nursing and midwifery council fitness to practise ......2017/11/07 · fitness to practise...

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Nursing and Midwifery Council Fitness to Practise Committee

Substantive Hearing 30 October 2017 – 7 November 2017

Nursing and Midwifery Council, 2 Stratford Place, Montfichet Road, London, E20 1EJ Name of registrant: Patsylin Palmer

NMC Pin: 99A0540E

Part(s) of the register: Registered Nurse – Adult

Area of registered address: England

Type of Case: Lack of Competence

Panel Members: Raymond Marley (Chair, Lay member)

Martin Bryceland (Registrant member)

Darren Shenton (Lay member)

Legal Assessor: Michael Epstein

Panel Secretary: Deepan Jaddoo

Miss Palmer: Present and represented by Emma Shafton,

counsel instructed by Thompsons Solicitors

Nursing and Midwifery Council: Represented by Will Cholerton, counsel,

instructed by NMC Regulatory Legal Team.

Facts proved by admission: 1.1, 1.2, 2.1, 3.1, 3.4, 4.2, 4.4, 5.1, 5.3, 5.5,

6.1, 6.2, 6.3, 6.6, 6.7, 6.10, 7.3.2.4, 8.2, 8.3,

8.4, 8.5, 9.2, 10.1, 10.3, 11.1, 11.6, 11.8, 12.2,

13.1, 13.3, 13.6, 14.1, 14.5, 15.7, 16.1, 18.1,

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19.5, 20.4, 23.1, 25.4, 25.6, 25.7.1, 26.4, 26.5,

26.6, 26.9, 26.10, 26.11 Facts proved: 2.2, 2.3, 3.2, 3.3, 4.1, 4.3, 5.2, 5.4, 6.4, 6.5,

6.8, 6.9, 6.11, 7.1, 7.2, 7.3.2.1, 7.3.2.2, 7.3.2.3,

7.3.2.5, 8.1, 8.6, 8.7, 9.1, 9.3, 11.2, 11.3, 11.4,

11.5, 11.7, 12.1, 12.3, 13.2, 13.4, 13.5, 13.7,

13.8, 14.2, 14.3, 14.4, 14.6, 14.7,15.2, 15.3,

15.4, 15.5, 15.6, 16.2, 16.3, 16.4, 17.1, 17.2,

17.3, 17.4, 17.5, 17.6, 18.2, 19.3, 19.4, 20.1,

20.2, 20.3, 20.5, 20.8, 21.1, 21.3, 21.4, 21.5,

22.1, 22.2, 23.2, 23.3, 23.4, 24.1, 24.2, 24.3,

25.1, 25.2, 25.7.2, 26.1, 26.2, 26.3, 26.7, 26.8.

Facts not proved: 10.2, 15.1, 18.3, 19.1, 19.2, 26.12

Fitness to practise: Impaired

Sanction: Suspension Order – 12 months

Interim Order: Interim Suspension Order – 18 months

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Details of charge (as amended): That you, whilst employed by University Hospitals Bristol NHS Foundation Trust, failed

to demonstrate the standards of knowledge, skill, and judgement required to practise as

a band 5 Staff Nurse without supervision in that:

1. On 25/26 June 2014, in relation to an unknown patient, you:

1.1 administered Oramorph at 02:00 without assessing and/or recording the

patient’s pain score;

1.2 administered Oramorph at 04:00 without ensuring that a new prescription had

been written up and without assessing and/or recording the patient’s pain

score;

Whilst subject to supervision in accordance with formal stage 2 of the Trust’s

performance management policy

2. On 11 August 2015, you:

2.1 did not complete the morning medication round until at or around 10:15;

2.2 did not check a patient’s wrist band before administering Naseptin;

2.3 did not check and/or record the assessment scores for cannulation sites

during your medication round;



3.2 did not check the names of two patients during the morning medication

round;

3.3 required prompting to administer a patient’s intravenous medication;

3.4 only completed approximately 50 percent of your documentation during the

shift;

4. On 17 August 2015,you:

4.1 prepared to administer antibiotics to a patient which had expired by 2 days;

4.2 did not complete the morning medication round until at or around10:00;

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4.3 did not record enough detail in patient notes;

4.4 did not check cardiac monitors without being prompted by your supervisor;



5.2 left medication unsecured as you left the locker unlocked;

5.3 prepared to administer furosemide to a patient without checking their current

systolic measurement;

5.4 required prompting to administer furosemide to a patient that was due at

14:00;

5.5 did not complete a record of intentional rounding for your patients;


6.1 did not complete the morning medication round until 10:00;

6.2 did not administer medication to the patient in bed 12 without prompting from

your supervisor;

6.3 required prompting to check the ward number recorded on patients’ MAR

charts;

6.4 required prompting to arrange for a patient’s prescription of Calceous to be

amended to Adcal D3;

6.5 did not administer bisoprolol to the patient in bed 12 until 18:00 when you

had been advised to administer this at 16:00;

6.6 did not ensure that all entries in patient notes were dated and timed;

6.7 did not complete the electronic handover form;

6.8 required prompting to take a blood sample from a patient;

6.9 required prompting to check patients’ care plans;

6.10 did not identify that the care plans for the patient in bed 6 were out of date;

6.11 did not check a patient’s intravenous heparin chart for approximately three

hours;


7.1 required prompting to order medication from the pharmacy;

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7.2 required prompting to check the INR score and/or seek a medical review for

a patient on intravenous heparin;

7.3 in relation to an unknown patient:

3.2.1 failed to administer enoxaparin as prescribed on the tea time

medication round;

3.2.2 did not record on the medication chart that you had administered

warfarin;

3.2.3 required prompting to check whether warfarin needed to be

administered in light of an improved INR score;

3.2.4 did not start completing your nursing notes until 19:15;

3.2.5 did not include adequate detail of care in your nursing notes;


8.1 did not check the blood pressure of a patient on an isoket infusion;

8.2 did not complete intentional roundings for your patients;

8.3 did not complete your nursing notes until after your shift had finished;

8.4 did not complete the electronic handover record in advance of shift handover;

8.5 required prompting by your supervisor to respond to cardiac monitors that

alarmed on the shift;

8.6 could not provide adequate information about one of your patients during

handover;

8.7 required prompting to respond to a patient’s high early warning score;


9.1 did not complete the electronic handover sheet as part of shift handover;

9.2 did not complete nursing notes for one of your patients;

9.3 did not include enough detail about care delivered to patients in the nursing

records;

10. On 1 September 2015, you:

10.1 required prompting to administer antibiotics to a patient on the lunchtime

medication round;

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10.2 did not notice that senna needed to be administered to one patient on the

evening medication round, which was prescribed as regular medication;

10.3 required assistance in completing your documentation;



11.2 did not check the ward numbers recorded on the drug charts for patients;

11.3 did not identify that the route for medication administration had not been

recorded for two medications on a drug chart;

11.4 prepared to administer 1.25mg bisoprolol to a patient when the

prescription was 2.5mg;

11.5 required prompting to conduct four hourly observations for one of your

patients;

11.6 did not check and/or did not record that you had checked the chest drain

before 12:00 as required for one of your patients;

11.7 did not complete an ECG for one of your patients by lunchtime, as

required;

11.8 did not update fluid charts during the morning;


12.1 did not sign to record that all medication had been administered on the

morning medication round;

12.2 incorrectly recorded that you administered Oramorph to a patient at 11:30

when you had administered it at 12:30;

12.3 did not complete your clinical duties without requiring assistance from your

supervisor;



13.2 required prompting to adjust a patient’s isoket infusion when their systolic

reading was above 180;

13.3 did not administer a patient’s oxycodone modified release analgesia

before they left the ward at 09:30;

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13.4 required prompting to ensure that a patient’s pressure areas were

checked;

13.5 did not check the groin site of your patient who was 6 days post operation;

13.6 did not complete your nursing records until after your shift had finished;

13.7 did not record enough detail in the nursing notes for your patients;

13.8 included inaccurate information in the electronic handover document;


14.1 did not demonstrate adequate knowledge of cardiac medication on the

medication round;

14.2 required prompting to sign to confirm that you had administered

medication to a patient;

14.3 incorrectly calculated an intravenous fentanyl dose as 1.25 ml when the

dose should have been 0.25 ml;

14.4 did not prioritise administering medication to a patient who needed to

leave the ward at 09:00;

14.5 did not administer medication to the patient in bed 8 as you incorrectly

thought that the patient was nil by mouth when they were not;

14.6 left the medication pod for the patient in bed 10 unlocked;

14.7 prepared to administer oral antibiotics for a patient when you had been

informed by the doctor that it should not be given;


15.1 took too long to complete the morning medication round;

15.2 incorrectly prepared to administer 100mg of gabapentin to a patient when

they were prescribed 200mg;

15.3 did not administer Ramipril as prescribed to a patient;

15.4 required prompting to identify that a patient’s prescribed does of Bisoprolol

had been altered;

