Ray Bange from Paramedics Australia has brought the findings of D H Mulligan, a coroner in Western Australia to our attention. Coroner Mulligan was conducting an inquest into the death of a young girl who overdosed on ecstasy at the 2009 “Big Day Out”. Coroner Mulligan’s findings were handed down on 8 March 2013.
On that day the only medical services were provided by St John Ambulance volunteers. The Coroner was impressed by their services but noted that the trained first aider who treated the young woman, was not a paramedic, doctor or nurse and did not have access to a registered health professional for assistance. Nor had he been given specific training on recognising the symptoms of overdosing on various types of drugs. This was not a criticism of him, but it was a criticism of St John Ambulance.
The interesting observation, for readers of this blog, was the finding that the event organisers had employed paramedics to assist staff and performers. The Coroner said:
Whilst I have referred to these paramedics as paramedics, it is important to appreciate that there is no definition in Western Australia as to what a paramedic is or what qualifications or experience a paramedic needs to have before he or she can properly be referred to as a paramedic.
The paramedics supplied by the owners of the Big Day Out, had no powers under Schedule 8 of the Poisons Act 1964 to dispense medications and there was no guarantee that their qualifications or expertise met the standard legitimately expected by the Western Australian public, of those who use that title and who respond to emergencies in our State.
The Coroner reviewed the medical arrangements for the 2013 Big Day Out and was impressed by the higher level of care, the use of paramedics, nurses and doctors as part of the St John Ambulance response and the cooperation between the employed, even paramedics and the St John team.
The Coroner noted that under 2009 Guidelines issued by the Department of Health on the preparations for events such as the Big Day Out there was a requirement to have paramedics on scene, but he noted that there is no definition of what is a paramedic or what qualifications a paramedic may have. He said:
In my opinion, there needs to be a State based definition as to what a paramedic is, so that organisers of events such as the Big Day Out, together with the general public, can have confidence in the abilities of those who are protecting their medical interests at large scale public events.
Coroners can make recommendations on steps they think should be taken to reduce the risk of future deaths. Coroner Mulligan recommended that
… the Director General of Health consider creating a definition of ‘paramedic’ and that he considers a form of registration that will ensure that only appropriately qualified people are entitled to use the title of paramedic and to be able to practise in Western Australia as a paramedic.
In the manuscript for the next edition of Emergency Law (Federation Press, 4th ed, forthcoming) Michael has written:
Paramedics are not registered health professionals so nowhere is it definitively said what paramedics can or cannot do or even what the word ‘paramedic’ means. In New South Wales, until December 2007, the term paramedic was reserved for level V intensive care paramedics; everyone else was called an ‘ambulance officer’. On 3 December 2007, the Ambulance Service announced that from that date forward, “our highly qualified ambulance officers will now be referred to as paramedics” (‘New uniform same excellence in care’ Ambulance Online Summer 2007-08 ). There was no change in the law, no change in role or duties; they became paramedics simply because the ambulance service decided that they would now be called paramedics. Humpty Dumpty said ‘”When I use a word… it means just what I choose it to mean — neither more nor less” (Lewis Carroll, The Complete Alice & The Hunting of the Snark (Jonathan Cape, 1986) 201) and in the absence of professional registration, the term ‘paramedic’ means whatever the person using it wants it to mean.
For the purposes of this discussion the term ‘paramedic’ will be used to mean anyone who claims to have special, advanced life support or first aid skills and who wishes to use the term…
It is known that the Australian Health Ministers’ Advisory Council, Health Workforce Principal Committee is considering options to regulate paramedic practice including registering paramedics under the same law as doctors and nurses (read the discussion paper, here). Hopefully the Coroner’s recommendation will add to the argument that such registration is in the public interest (see also Michael Eburn and Jason Bendall, ‘The provision of Ambulance Services in Australia: a legal argument for the national registration of paramedics’ The Journal of Emergency Primary Health Care: Vol. 8: Iss. 4, Article 4.
Michael Eburn and Ruth Townsend
25 March 2013.
Australian Emergency Law 
Michael – You are incorrect when you say NSW Ambulance just changed the title to Paramedic without upgrading skills. I was in the 1st class of the new training curriculum for P1 Paramedics and right from day one we were given an increased amount of knowledge and skills to learn over the 3 years it takes to become qualified as a Paramedic, when compared to the earlier training for Ambulance Officers.
