to go away. It wasn't going to stop. We had to have the hearing, we had to come to a decision. ... He and his rep chose to carry on.'
We went on to discuss whether there might have been another way to deal with Eddie's 'misconduct', but Jason insisted that due to the grave nature of the allegation, despite Eddie being 'a model employee', the 'material breach of contract' gave Jason no choice in the matter. He said, 'if I had my time again, I'd be saying to Eddie “don't say the things you said. Don't do what you did that night. Do the job.” ... I'm not advocating telling fibs. What I'm saying is that if you're unwell, then the member of staff needs to say that they're unwell. … What I'd say to you is that Eddie Daly was a one-off, isolated case. There are very small numbers of people who were dismissed for circumstances like that. But having done what he did, I had no choice. And I believe that it was the right decision and I would do it again.'
Fionna offered this on Eddie’s traumatic experiences and whether she thought that related to the misconduct incident. ‘It doesn't take anything away from the fact that Eddie was a great bloke with thirty years of great service and in that dreadful incident in Lakanal House, the fire there, that was absolutely dreadful. I've listened to the tape of that, of Eddie on the phone, and I know how awful it was when we talked about it. So none of that [is relevant]... it's just two completely different episodes.’
Sword of Damocles or Executioner's Axe?
|LAS execs at the 7/7 bombing inquest in 2011|
I am sympathetic to the pressures and responsibilities of senior executives dealing with cases like Eddie Daly’s, and I understand that, in a way, Eddie’s brinkmanship left Jason Killens with a ‘damned if you do, damned if you don’t’ decision.
In my opinion, the ultimate problem is one of overworked staff, an unforgivable state of affairs caused by numerous factors, not all of them in Jason and Fionna’s control. It is fair to say that, had Mr. Killens been seen to allow Edmund Daly a pass for refusing a 999 call, it would have set a different precedent and potentially opened the floodgates to an increasing number of similar ‘refusals’.
However, with the Operations Director admitting himself that 'utilisation' is unacceptably high at 95%, staff are pushed far too hard. Dangerously so. Under those conditions, it is inevitable that clinician health, attitude, welfare and ability to function will be impaired. Had those intolerable circumstances been avoided in the first place, then Eddie Daly would never have felt the need to make his stand. It is Jason Killens and Fionna Moore who are ultimately responsible for pushing staff to the brink and that they fail to see their part in that - and its relationship to Eddie Daly's predicament - is worrying.
The hearing outcome which Jason Killens chose still sets a dramatic precedent, one which is deeply damaging to any claims that staff welfare is a priority.
Why should a single paramedic pay the highest price for failing to attend one 999 call when the executive management team who are ultimately responsible for the conditions which lead failures of far greater magnitude remain beyond recrimination?
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