15.5 required prompting to obtain a prescription for Warfarin for a patient;

15.6 did not give furosemide to a patient until 21:00 when it was due at 16:30;

15.7 did not complete your record keeping in nursing notes without assistance;

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16.1 did not administer furosemide to a patient until 10:25, when it was due at

08:00;

16.2 required prompting to record that paracetamol had been administered to a

patient;

16.3 required prompting to record that 20 mg Oramorph had been administered

to a patient;

16.4 did not complete nursing documentation until 18:00;

Whilst subject to supervision on an extended plan in accordance with formal stage 2 of

the Trust’s performance management policy

17. On 2 December 2015, you:

17.1 did not demonstrate adequate knowledge of the following medication:

17.1.1 amiodarone;

17.1.2 canedersarian canderstan; (Amended) 17.1.3 ivabradine;

17.1.4 metolazone;

17.1.5 nicorandil;

17.2 administered medication to a patient before checking their wrist band;

17.3 needed to be reminded to check the drug chart for other medication that

was due after administering intravenous medication;

17.4 when checking observations prior to administering medication to the

patient in bed 5, checked observations recorded for 1 December 2015

instead of 2 December 2015;

17.5 did not include an adequate assessment of clinical needs in your record

keeping;

17.6 when completing venepuncture, inappropriately retouched areas that you

had cleaned;


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18.1 did not demonstrate an understanding of cardiac medication;

18.2 did not provide any or adequate detail when you recorded clinical care in

patients’ notes;

18.3 did not demonstrate an ability to prioritise patient care;


19.1 did not check medication in the British National Formulary on your

medication round for medication that you did not understand;

19.2 required assistance to calculate an intravenous furosemide dose;

19.3 did not ensure that comfort rounding was completed as required for

patients in bay 22-25.

19.4 did not attend to patients regularly enough to ensure that their needs were

met;

19.5 recorded details of a patient’s care in the wrong patient’s notes;


20.1 did not check allergies for failed to observe patients in beds 15 and/or 18

when administering taking medication;

(Amended) 20.2 did not record the reason why one patient could not have their medication

administered;

20.3 inaccurately recorded that the patient in bed 15 needed an internal cardio

defibrillator when this was already in place;

20.4 did not demonstrate an understanding of what an internal cardio

defibrillator was;

20.5 did not demonstrate an ability to prioritise care;

20.6 did not demonstrate an understanding of your patients’ needs;

20.7 did not ask patients about their pain management;

20.8 did not check a patient’s normal bowel habits with his relatives, which had

been requested following shift handover;


21.1 did not complete the medication round in an adequate period of time;

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21.2 did not know whether you had administered rivaroxaban to a patient, when

they asked about its administration;

21.3 did not demonstrate an ability to manage patients’ nursing needs;

21.4 provided inaccurate information about a patient at shift handover;

21.5 did not record enough information about a patient’s shortness of breath in

their nursing notes;


22.1 incorrectly calculated a dose of Oramorph for the patient in bed 19;

22.2 did not demonstrate an adequate level of drug knowledge;

23. On 15 December 2015:

23.1 your records in patient notes did not include detail of what assessments

had been undertaken;

23.2 did not demonstrate ability to manage full case load of patients on the

shift;

23.3 your record in a patients nursing notes included incorrect information that

a patient suffered from an abnormal heart rhythm;

23.4 you did not ensure that a patient’s blood pressure was monitored

throughout the shift;


24.1 prepared 10mg of nicorandil for administration to a patient, when they

were prescribed 5mg of ramipril;

24.2 required prompting to ensure that a patient’s blood pressure was taken;

24.3 did not ensure that a patient’s pressure ulcers areas were checked until

16:00;

(Amended)


25.1 did not check patients’ observation charts before administering

medication;

25.2 started the lunch time medication round late;

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25.3 incorrectly prepared 40mgs furosemide for the patient in bed 20 when the

patient was prescribed with 80mgs furosemide;

25.4 did not make a GP appointment for the removal of the patient in bed 25’s

sutures prior to discharge;

25.5 after being asked to take a blood sample from the patient in bed 2 at

11:00, did not do this until at or around 13:00;

25.6 did not check the pressure areas for patients in beds 3 and/or 4;

25.7 in relation to record keeping,

25.7.1 did not complete your record keeping until after your shift had

finished;

25.7.2 did not include enough detail in your records of patient care;

26. On 4 January 2016, you:

26.1 did not demonstrate an understanding of the purpose of cardiac

medication;

26.2 required assistance in planning the care for a patient who did not want to

take his 08:00 medication until immodium had been prescribed;

26.3 did not complete the 08:00 medication round in an appropriate length of

time;

26.4 did not administer intravenous antibiotics which had been prescribed for

12:00 until at or around 13:00;

26.5 during the evening drug round, did not administer intravenous antibiotics

to a patient until 18:45.

26.6 did not record care for patients in the nursing notes until the end of the

shift;

26.7 did not include adequate detail about care delivered to patients in the

notes;

26.8 did not prepare a wound care plan for the patient in Bed 24, as required.

26.9 completed some notes without recording a date and/or time for the entries;

26.10 did not record the National Early Warning Score for a patient in their notes;

26.11 did not check with the nurse in charge whether the patient in bed 22

needed a procedure in the cardiac catheter lab even though you fasted the

patient;

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26.12 did not demonstrate an awareness of the classification of drugs being

administered;

AND by reason of the matters outlined above, your fitness to practise is impaired by

reason of your lack of competence.

Background

You qualified as a registered nurse in February 2002 and were employed by University

Hospitals Bristol NHS Foundation Trust (“the Trust”), as a Band 5 Staff Nurse from 7

February 2005 to 13 November 2014.

In 2013, a number of concerns were raised about your basic nursing practice. Broadly,

the concerns related to medication administration, record keeping and accountability.

Following these concerns being reported, you were provided with a final written warning

for a period of 24 months and placed on a Stage 1 performance management plan (“the

Plan”). The plan focused on: medicines management, safe patient transfers, personal

accountability and documentation.

Further concerns were identified on 26 June 2014, where it is alleged that at both

02:00 and 04:00, you administered Oramorph to a patient without assessing

and/or recording the patient’s pain score. It is further alleged that at 04:00, in

relation to the same unknown patient, you failed to ensure that a new prescription

had been written up.

Following these concerns, you attended a disciplinary hearing on 31 March 2015

at which you were dismissed. Upon appeal, you were re-instated on 2 June 2015

and directed to undertake an 8 week assessment on Ward C705 (“WC705”) in

accordance with Stage 2 of the performance management policy. WC705 was a

cardiac ward which you had never worked on before. You were assigned three

dedicated supervisors, who were supernumerary, to ensure that you met your

NMC interim order conditions. These supervisors were Ms 2, Ms, 3 and Ms 4. The

supervision period was for a period of 8 weeks during July and August.

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15 separate incidents occurred between 11 August 2015 and 15 September 2015,

whilst subject to supervision in accordance with formal stage 2 of the Trust’s

performance management policy (“the performance plan”), with regard to the

following areas of competency:

• medication administration;

• safe handling and storage of medication;

• observation;

• record keeping and documentation.

As a result of concerns that your objectives had not been met during July and

August 2015, a Stage 3 performance hearing took place on 14 October 2015 at

which you were provided with a further opportunity to demonstrate your capability

in a four week assessment period on WC805. Again you were provided

supernumerary supervisors who were put in place to monitor and support you on

your performance plan.

Between 2 December 2015 and 4 January 2016, there were 10 separate incidents

later occurred on dates involving the same areas of competency as outlined

above, whilst you were subject to supervision on an extended plan in accordance

with the performance plan.

Two incidents occurred on 25/26 June 2014, whilst a further 24 occurred between

August 2015 and January 2016 during a 12 week working period whilst you were

under direct supervision. The NMC allege that when taken as a whole, between

25/26 June 2014 and 4 January 2016, you failed to demonstrate the standards of

knowledge, skill and judgment required to practise as a Band 5 Staff Nurse without

supervision.

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Amendment to charge pursuant to Rule 28 of the Nursing and Midwifery Fitness to Practise Rules 2004 (“the Rules”)

The panel proposed that minor amendments to charges 17.1.2, 20.1 and 24.3 were

necessary, for the sake of clarity and accuracy.

The proposed amendment to charge 17.1.2 was as follows:

canedersarian canderstan;

The proposed amendment to charge 20.1 was as follows:

did not check allergies for did not observe patients in beds 15 and/or 18 when

administering taking medication;

The proposed amendment to charge 24.3 was as follows:

“did not ensure that a patient’s pressure ulcers areas were checked until 16:00”

Both Mr Cholerton and Ms Shafton, on your behalf were in agreement with the

proposed amendments.

The panel accepted the advice of the legal assessor.