All existing officers were given training to increase their skill level to the new standard. This wouldn’t have appeared evident to someone outside the Service.
Anthony Judd
Anthony, thanks very much for that extra information.
I believe that paramedics Australia wide should be registered in the same way as all nurses, doctors etc are. It shouldn’t take much for AHPRA to be able to register them.
Michael
I for one have seen this and have followed the case from when it first occurred and I for one find the whole case tragic and hope that such a case would never happen again.
But and I refer you back to your previous post on whether St John volunteers should be registered (because it was a St John volunteer who dealt with this case) while I support that proposition in principle I do also think that it could be problematic, as under what scope would a St John volunteer be registered especially when the only qualification the volunteer has nothing more than first aid certification.
Also what your article does not show is that while tragic as this case was it did not show that the victim concerned intentionally took 3 ecstasy tablets because of the fear of being caught by police who were using sniffer dogs at the event and that she failed to inform the St John volunteer that she had taken them and from what I understand denied taking anything. I am sure if the volunteer was informed of these facts then one would hope a different outcome would have resulted.
I also agree with the coroners recommendation for more training because as it stands I do think that there is room for more and I have always been of the belief that if you are providing a first aid service for the benefit of the public then I do feel that a standard first aid qualification is sadly lacking and that a minimum certificate 4 (ambulance) should be the standard set before someone is allowed to undertake an event unsupervised.
Thanks again, Dodge for your comments. For the benefit of other readers, the previous post on whether or not St John volunteers fall within the definition of a ‘paramedic’ or whether they should, was “Are St John volunteers paramedics? Should they be?”
With respect to this particular case it was indeed tragic as I guess every case a coroner looks into is tragic, and the tragedy is compounded by the girls young age and the decision of her and her friends to lie about her age and the number of drugs she took.
With respect to St John Ambulance it is my understanding that today, members do have training above and beyond a basic first aid certificate before they go on duty but I’m not sure of the details. Perhaps a follower of this blog with current St John experience could give us some advice? The Coroner did note that in 2013 there was more training on drug use, the different types of drugs that may be encountered and how to recognise symptoms of overdose.
In 2009 the St John and medical response to the Western Australia Big Day Out complied with the then Department of Health Guidelines. Those were rewritten after this event and when the coroner visited the 2013 Big Day Out he found that not only was the level of available medical care much higher than it had been in 2009, it exceeded that required by the current version of the guidelines. Clearly there had been a lot of learning from the events under investigation even without the coroner’s formal findings.
Tragically, however, I doubt whether this or anything can actually prevent another occurence of such an event. People will continue to take drugs and lie about it. Perhaps the answer is to see drug taking as a health issue rather than a criminal law issue but that is a matter for debate in another forum.
As you say “she failed to inform the St John volunteer that she had taken them and from what I understand denied taking anything. I am sure if the volunteer was informed of these facts then one would hope a different outcome would have resulted.” My reading of the coroner’s report is that she admitted taking ‘Dexies’ (some less dangerous drug) but not ecstasy. Had she given a true history she may have got to hospital sooner but again my reading of the coroner’s findings is that it probably wouldn’t have made a difference to the ultimate, fatal, outcome.
In response to Dodge. Clinical standards for St John volunteers has changed since 2009. Currently general members are referred to as “First Responders” and are qualified to a Certificate 2 (Emergency Medical Service – First Response). Advanced Responders who have additional knowledge and skills are qualified to Certificate 3 (Basic Health Care).
The service model determination for an event is based on risk and required clinical capabilities rather then simply manpower. There is no event which is covered purely by a “first aider”, the minimum clinical standard is a First Responder and of course St John can offer services right up to a full medical centre staffed by specialist doctors, nurses and paramedics. In addition to the qualification framework, regular in servicing takes place to ensure volunteers are up to date with the latest information and in the case of music festivals the latest drug trends, treatments and standards.
Like any medical service there is always room for improvement. However St John as an organisation has made significant advances and continues to be committed to providing optimal care to patients.
Hi Michael,
This is a very interesting and topical conversation about the most tragic of circumstances. I wonder whether or not we ought to be focusing on ‘the system’ and what happened from an end-to-end perspective and not the individual at the coal face, doing his best to serve his community and in doing so, on this occasion, under very difficult and unknown circumstances.