Rule 28 of the Rules states:

28 (1) At any stage before making its findings of fact …

(i) … the Conduct and Competence Committee, may amend

(a) the charge set out in the notice of hearing …

unless, having regard to the merits of the case and the fairness of the

proceedings, the required amendment cannot be made without injustice.

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The panel was satisfied that there would be no prejudice to you and no injustice would

be caused to either party by the proposed amendments. It was therefore appropriate for

the amendments to be made to ensure clarity and accuracy.

Decision and reasons on application under Rule 19 At the outset of the hearing Miss Shafton, on your behalf, made a request that parts of

the hearing of your case be held in private on the basis that proper exploration of your

case involves private matters relating to your health. The application was made

pursuant to Rule 19 of the Rules.

Mr Cholerton, on behalf of the NMC, indicated that he supported the application to the

extent that any detailed reference to your health should be heard in private.

The legal assessor reminded the panel that while Rule 19 (1) provides, as a starting

point, that hearings shall be conducted in public, Rule 19 (3) states that the panel may

hold hearings partly or wholly in private if it is satisfied that this is justified by the

interests of any party or by the public interest.

Rule 19 states

19. (1) S ubje ct to

public.

(2) Subject to paragraph (2A), a hearing before the Fitness to Practise

Committee which relates solely to an allegation concerning the registrant’s

physical or mental health must be conducted in private.

(2A) All or part of the hearing referred to in paragraph (2) may be held in public

where the Fitness to Practise Committee—

(a) having given the parties, and any third party whom the Committee

considers it appropriate to hear, an opportunity to make representations;

and

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(b) having obtained the advice of the legal assessor, is satisfied that the

public interest or the interests of any third party outweigh the need to

protect the privacy or confidentiality of the registrant.

(3) Hearings other than those referred to in paragraph (2) above may be held,

wholly or partly, in private if the Committee is satisfied

(a) having given the parties, and any third party from whom the Committee

considers it appropriate to hear, an opportunity to make representations;

and

(b) having obtained the advice of the legal assessor, that this is justified

(and outweighs any prejudice) by the interests of any party or of any

third party (including a complainant, witness or patient) or by the public

interest.

(4) In this rule, “in private” means conducted in the presence of every party and

any person representing a party, but otherwise excluding the public.

Having heard that there will be reference to your health, the panel determined to hold

such parts of the hearing in private. The panel determined to rule on whether or not to

go into private session as and when such issues are raised.

Decision on the findings on facts and reasons In reaching its decisions on the facts, the panel considered all the evidence adduced in

this case together with the submissions made by Mr Cholerton, on behalf of the NMC

and heard evidence from:

• Ms 1, Matron within the Division of Medicine

• Ms 2, Matron for the speciality of care of elderly patients

• Ms 3, Ward Sister of Ward C705

• Ms 4, Band 6 Senior Staff Nurse on Ward C705

• Ms 5, Band 6 Clinical Nurse Specialist in Supportive and Palliative Care

• Mr 6, Ward Manager on the Mixed Cardiology Ward C805

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• Ms 7, Band 6 Senior Staff Nurse on Ward C805

• Mr 8, Band 6 Senior Staff Nurse on Ward C805 and your Mentor

The panel also heard submissions made by Ms Shafton on your behalf and heard

evidence from you under oath.


The panel was aware that the burden of proof rests on the NMC, and that the standard

of proof is the civil standard, namely the balance of probabilities. This means that the

facts will be proved if the panel was satisfied that it was more likely than not that the

incidents occurred as alleged.

The panel considered Ms 1 to be a credible witness. The panel considered that Ms 1’s

evidence was clear, straightforward and consistent. The panel noted that whilst Ms 1

was not a direct witness to any of the incidents, it found that she provided useful

background to the panel.

The panel considered Ms 2’s evidence to be balanced and fair. Ms 2 was a clear and

credible witness. Where there were limitations in the investigation, Ms 2 refrained from

speculating and was prepared to make concessions.

The panel was of the view that Ms 3 was a credible and honest witness. She provided

reflective answers which were corroborated by good supporting documentation that was

clear, concise and contemporaneous. Her evidence was straightforward and consistent.

Ms 3 had a clear understanding of her role as a supervisor and the panel accepted that

she had been supportive towards you, providing the panel with good examples of what

she did to support you whilst accepting that it was a difficult situation for both of you to

be in at the time. She was honest about periodic distractions and the difficulties in being

a supervisor as a Band 7.

The panel considered Ms 4 to be an honest witness and found her evidence consistent

with her written accounts. The panel noted that at times, Ms 4 seemed hesitant due to

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her nervousness, however the panel found that her answers were thoughtful and

measured and that this added to her credibility. She was very clear in her understanding

of her role and provided useful information to the panel in relation to what she did to

help support you. Her evidence was supported by very clear documentary evidence. Ms

4 made several amendments to her statement which demonstrated attention to detail.

The panel found Ms 5 to be a professional, confident and assertive witness. The panel

was of the view that Ms 5 provided the panel with a truthful account of what had

occurred and was consistent during cross examination. The panel found that she

provided clear and helpful evidence, supported by comprehensive documentary

evidence. Ms 5 took her role seriously and the panel accepted that she did her best to

maintain patient safety whilst providing you with support. Ms 5 was clearly disappointed

by the allegation that she had not tried her best to support you, which added to her

credibility.

The panel found Mr 6 to a credible witness. His answers to questions were balanced

and measured. The panel considered that he had been very supportive of you and

wanted you to succeed. Mr 6 took the negative outcome of your improvement plan

personally and invested himself in you. Mr 6 was able to provide significant detail into

incidents which he had directly observed and was able to recall events easily. He was

professional in his role and was able to provide insight into recurring issues and themes,

which independently corroborated other similar accounts from colleagues working on

WC705. Mr 6 showed a good understanding of what your improvement plan required

and ensured that a mentor was allocated to you early on.

Ms 7 presented as a witness who did her best to provide the panel with accurate

information. The panel found that her evidence was in the main confined to her witness

statement but that there was some disparity between her contemporaneous records

made at the time of the incidents, and her oral evidence. The panel found that she was

exceptionally fair and honest, and made concessions to your counsel. There was no

evidence of malice or any attempt to mislead the panel. Whilst there were some

discrepancies in her evidence, this was not fatal to her overall reliability. The panel

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determined that she was able to provide a good recollection of the factual events which

occurred.

The panel found that Mr 8 provided useful background to the mentoring process, and

determined that whilst his evidence was consistent with his statement, this was of

limited value to the panel. Mr 8 was an honest witness who appeared to bear no malice

towards you and did his best to assist the panel.

The panel considered your evidence and found it, on the whole, to be quite vague as it

contained general observations and assertions about your perceived general clinical

practice. By your own admission, you struggled to remember details surrounding the

incidents and provided no material evidence into serious claims of bullying and

harassment from other witnesses. When questioned about this, you could not provide

any specific examples of any such behaviour displayed by these witnesses. The panel

considered these claims to merely be a smokescreen, used in attempt to hide from the

failings and deficiencies in your practice. The panel found your evidence to lack

credibility and found that you showed a continued unwillingness to make concessions

when there were gaps in your evidence. When questioned, the panel found some of

your responses to be evasive. The panel found that your evidence in relation to issues

you refuted was generally weak and lacking in substance.

At the outset of this hearing you admitted the following charges: 1.1 (in part), 1.2 (in

part), 2.1, 3.1, 3.4, 4.2, 4.4, 5.1, 5.3, 5.5, 6.1, 6.2, 6.3, 6.6, 6.7, 6.10, 7.3.2.4, 8.2, 8.3,

8.4, 8.5, 9.2, 10.1, 10.3, 11.1, 11.6 (in part), 11.8, 12.2, 13.1, 13.3, 13.6, 14.1, 14.5,

15.7, 16.1, 18.1, 19.5, 20.4, 23.1, 25.4, 25.6, 25.7.1, 26.4, 26.5, 26.6, 26.9, 26.10, 26.11

These were therefore announced as proved, by virtue of your admissions, pursuant to

Rule 24(5) of the Rules.

The panel considered the remaining charges and made the following findings:

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That you, whilst employed by University Hospitals Bristol NHS Foundation Trust, failed

to demonstrate the standards of knowledge, skill, and judgement required to practise as

a band 5 Staff Nurse without supervision in that:

Charge 1 This charge is found proved.

1. On 25/26 June 2014, in relation to an unknown patient, you:

1.1 administered Oramorph at 02:00 without assessing and/or recording the

patient’s pain score;

1.2 administered Oramorph at 04:00 without ensuring that a new prescription had

been written up and without assessing and/or recording the patient’s pain

score;

In reaching this decision, the panel took into account all of the oral and documentary

evidence presented in this case.

The panel noted that you made partial admissions to both charges. The panel also

noted that there were no direct witnesses in relation to both incidents and that the only

evidence to support this charge was in the form of hearsay evidence provided and

exhibited by Ms 2. Ms 2 was not able to provide any further detail regarding this incident

during her oral evidence.

The panel took into account your oral evidence and accepted, by your own admission

that you had failed to record the patient’s pain score. However, in the absence of any

direct evidence, the panel was not satisfied, on balance, that you had not assessed the

patient at 02:00 or at 04:00. Furthermore, the panel noted that there was documentary

evidence in support of your assertion that you obtained permission from a doctor to

administer the Oramorph at 04:00. The panel therefore determined that the NMC had

failed to discharge its evidential burden in relation to assessing the patient’s pain score,

accordingly the panel found charges 1.1 and 1.2 proved, in accordance with your

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admission that you had administered Oramorph without recording the patient’s pain

score .

Whilst subject to supervision in accordance with formal stage 2 of the Trust’s

performance management policy

Charge 2

2.2 did not check a patient’s wrist band before administering Naseptin;

This charge is found proved.

Ms 3, in her written statement stated the following: “I observed that the Registrant

completed all the necessary checks except one. The Registrant forgot to check the

name of one patient on their wrist band prior to administering Naseptin… I explained to

the Registrant she needed to remain vigilant when undertaking checks during the drug

round to ensure that she administered the correct drugs to the correct patient.” Ms 3

reiterated this in her oral evidence.

You told the panel that it wasn’t hospital policy to check the wristbands of patients, but

that it was nevertheless your common practice to double check wristbands twice.

In the panel’s view, your oral evidence makes Ms 3’s assertions more credible, as if by

your own admission you normally check wristbands twice, it is less likely for Ms 3 to

miss noticing you do this at all. Ms 3 was one of three supervisors who was

supernumerary, therefore it is further less likely for her to be distracted when

supervising you. Ms 3’s oral evidence is corroborated by her written statement and by

the clear and contemporaneous record contained within exhibit 2. The panel also found

hospital policy is that wristbands should be checked before administration of

medication.

2.3 did not check and/or record the assessment scores for cannulation sites

during your medication round;

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The panel noted that you could not recall this incident. The panel preferred Ms 3’s

evidence in relation to this incident, which is corroborated by the contemporaneous

supervised medicine round record dated 11 August 2015 contained within exhibit 2,

where Ms 3 stated “Not noticed on AM or lunch drug round VIP scores for canula

(renewed but not documented).”

On the evidence before it, the panel considered that, on the balance of probabilities, it

was more likely than not that you did not check and/or record the assessment scores for

cannulation sites during your medication round. Accordingly, the panel found charge 2.3

proved.

Charge 3

On 14 August 2015, you:

3.2 did not check the names of two patients during the morning medication

round;


The panel noted that you could not recall this incident. The panel preferred Ms 3’s

evidence in relation to this incident, which is supported by her written statement, where

she stated: “During this drug round the Registrant also missed two name checks (which

she told me was because she was distracted by her surroundings).”

This is also corroborated by the contemporaneous supervised medicine round record

dated 14 August 2015, contained within exhibit 2, where Ms 3 stated “Missed 2x Name

checks – needed prompting to do so”.

Accordingly, the panel found this charge proved.

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3.3 required prompting to administer a patient’s intravenous medication;


The panel noted that you could not recall this incident. The panel accepted Ms 3’s

evidence in relation to this incident, which is supported by her written statement, where

she stated: “I had to gently remind her about an intravenous medication that needed to

be administered to a patient during the round.”

Accordingly, the panel found this charge proved.

Charge 4 On 17 August 2015, you:

4.1 prepared to administer antibiotics to a patient which had expired by 2 days;

This charge is found proved. In reaching its decision, the panel noted that in respect of this charge there was a direct

conflict between Ms 5’s account of events and yours. The panel therefore carefully

considered the issue of credibility first. The panel noted that there are many instances of

conflicting evidence in this case and determined that it would adopt the same approach

for all similar situations.

Ms 5 explained that whilst supervising you, she noticed that you were preparing

antibiotics from a bottle clearly marked ‘expired’. In her statement Ms 5 stated: “I

allowed the Registrant to draw up the antibiotic to give her the opportunity to identify the

error herself but I intervened before it was given to the patient. I explained to the

Registrant that this could not be given as it was out of date. The Registrant explained

that she sometimes found expiry dates hard to read, and sometimes read ‘2016’ as

‘2018’.” Ms 5 gave clear oral evidence that she intervened to take medication out of

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your hand as she was concerned that not to do so would have led to administering

drugs leaving the patient at risk of harm.

You denied this allegation and said you were still in the process of checking the drug

and would not have given it, had she not snatched it out of your hand.

The panel preferred Ms 5’s evidence and found that your explanation did not mitigate or

excuse your actions. Accordingly, the panel found this charge proved. 4.3 did not record enough detail in patient notes;


Ms 5 provided oral evidence to the panel which reaffirmed her statement contained in

her contemporaneous record within the Daily Reflective Feedback form (DRF form)

dated 17 August 2015 which, under the heading ‘points for improvement’, stated

“expanding on medical notes – patsy highlights a point (e.g. patient had high pulse) but

did not expand on what was done about it. I feel this is very important and notes need to

be more detailed”.

You denied this allegation, outlining you did feel you had put sufficient information in

your notes and said there was a disparity in working practices between wards in which

you had previously practiced.

Whilst the panel noted that it had not been provided with a copy of the notes in

question, the panel preferred Ms 5’s evidence. Accordingly, the panel found this charge

proved.


5.2 left medication unsecured as you left the locker unlocked;

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This charge is found proved. The panel took into account Ms 5’s written statement which stated “The Registrant

finished the morning drug round extremely late at approximately 10:15 and left a

medication locker wide open and unlocked; even though we had previously discussed

the importance of ensuring medication is securely stored.” She reiterated this in her oral

evidence which was also corroborated by the contemporaneous SMR dated 19 August

2015, which stated “One POD was left unlocked + wide open, I had to ask Patsy to

close it”.

You denied this charge and told the panel that you couldn’t have left the locker unlocked

as this wasn’t part of your usual practice, and you had not left the nursing bay.

The panel noted that it had oral, written and contemporaneous documentary evidence

from Ms 5. It also noted that you had signed the Supervised Medicines Round (SMR). It

therefore preferred Ms 5’s evidence. Accordingly, the panel found this charge proved.

5.4 required prompting to administer furosemide to a patient that was due at

14:00;

This charge is found proved. The panel took into account Ms 5’s written statement which stated “There had also been

a further dose of Furosemide due to be administered (although I am unsure as to which

patient) at 14:00 which I feel the Registrant would have forgotten had I not reminded

her”. She reiterated this in her oral evidence which was also corroborated by the

contemporaneous SMR dated 19 August 2015.

You had no recollection of this charge.

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from Ms 5. It also noted that you had signed the SMR. It therefore accepted Ms 5’s

evidence. Accordingly, the panel found this charge proved.


6.4 required prompting to arrange for a patient’s prescription of Calceous to be

amended to Adcal D3;

This charge is found proved. The panel took into account Ms 4’s written statement which stated “During the lunch

time drug round, the Registrant again required prompting to seek a pharmacist/doctors

review of Calceous (a vitamin supplement) which is not a ward stock medication, and

required re-prescribing to Adcal D3 (ward stock). This had been explained to the

Registrant during the morning drug round as needing to be done, but had not been

actioned by lunchtime. To ensure that further delay in giving the medication to the

patient was avoided, I intervened and requested this change.” Ms 4 reiterated this in her

oral evidence.

You denied this charge and told the panel that as this medication was a vitamin

supplement, it was not critical and therefore not time specific. You told the panel that

you would have “got round” to administering this later when you had more time.

The panel noted the oral and written evidence from Ms 4. In the panel’s view, your

reasoning for not providing the medication was irrelevant. The panel determined that

you did require prompting from Ms 4, and therefore found this charge proved.

6.5 did not administer bisoprolol to the patient in bed 12 until 18:00 when you had

been advised to administer this at 16:00;


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from Ms 4, as per the SMR dated 21 August 2015, contained in exhibit 2, which stated

“Bed 12 – advised to give Bisoprolol at 4pm -> given at 18:00” It accepted Ms 4’s

evidence. Accordingly, the panel found this charge proved.

6.8 required prompting to take a blood sample from a patient;

This charge is found proved. The panel took into account Ms 4’s written statement which stated “During this shift the

Registrant was prompted on two separate occasions to take a scheduled blood test to

check blood clotting levels needed to monitor the intravenous (IV) Heparin rate and the

appropriateness of continuing the infusion to prevent unnecessary administration of an

anti-coagulation medication, with additional risk of bleeding if over coagulated. For

example, the morning blood test was required at 10:00 but the Registrant failed to take

them and was reminded at 10:30 to do so. I intervened to check and action the result

of the blood test taken for the IV Heparin infusion when not done so by the Registrant

later that day.” She reiterated this in her oral evidence.

You told the panel that as this particular patient was not yours, and you had been asked

to help. Therefore there was no onus on you to take this particular patient’s blood

sample.