I think it’s reasonable to say that St John, as an integeral member of the Australian health system, has amongst other organisations, improved its approach to mass gatherings. From any tragedy such a death at a mass gathering through to a large-scale emergency, there are always lessons to be learnt which should influence change and where possible risk mitigation.
St John, amongst other health orientated organisations has an ever-increasing focus on recognising and responding to the deteriorating patient. This very subject will be a focus topic for training and development in 2014.
Brett, thanks very much for joining in the debate. Also thank you Didier, two very senior St John people.
Brett, the reason I made the original post was to raise the issue of the Coroner’s recommendation that there should be a state wide definition of ‘paramedic’ and even national registration. I think it’s important for those that haven’t read the findings (and I don’t think they are readily available online) that the coroner was not critical of the first aider and he certainly noted that there had been changes between 2009 and 2013 and that St John was in fact providing service at a level above that required by the current guidelines.
As I say, my point in making the post was to note that the term paramedic is undefined and the coroners recommendation in that regard rather than make any criticism of the first aiders. Hopefully nothing here is taken as a criticism of that volunteer.
Michael
Didier
Thanks for the clarification but on the broader registration topic I still feel the introduction of the tiered registration system they have in the states would be the way to go in the Emergency Responder would be the appropriate level to be classed as if you do not hold a relevant ambulance qualification and Ambulance Officer if you do but not the tertiary level paramedic degree it would save a lot of confusion.
Another problem I have with volunteer registration is who is going to cop the cost of the registration costs for the individual volunteer and if so registered how would this impact in the areas of vicarious liability or would all legal responsibility for the care provided be passed to the individual that is registered. As I see this would rapidly impact on people that are willing to volunteer if they are not only made responsible for the cost of registration and then have to take out additional professional indemnity insurance which I feel would place a significant financial burden on the individual volunteer. .
Dodge
the issue of a tiered system and the place of volunteers should be the subject of discussion; the problem I had with the discussion paper on paramedic registration and which led to my original post was that they had already excluded volunteers from the registration scheme. That may be an understandable ultimate position, I express no view on that, but if there is to be a discussion it should include a discussion of the very points you raised, not define them away before the discussion starts.
With respect to vicarious liability, registration wont make a difference there any more than it does for doctors and nurses. Where they are employed it is their employer, whether a medical practice, a hospital or an area health service that is liable for any damages. That would also be true for volunteers who are volunteers for an organization and that position is further confirmed by civil liability legislation. Registration does however open the door for professional discipline proceedings (that being one of the ‘pros’ of registration, people who are not fit and proper can be ‘struck off’). Professional discipline is personal and can be expensive so for example, doctors may take out medical indemnity insurance even if they are employed and will not be liable to pay damages, but because it may provide assistance in defending professional disciplinary action.
Michael.
Hi Michael et al,
I couldn’t agree more; I think the sooner we see paramedic registration and the accompanying definition and consistency that should bring, the better.
Didier makes some great points which are reflective of St John policy. In relation to comments made by Dodge – I’m not sure having a tiered system and there adding additional layers of complexity is the way to go. St John has a robust and nationally consistent clinical accreditation framework and sufficient supporting definitions and scopes of practice.
Registration of the term and profession of paramedic must be implemented in Aus and NZ. However all other registered Health Practitioners (in NZ) generally have degree or equivalent qualification. To register a volunteer first aider defeats the purpose!
Oh please, as if this is ever going to happen. All those ‘industrial paramedics’ that swan around mine sites dishing out medications they have no idea whatthey are used for are idiots!!!! A four week mickey mouse course and anyone can claim to be a ‘paramedic’!!!!!
Joey – I find your narrow minded, simplistic and ignorant view of Paramedics who CHOOSE to work in the mining industry offensive and insulting.
Please note, that calling people ‘idiots’ as you so elegantly put it, just goes to show that it does not matter if the ‘Paramedic’ is Cert IV or Bachelors qualified , it is people like who make our struggle to be taken seriously as health providers in the mining and construction industry all that more difficult.
Based on your comment I’m am going to go as far as saying that you are also a Paramedic and I feel your frustration with the title “paramedic” being used by everyone with more than a senior first certificate.