The panel noted that your assertion was not put to Ms 4 during cross examination.

Therefore on balance, it found it more likely than not that you required prompting to take

a blood sample and preferred the evidence of Ms 4. Accordingly, the panel found this

charge proved.

6.9 required prompting to check patients’ care plans;

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Whilst the panel noted that you could not recall this incident, the panel found this charge

proved for similar reasons as set out in 6.8, when taking the oral and written evidence of

Ms 4 into consideration, which it preferred.

6.11 did not check a patient’s intravenous heparin chart for approximately three

hours;


Whilst the panel noted that you could not recall this incident, the panel found this charge

proved for similar reasons as set out in 6.8, when taking into consideration the oral and

written evidence of Ms 4, corroborated by the contemporaneous DRF form dated 21

August 2015 which stated “IV Heparin chart not checked for 3 ½ hours- I intervened”.

Charge 7


7.1 required prompting to order medication from the pharmacy;

7.2 required prompting to check the INR score and/or seek a medical review for a

patient on intravenous heparin;

3.2.1 failed to administer enoxaparin as prescribed on the tea time

medication round;

3.2.2 did not record on the medication chart that you had administered

warfarin;

3.2.3 required prompting to check whether warfarin needed to be

administered in light of an improved INR score;

3.2.5 did not include adequate detail of care in your nursing notes;

These charges are found proved.

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The panel noted that the evidence in support of all charges stemming from charge 7

was contained both within the written statement of Ms 5 and contemporaneous DRF

form dated 23 August 2015. In relation to charge 7.1 the panel did not find your

assertion, that it was the duty of the pharmacist on your previous ward to order

medication, to be material. The panel also noted that you had signed the DRF form for

all incidents recorded by Ms 5 which stated:

In relation to 7.1: “Patsy would have missed a medication order from pharmacy had I

not prompted her”. You told the panel that there was no requirement for you to do this,

you hadn’t been prompted to this and expected the pharmacist to come round to do this.

In relation to 7.2:”Patient prescribed warfarin based on INR of 1.8. However, INR from

this afternoon blood test came back as 2.1. I had to encourage Patsy to check with the

Dr that they were happy with the same prescription”. You told the panel that it happens

to everyone and you asserted to the panel that you did comply with the procedure.

In relation to 7.3.2.1:”Enoxparin dose missed at tea time”

In relation to 7.3.2.5:”I have had to write in nursing notes to add detail to Patsy’s entries”

The panel considered Ms 5’s evidence and contemporaneous supervisory records in

relation to 7.1, 2.7, 7.3.2.1, 7.3.2.5, the panel preferred her evidence in this regard. The

panel considered Ms 5’s written statement in relation to 7.3.2.2 and 7.3.2.3 as quoted in

the panel’s decision of charge 6.8. Accordingly the panel found these charges proved.


8.1 did not check the blood pressure of a patient on an isoket infusion;

8.6 could not provide adequate information about one of your patients during

handover;

8.7 required prompting to respond to a patient’s high early warning score;


The panel noted that the evidence in support of all charges stemming from charge 8

was contained both within the written statement of Ms 5 and contemporaneous SMR

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dated 27 August 2015. The panel also noted that you had signed the SMR for all

incidents recorded by Ms 5 which stated:

In relation to 8.1: “Isoket infusion not checked by Patsy during shift…;Although after

discussion Patsy informs me that she was asking nurse in charge to do this delegating

(sic) work”. Despite initially indicating to the panel you could not recall this incident, you

later told the panel you had delegated this work to the nurse in charge. In the absence

of any evidence to support this, the panel preferred Ms 5’s evidence.

In relation to charge 8.7, which you have denied, you told the panel that you would have

responded to the patient’s EWS score, as “you’ve always done this since starting

nursing”. The panel preferred Ms 5’s evidence as contained in the SMR.

The panel considered Ms 4’s written statement in relation to 8.6. The panel considered

and accepted Ms 5’s evidence. Accordingly the panel found these charges proved.

Charge 9


9.1 did not complete the electronic handover sheet as part of shift handover;

9.3 did not include enough detail about care delivered to patients in the nursing

records;

These charges are found proved. In relation to charge 9.1, the panel took into account Ms 5’s written statement in which

she stated: “I asked if the Registrant would like help in completing the e-handover but

she declined, and as noted in the improvement section my DRF form the e-handover

was not completed by the Registrant on this shift even though I offered to assist”.

In relation to charge 9.3, the panel took into account Ms 5’s written statement which she

stated: “In relation to the Registrant’s record keeping on this shift, due to time

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constraints I was required to document in one set of patient notes. I also had to add

information and detail to the notes already completed by the Registrant.”

She reiterated this in her oral evidence which was also corroborated by the

contemporaneous DRF form dated 31 August 2015, which you countersigned.



from Ms 5. It also noted that you had signed the DRF form. It therefore accepted Ms 5’s

evidence. Accordingly, the panel found these charges proved.

Charge 10 On 1 September 2015, you:

10.2 did not notice that senna needed to be administered to one patient on the

evening medication round, which was prescribed as regular medication;

This charge is found NOT proved.

The panel noted your contemporaneous record contained within the SMR which stated:

”Patient has loose stool on Senna. Senna not given.”

The panel therefore determined that by your own assertions, as well as those of Ms 4,

Senna needed not to be administered to this patient. As such, the panel determined that

this charge had not been made out by the NMC. Accordingly, the panel found this

charge not proved. The panel noted this was one of the few areas you had completed,

detailed and relevant feedback to supervisory comments and observations.


11.2 did not check the ward numbers recorded on the drug charts for patients;

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11.3 did not identify that the route for medication administration had not been

recorded for two medications on a drug chart;

11.4 prepared to administer 1.25mg bisoprolol to a patient when the prescription

was 2.5mg;

11.5 required prompting to conduct four hourly observations for one of your

patients;

11.6 did not check and/or did not record that you had checked the chest drain

before 12:00 as required for one of your patients;

11.7 did not complete an ECG for one of your patients by lunchtime, as required;

These charges are found proved. In reaching its decision, the panel considered the written statement of Ms 5, her oral

evidence and the SRM dated 4 September 2015.

In relation to charge 11.2, the panel noted that your refuted this allegation by stating that

you would do this as a matter of practice. The panel also noted that in relation to charge

11.3, you maintained, contrary to the evidence of Ms 5, that it was you who had

identified the route of medication administration and raised it with Ms 5 and that it had

not been recorded. In relation to charge 11.4, you told the panel that the prescription

was dark, despite Ms 5 stating that the prescription could be clearly read and was

perfectly legible. You denied 11.5 and told the panel that this was delegated to a

nursing assistant and that you did not consider this patient to be a critical patient. In

relation to charge 11.6, you told the panel that you accepted that no record had been

made, but you would have checked the chest drain. You could not recall charge 11.7.

The panel considered Ms 5’s statement which stated: “I noted in the Appendix 1

document that again the Registrant had failed to check the ward number on patients’

drug charts and that as a result of this three of the ward numbers were incorrect. In

addition to this, the Registrant also failed to notice that the route of two medication on

one of the charts had not been written and I had to bring this to her attention…

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The Registrant did remember to review the patient after he had returned from the Echo

to administer their Bisoprolol however, the Registrant went to administer 1.25mg when

the patient was prescribed 2.5mg of Bisoprolol. I spoke to the Registrant about this at

the time and she told me that the prescription was unclear, but she still proceeded to try

and administer the medication without asking a doctor to make the prescription

clearer… She did not comment directly on the incident in her Daily Feedbak form, other

than to state the prescription was unclear…

The Registrant also failed to undertake an ECG in respect of one of the patients on the

ward by lunchtime as required, and I had to bring this to the attention of the Registrant.”

The Registrant was also due to complete observations for a patient every 4 hours…

However, I had to keep reminding the Registrant to undertake these observations

throughout the day…

The Registrant was also responsible for checking a patient with a chest drain by 12:00

on this shift. However, I felt she had not checked the drain at 12:00, as I had been

shadowing her all morning and had not seen her go into the patient’s cubicle to check

the drain… If the Registrant had checked the drains, she should have documented it on

the fluid output chart, and this had not been done”.

The panel preferred Ms 5’s evidence in relation to the charges as set out in charge 11,

as contained within her statement above and reiterated in her oral evidence. The panel

determined that it had clear, contemporaneous documentation in relation to these

incidents and had no evidence to support your claims. Accordingly, the panel found

these charges proved.


12.1 did not sign to record that all medication had been administered on the

morning medication round;

12.3 did not complete your clinical duties without requiring assistance from your

supervisor;

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You could not recall these incidents.

Ms 4 provided oral evidence to the panel which reaffirmed her statement contained in

her contemporaneous record within the SMR dated 6 September 2015, which stated:

“x8 Patient documentation still outstanding… Patsy felt she would be able to quickly do

the medication but I felt that this was unrealistic. Patient care then undertaken by [Ms

4].” The panel accepted Ms 4’s evidence. Accordingly the panel found these charges

proved.

Charge 13

On 8 September 2015, you:

13.2 required prompting to adjust a patient’s isoket infusion when their systolic

reading was above 180;

13.4 required prompting to ensure that a patient’s pressure areas were checked;

13.5 did not check the groin site of your patient who was 6 days post operation;

13.7 did not record enough detail in the nursing notes for your patients;

13.8 included inaccurate information in the electronic handover document;


You told the panel that you could not recall the incidents relating to charges 13.2, 13.4,

13.5, & 13.8 and that you denied charge 13.7.

In reaching its decision, the panel considered the oral evidence of Ms 5 together with

her witness statement and SRM dated 8 September 2015.

Ms 5 in her statement, stated:

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“The patient who had received the Isoket infusion had a blood pressure reading above

180 systolic. The Registrant should have taken this reading into account and adjusted

the rate of infusion accordingly, however she left the Isoket infusion at the same rate…

She stated how she had to check a patient’s groin and that despite shadowing you, she

had not seen you complete this check. She documented lumps on the patient’s groin

and referred the matter to an F1 doctor. She then explained how she had to “add in

additional detail to [your] handover notes for every single patient on this shift” and had

to correct inaccurate information for 4 patients in the electronic handover document.

The panel accepted Ms 5’s evidence and noted that you had countersigned the

contemporaneous DRF form dated 8 September 2015 which corroborates Ms 5’s

statement. The panel noted your denial in respect of charge 13.7 but in the absence of

any further evidence regarding this, it preferred the evidence of Ms 5. Accordingly, the

panel found these charges proved.

Charge 14


14.2 required prompting to sign to confirm that you had administered

medication to a patient;

14.3 incorrectly calculated an intravenous fentanyl dose as 1.25 ml when the

dose should have been 0.25 ml;

14.4 did not prioritise administering medication to a patient who needed to

leave the ward at 09:00;

14.6 left the medication pod for the patient in bed 10 unlocked;

14.7 prepared to administer oral antibiotics for a patient when you had been

informed by the doctor that it should not be given;


You denied charges 14.2 and14.3. You told the panel, that in relation to 14.2, you were

still unfamiliar with the process of signing medication prior to it’s administration, which

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was different from your experience on other wards. In relation to 14.3, you said that you

wouldn’t have made an incorrect calculation, as you would have noticed the different

syringe sizes applicable to both sets of dosages. In relation to 14.4, you could not recall

the allegation.

You told the panel that you could not recall the incidents contained within charges 14.6

and 14.7.

In reaching its decision in relation to charges 14.2, 14.3 and 14.4, the panel considered

the oral evidence of Ms 4 together with her witness statement and SRM dated 10

September 2015.

Ms 4 in her statement, stated: “During this shift the Registrant forgot to sign for

medication for a patient until prompted. The Registrant also incorrectly worked out an

intravenous Fentanyl opioid pain medication) dose as 1.25ml (when it should have been

0.25ml). She did correct herself after given more time when pointed out that the dose

was incorrect. The Registrant failed to appropriately prioritise the administration of

morning medication to a patient who was due to have an investigation at 9:00

(information handed over at the start of the shift) and so ideally should have received

his morning medication before he left the Ward.” Ms 4 reiterated this in her oral

evidence, which was corroborated with her recordings in the SRM.

In relation to charges 14.6 and 14.7, the panel took into account the contemporaneous

record held in the SRM, in which Ms 4 stated: “1x POD (Bed 10) left unlocked ->

prompted to close once Patsy had moved onto the next side room…

Doctor was asked by Patsy to renew heparin for the same patient and whilst reviewing

this told her not to give the antibiotic. It was also clearly handed over to seek review of

the antibiotic before giving”

The panel noted that there was no evidence to corroborate your denial or non-

recollection of events, therefore, on balance, it considered that the allegations contained

within charges did occur and accordingly found these charges proved. The panel found

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it concerning that an experienced nurse such as yourself was unable to adapt to the

basic working practices on a different ward in respect of basic medicines administration.


15.1 took too long to complete the morning medication round;


The panel considered Ms 4’s evidence contained within the SRM dated 11 September

2015, in which she stated: “During feedback we discussed the lengthy morning drug

round. Patsy highlighted that we spent 30mins with a palliative care patient. I said that

the patient needed this time. Patsy felt that we should have done the drug round +

come back to her. I pointed out that her MST was due at 0800 and that’s why she was

seen 1st. I asked Patsy why she didn’t assert herself and say she was moving to the

next patient. She said because the patient needed the time which I agreed”.

You denied this allegation.

The panel was of the view that by Ms 4’s own admission, she agreed with your clinical

judgment and decision making. The panel therefore determined that the charge had not

been made out by the NMC. The panel therefore found this charge not proved.

15.2 incorrectly prepared to administer 100mg of gabapentin to a patient when

they were prescribed 200mg;

15.3 did not administer Ramipril as prescribed to a patient;

15.4 required prompting to identify that a patient’s prescribed dose of Bisoprolol

had been altered;

15.5 required prompting to obtain a prescription for Warfarin for a patient;

15.6 did not give furosemide to a patient until 21:00 when it was due at 16:30;


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You told the panel that you could not recall the incidents as set out in charges 15.2 –

15.6.

Ms 4, in her statement stated: “During this morning drug round the Registrant incorrectly

dispensed 100mg of Gabapentin (a medication used to treat epilepsy, neuropathic pain)

instead of the 200mg that was prescribed…

The Registrant, during the lunch time drug round, failed to administer a dose of

Ramipril (a medication used to treat high blood pressure) to a patient. The

Registrant also failed to notice that a dose of Bisoprolol (a medication used for

the management of heart rate) administered to a patient had been increased…

I was also required to prompt the Registrant to request Warfarin to be prescribed for

another patient when this was not actioned. These were subsequently actioned

following my prompt...

The panel accepted Ms 4’s evidence and was satisfied that the events contained within

charges 15.2 – 15.5 had occurred.

The panel considered the SRM dated 11 September 2015 in which Ms 4 recorded: “IV

furosemide stat written at 1630 STAT -> to prioritise IVS – given at 2100.” The panel

accepted this evidence and was satisfied, on balance, that this event had more likely

than not occurred.

Accordingly, the panel found charges 15.2 – 15.6 proved.

Charge 16


16. 2 required prompting to record that paracetamol had been administered to a

patient;

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16.3 required prompting to record that 20 mg Oramorph had been administered

to a patient;

16.4 did not complete nursing documentation until 18:00;


You told the panel that you could not recall the incidents as set out in these charges.

In relation to charge 16.2, the panel had sight of Ms 4’s recording in the SRM dated 15

September 2015, in which it stated “Prompted Patsy to sign paracetamol as

administered”.

In relation to charge 16.3, Ms 4, in her statement stated “During the lunch time round

with me, the Registrant administered Oramorph to a patient who had chest pain but

failed to sign that the medication had been administered on the patient's drug chart.

This was brought to her attention to correct once she had gone on to attend the next

patient's medication. I reminded the Registrant again that she needed to

document and sign for every medication that she dispensed to ensure the safety

of her patient as another health professional could dispense Oramorph (an opioid

analgesic) unwittingly, not realising that a dose had been previously

administered.”

In relation to charge 16.4, the panel had sight of Ms 4’s recording in the DRF form dated

15 September 2015, in which it stated “Documentation completed at 1800 for your early

shift, continue to work on time management skills”.

In light of the lack of evidence to suggest anything otherwise, the panel accepted the

entirety of Ms 4’s evidence and was satisfied, on balance, that it was more likely than

not that these incidents had occurred.

Accordingly, the panel found these charges proved.

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Whilst subject to supervision on an extended plan in accordance with formal stage 2 of

the Trust’s performance management policy

Charge 17 On 2 December 2015, you:

17.1 did not demonstrate adequate knowledge of the following medication:

17.1.1 amiodarone;

17.1.2 canderstan;

17.1.3 ivabradine;

17.1.4 metolazone;

17.1.5 nicorandil;

17.2 administered medication to a patient before checking their wrist band;

17.3 needed to be reminded to check the drug chart for other medication that

was due after administering intravenous medication;

17.4 when checking observations prior to administering medication to the

patient in bed 5, checked observations recorded for 1 December 2015

instead of 2 December 2015;

17.5 did not include an adequate assessment of clinical needs in your record

keeping;

17.6 when completing venepuncture, inappropriately retouched areas that you

had cleaned;


You told the panel that you denied charge 17.1.1, 17.1.2, 17.2 and 17.5. You said that

you could not recall the incidents relating to the remainder of the charges as set out

above.