That’s my rant over, I’ll now go back to ‘swanning’ around the site.
Just for the record, it’s a two week course.
I try to discourage personal insults, but given I approved Joey’s comments I’ll let this stand as the ‘right of reply’ but if we could focus on the issues for future posts I think that would be for the best. Thanks, Michael.
Joey, we do need to be careful how we describe others, so assuming that all industrial paramedics, or anyone, are ‘idiots’ is unhelpful, but the point I do want to comment on is that you don’t need a four week course to call yourself a paramedic, you don’t even need a two day first aid course. All you need is a over confident belief in your own abilities (I can call myself a paramedic if I want to). And that’s the argument (or an argument) for registration so only people qualified as paramedics can use that term. What constitutes ‘qualified’ needs to be debated, is it the three year degree or something else?
In the first instance, I would like to make my response to Joey, I understand your frustration, as a Paramedic of over 20 years, I too struggle with the title of Paramedic being used as freely as it currently is in Australasia. However I am also an Industrial Paramedic, I have undergraduate and post graduate qualifications in advanced practice and hold a Master’s degree in Paramedic Science. I have studied at three universities in two countries, to gain my qualifications. I do not consider myself to be an idiot in any terms.
In my humble opinion the title of Paramedic should be reserved for those who have qualified at advanced diploma or degree level and can demonstrate that they have gained relevant and measurable experience in provision of healthcare. I cannot bring myself to agree with Pete, a Cert IV, does not, a Paramedic make. You will note however, I do not suggest that a Paramedic must work for an ambulance service to qualify for the title, but must demonstrate adequate knowledge and experience. There are many other areas of practice which a Paramedic can operate in, including remote or industrial settings or indeed in a hospital setting or walk in centre as my colleagues in the UK continue to do so.
On the question of registration of those healthcare staff who are not qualified to Advanced Diploma level and above, I see no need. Hospital Care Assistants are not registered nor are Enrolled Nurses to my knowledge, so why would Ambulance volunteers or officers need to be? The act of registration is in recognition of certain levels of knowledge and of skill, those standards are designed to enable a body to regulate those registrants. If anyone is in any doubt why we need to register healthcare professionals, please visit the Health Care Professionals Council website and observe how that body deals with impropriety, poor practice and by doing so protects the public we serve.
And “If anyone is in any doubt why we need to register healthcare professionals…” including paramedics, see these two articles (and thank you to Ben who provided these links in a comment in response to the post Volunteer nurses and their skills):
A couple of very interesting articles on the subject…
http://www.theage.com.au/victoria/first-aid-second-rate-20130403-2h6z0.html
http://www.theage.com.au/victoria/emergency-the-true-state-of-victorias-first-aid-20130403-2h77w.html
Paramedics Australia has released a press release responding to these stories – see http://www.paramedics.org.au/content/2013/04/Paramedics_MediaRelease-04APR2013.pdf
Just feel like making a comment here as I am a Paramedic and happy to call myself one as serving 10 years in the Navy as a medical sailor and leaving with a Diploma in Paramedical Science (Ambulance) and many other medical Certs feel that that and the life experience allows me to call myself one. I think registration is a good thing for sure no problems with it, I do have a problem with places like South Australia etc not recognising life experience with a Diploma, instead the like to take kids that have just left school and have no life experience and put them into ambulances calling them paramedics. Anyone smart enough can do the degree and follow a protocol/Guideline it’s when things aren’t quote text book that the life experience is needed. I remember when I joined the Navy it took 10 years before you could get to that sort of level and at the time so did NSW Ambulance service which made sense you had to gain the life experience and earn it. Now all you need is the money and the brains to study and pass a degree. The Channel 10 news story really annoyed me telling members of the public that there’s no formal training etc and splashing SA Ambulance service with their snotty nose teenage paramedics with their degrees all over the screen. They should have also asked the public would you prefer a teenager treating you or someone with that valid life experience and a qualification. Life experience and a bit of paper mean more than just a piece of paper. Defence medics use to walk into these roles and I haven’t met one that let an ambulance service down yet must mean something?
Hi, Im not a paramedic, but Im an Anaesthetic Technician in W.A. Our Anaesthetic society has been trying to get registered for the last 10 to 15 years, so good luck paramedics.