In relation to charges 17.1.1, 17.1.2, the panel took into account your own entry on the

DRF form dated 2 December 2015, in which you stated “I need to familiarise (sic) with

the medication used on cardiac ward and improve in the use of the medication”. This

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was on the same page as Mr 6’s entry stating that he had asked you what Amiodarone

was, to which you incorrectly stated “failing ventricles”. Mr 6 also noted that you did not

know what Ivoabradine, Metolazone or Nicorandil were. The panel noted that by your

own admission you appeared to agree with Mr 6’s assertions that you did not know what

any of the medication listed, as per his entries on the same form, was for, despite

denying that you had told him this in your oral evidence. The panel noted that you

claimed previous experience of patients taking Amiodarone and Candestan,for which

you still had limited understanding.

In relation to charge 17.2, Mr 6’s entry in the DRF form dated 2 December 2015 stated

“medication given to one patient who then took them before his wrist band was

checked.” You denied this allegation by stating that it was your usual practice to always

check wristbands prior to medicine administration.

In relation to charges 17.3 – 17.5, the panel took into account the evidence contained

within the DRF form dated 21 September 2015, in which Mr 6 made the following

entries:

“Patsy needed to be reminded to check a patients drug chart after putting up IV

furosemide. Although no other medication were (sic) due…

Bed 5 – Checkd Obs from 1/12 no 2/12…

In relation to charge 17.5, an allegation which you denied, you stated that it was your

practice to always right up sufficient medical notes for patient which includes issues

such as observation and plans of care. The panel preferred the evidence of Mr 6 who

said “No evidence of a specific plan of care for individuals, no entries into carelog by

PP.”

In relation to charge 17.6, the panel took into account Mr 6’s statement in which he

stated: “In terms of the Registrant's professional accountability, she failed to

adhere Trust policy for venepuncture and cannulation when I had to physically tell

her to stop in the middle of taking blood as she was continually re-touching areas

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she had cleaned.”

In light of the lack of evidence in support of your contentions, the panel accepted the

entirety of Mr 6’s evidence and was satisfied, on balance, that it was more likely than

not that these incidents had occurred as he described.

Accordingly, the panel found these charges proved.


18.2 did not provide any or adequate detail when you recorded clinical care in

patients’ notes;


The panel noted that you denied this incident. The panel preferred Ms 7’s evidence in

relation to this incident, which was supported by her written statement, where she

stated: “In relation to the documentation completed by the Registrant on this shift, I

noted that she needed to give more detail in the notes on all care given to the patient,

rather than just writing ‘plan from doctor’ in the notes. The patient notes should set out

how the patient was clinically on each particular day, and detail all the care provided to

the patient so that there is always a record of the patient’s condition from a nurses point

of view.”

This is also corroborated by the contemporaneous DRF from dated 3 December 2015,

contained within exhibit 2, where Ms 7 stated, under the ‘Points for Improvement’

heading: “To give more detail on patients clinical condition and all care given, not just

‘plan from doctor’.”

In light of the lack of evidence in support of your denial, the panel accepted that it was

more likely than not that this incident had occurred.

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18.3 did not demonstrate an ability to prioritise patient care;


The panel heard oral evidence from Ms 7, who told the panel that you were unfamiliar

with the ward and “needed a helping hand”.

Ms Shafton, on your behalf, invited the panel to find this charge not made out by the

NMC.

The panel accepted Ms Shafton’s submission and determined that Ms 7’s evidence had

effectively undermined this charge. The panel found this charge not proved.

Charge 19

On 7 December 2015, you:

19.1 did not check medication in the British National Formulary on your

medication round for medication that you did not understand;


The panel considered Ms 7’s statement in which she stated: “On the morning round, I

noted that although the Registrant took the British National Formulary (“BNF”) book on

the trolley with her on the round, she did not pick it up to look at any medications and

she did not question any medications with me. I would expect the Registrant to use the

BNF if she was giving a drug that she wasn’t familiar with, or that she didn’t know the

side effects of.”

You denied this allegation.

The panel determined that the documentary evidence provided for this charge by the

NMC was unsatisfactory. Whilst the panel accepted that you didn’t check the BNF, there

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was no evidence within Ms 7’s statement to suggest that this was a requirement, until

you were unsure about the drugs in question. No such evidence was adduced and

therefore the panel determined that the NMC had not discharged their evidential burden

in this case and therefore found this charge not proved.

19.2 required assistance to calculate an intravenous furosemide dose;

This charge is found NOT proved. Ms 7, in her oral evidence told the panel that she “wouldn’t be surprised if the method of

administering and preparing an intravenous furosemide dose differed from ward to

ward.”

You denied that you had calculated the dose incorrectly and told the panel that you had

normally administered this using a bag rather than a syringe.

On balance, the panel found this charge not made out.

19.3 did not ensure that comfort rounding was completed as required for

patients in bay 22-25.

This charge is found proved. You could not recall this incident.

The panel considered the evidence of Ms 7, as contained within the DRF form dated 7

December 2015, in which she had entered, under ‘Points for Improvement’: “PP wrote

notes in wrong patients’ notes on 2 occasions – one in bay 1-4, one in 22-2, CW noticed

the one in 22-25”.

In light of this contemporaneous evidence, the panel accepted that it was more likely

than not that this incident had occurred. The panel therefore found this charge proved.

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19.4 did not attend to patients regularly enough to ensure that their needs were

met;


You denied this allegation. You told the panel that you had completed a “medical

picture” of the patient and had decided what to give and delegate to the Nursing

Assistant on hand.

The panel considered the evidence of Ms 7, as contained within the DRF form dated 7

December 2015, in which she had entered, under ‘Points for Improvement’: “CW did not

see PP oversee patients in both bay with washes/hygiene needs. Bank HCA went to

help nurses in bay 14-21 but didn’t tell PP and I didn’t observe PP attending to bay

regularly.”

In light of this contemporaneous evidence, the panel preferred Ms 7’s evidence and

determined that it was more likely than not that this incident had occurred. The panel

therefore found this charge proved.


20.1 failed to observe patients in beds 15 and/or 18 when taking medication;

20.2 did not record the reason why one patient could not have their medication

administered;

20.3 inaccurately recorded that the patient in bed 15 needed an internal cardio

defibrillator when this was already in place;

20.5 did not demonstrate an ability to prioritise care;

20.6 did not demonstrate an understanding of your patients’ needs;

20.7 did not ask patients about their pain management;

20.8 did not check a patient’s normal bowel habits with his relatives, which had

been requested following shift handover;

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These charges are found proved. You denied charges 20.1, 20.5, 20.6 and 20.7. You could not recall charges 20.2, 20.3,

20.8.

The panel took into account Ms 7’s statement: “I can see from [Ms 9’s] feedback form

that the Registrant did not check patient’s allergies and failed to observe the patients in

Bed 15 and 18 taking their drugs…

[Ms 9] also noted that the Registrant needed to be more aware of the classification of

drugs that she was giving as prescribed (or not). [Ms 9] also said that the Registrant

needed to add reasons into the records for why she had not given drugs to a patient (as

the patient was unavailable), and said that overall the Registrant needed to interact

more with her patients. The feedback form completed by [Ms 9] has been signed by the

Registrant to state that she agreed with the contents… I also noted that the Registrant

did appear to have any awareness of how to prioritise care and how to fully understand

her patient’s needs to enable her to care for them to the best of her ability on this shift…

I recall that the Registrant can said ‘as you can see on the handover’ rather than

explaining the two patients’ admission diagnosis (and the pain these patients had been

experiencing) to the nurse taking over which, in my view (showed her lack of knowledge

about her patients and their medical conditions. She also didn’t follow up on the pain

that these patients had been experiencing overnight with them during her shift). I would

have expected her to ask the patients about their pain throughout the day to ensure that

their pain was correctly managed. I recorded each of these points as areas for

improvement in her daily reflective feedback form.”

In light of this contemporaneous evidence, the panel preferred Ms 7’s evidence and

determined that it was more likely than not that these incidents had occurred. The panel

noted that in the observational feedback sheets, you had signed the notes of Ms 9, so

the panel gave this document sufficient weight to consider that on balance the facts

found were proved.

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21.1 did not complete the medication round in an adequate period of time;

21.2 did not know whether you had administered rivaroxaban to a patient, when

they asked about its administration;

21.3 did not demonstrate an ability to manage patients’ nursing needs;

21.4 provided inaccurate information about a patient at shift handover;

21.5 did not record enough information about a patient’s shortness of breath in

their nursing notes;

Charge 21.2 is found NOT proved The remaining charges are found proved. You denied charges 21.2, 21.3 and 21.5. You could not recall charges 21.1, 21.4.

In relation to 21.2, the panel noted that the charge as written was unclear and as a

result, determined that this was not proved.

In relation to 21.1, Mr 6, in the DRF form dated 10 December 2015, stated: “Took a long

time. Joseph had to do 4 patients medication. You asked the patient if they had had

their blood thinner. Did not initially know that she was on Rivaroxaban.”

In relation to 21.3, Mr 6, in his statement stated: “There was a clear indication that the

Registrant did not know what was happening with her patients. She was aware that the

patient needed to be reviewed but did not know why or what they were being reviewed

for.” You told the panel that you denied this charge as whilst not giving specific evidence

to this patient, you reiterated that this was her usual practice.

In relation to 21.4, he went on to say “The Registrant, when handing over a patient with

chest pain to night shift nurse Jolly George, the Registrant stated the doctor had

reviewed the patient’s blood results and that an electrocardiogram needed to be

undertaken. It was in fact the other way round.”

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In relation to 21.5, he said “The Registrant however failed to note further documentation

or observations as to whether the patient was still short of breath. The Registrant would

be expected to undertake these observations as part of the care provide to patients as it

allows the team to understand whether the care plan is working and whether it needed

to be varied according to the patient’s needs.” You told the panel that you believed that

you had made sufficient entries in the patient notes relative to the patient’s condition,

however the panel noted from the notes exhibited that Mr 6 had been required to insert

additional supplementary information into the notes, in addition to the notes written by

you.

In light of the evidence of Mr 6, and the contemporaneous records made, the panel

preferred Mr 6’s evidence and determined that it was more likely than not that these

incidents had occurred, albeit for 21.2.

Charge 22


22.1 incorrectly calculated a dose of Oramorph for the patient in bed 19;

22.2 did not demonstrate an adequate level of drug knowledge;


You denied charges 22.1 and could not recall charge 22.2.

Ms 7 in her statement, in relation to charge 22.1, stated: “I still felt that the Registrant’s

drug knowledge could be improved, as she nearly dispensed a dose of Oramorph to a

patient incorrectly due to her incorrect calculation.” In your evidence to the panel, you

denied that you had got the dose wrong and said that Ms 7 was wrong in her evidence.

In the DRF form dated 11 December 2015, Ms 7 states, in relation to charge 22.2: “Drug

knowledge still to improve”.

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In light of Ms 7’s evidence and and contemporaneous records, the panel preferred Ms

7’s evidence and determined that it was more likely than not that these incidents had

occurred.

Charge 23

On 15 December 2015:

23.2 did not demonstrate ability to manage full case load of patients on the

shift;

23.3 your record in a patients nursing notes included incorrect information that

a patient suffered from an abnormal heart rhythm;

23.4 you did not ensure that a patient’s blood pressure was monitored

throughout the shift;


You denied charges 23.2 and 23.4 and could not recall charge 23.3.

In relation to 23.2 and 23.4, Mr 6, in his statement, stated: “The Registrant failed to

regularly check the patients were drinking and eating properly and only ever seemed to

focus on administering medication, preparing patients for procedures, and taking blood

if necessary. The Registrant did not necessarily have to take the observations herself,

but she had to make sure they were either taken or delegated accordingly. I was

required to step in to get another member of staff to take the observations due to the

Registrant forgetting to get someone to take the observations”. You asserted in your

evidence that you were able to manage your case load but provided little detail in

support of this.

In relation to 23.3, Mr 6, in his statement stated: “She had copied from the notes that the

patient was suffering from an abnormal heart rhythm. This was actually an old condition

which had been treated and was not longer an issue for the patient. The way in which

the Registrant produced the nursing note, it read as if this was still an issue for the

patient and would have led to confusion when caring for the patient.”

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The panel preferred Mr 6’s evidence and determined that it was more likely than not that

these incidents had occurred.

Charge 24


24.1 prepared 10mg of nicorandil for administration to a patient, when they

were prescribed 5mg of ramipril;

24.2 required prompting to ensure that a patient’s blood pressure was taken;

24.3 did not ensure that a patient’s pressure areas were checked until 16:00;


You denied charges 24.1 and could not recall charges 24.2 or 24.3.

In relation to 24.1 Mr 6, in his statement, stated: “On this day, the Registrant went to

administer 10mg of Nicorandil to the patient. The patient was on the verge of putting it

to his mouth and I stopped him.” In your evidence to the panel, you simply denied this

charge, saying that Mr 6’s evidence was wrong and that it “probably never happened”.

In relation to 24.1 Mr 6, in his statement, stated: “One of the patients who had required

4 hourly observations had to physically remind the Registrant that he was due to have

his blood pressure taken.”

In relation to 24.3 Mr 6, in his statement, stated: “the Registrant failed to check the

pressure areas, or delegate the task to another member of staff of another patient who

was bed bound…”

The evidence in relation to the charges above is corroborated on the DRF form dated

16 December 2015 and signed by you. The panel preferred Mr 6’s evidence and

determined that it was more likely than not that these incidents had occurred.

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25.1 did not check patients’ observation charts before administering

medication;

25.2 started the lunch time medication round late;

25.3 incorrectly prepared 40mgs furosemide for the patient in bed 20 when the

patient was prescribed with 80mgs furosemide;

25.5 after being asked to take a blood sample from the patient in bed 2 at

11:00, did not do this until at or around 13:00;

25.7 in relation to record keeping,

25.7.2 did not include enough detail in your records of patient care;

These charges are found proved. You denied charges 25.1, 25.3 and could not recall charges 25.2, 25.5 or 25.7.2.

In relation to 25.1 and 25.2, Ms 7, in her statement, stated: “I noted that she did not

check the patient observation charts prior to giving medication on the morning drug

round… The Registrant also started the lunchtime drug round late as she was sorting

out a patient’s discharge to the discharge lounge… “. You denied this allegation and told

the panel that this was your regular practice and something you would do as a matter of

course.

In relation to 25.3, she stated: “The Registrant, however only prepared 40mgs to be

given to the patient and I had to correct her and tell her that she needed to dispense

80gs to the patient.” You told the panel that you would not be mistaken with regards to

this dose and pointed out that the furosemide was in table form and simply did not

accept the account of Ms 7.

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In relation to 25.5, she stated: “She was also asked by a doctor at around 11:00 to take

bloods from a patient in bed two; however I noted that she not complete this task until

around 13:00”

In relation to 25.7.2, she stated “Upon review of the paperwork she had completed, I

noted that there was not enough detail within the notes, for example there was no

mention of patient hygiene needs and a lack of detail regarding the clinical condition of

her patients.”

In light of Ms 7’s written statement and contemporaneous records, the panel accepted

Ms 7’s evidence and determined that it was more likely than not that these incidents had

occurred.

Charge 26 On 4 January 2016, you:

26.1 did not demonstrate an understanding of the purpose of cardiac

medication;

26.2 required assistance in planning the care for a patient who did not want to

take his 08:00 medication until immodium had been prescribed;

26.3 did not complete the 08:00 medication round in an appropriate length of

time;

26.7 did not include adequate detail about care delivered to patients in the

notes;

26.8 did not prepare a wound care plan for the patient in Bed 24, as required.

These charges are found proved

You denied charge 26.7 and could not recall the remaining charges.

In relation to 26.1, Ms 7, in her statement, stated: “The Registrant tried to demonstrate

knowledge of medications but was still struggling to remember the purpose of some

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cardiac medications when asked during the morning round. I noted in the Registrant’s

daily reflective feedback form that she still needed to improve her cardiac drug

knowledge….”

In relation to 26.2 and 26.3, she stated: “I have noted in the medicine round feedback

form that the patient in Bed on stated that he did want to take any of his 08:00

medication until he had taken Imodium. He was then asked for a second time and again

said he did not want to take his medication however the Registrant started to dispense

tablets and was unsure whether to give the patient his diabetic medication… The

Registrant did then action this, and also escalated the patient to Staff Nurse on duty

later that day asking for his medications to be reviewed… I made it clear to the

Registrant that I appreciated it could be hard carrying out a drug round under

supervision but that there were a number of diabetic patient on the Ward, so she

needed to make sure their medications were given on time”.

In relation to 26.7, she stated: “She also did not include enough detail in relation to her

assessment of each patient and their cardiac monitor rhythms.” You told the panel that

in your opinion, you had given enough detail, however provided no supporting evidence

in this regard.

In relation to 26.8, she stated: “I also suggested to the Registrant that wound care plan

should have been in place for the patient in Bed 24… But that this had not been done

by the end of her shift”.

In light of Ms 7’s evidence and contemporaneous records of supervision, the panel

preferred Ms 7’s evidence and determined that it was more likely than not that these

incidents had occurred.

26.12 did not demonstrate an awareness of the classification of drugs being

administered;

This charge is found NOT proved

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The panel determined that there was no evidence within Ms 7’s statement or within any

contemporaneous record which could lead the panel to determine that you did not

demonstrate an awareness of the classification of drugs being administered. The panel

determined that the NMC had not discharged their evidential burden in this case and

therefore found this charge not proved.

Decision on lack of competence:

When determining whether the facts found proved amount to a lack of competence the

panel had regard to the terms of the 2015 Code.

The panel, in reaching its decision, has had regard to the public interest and accepts

that there is no burden or standard of proof at this stage and exercised its own

professional judgement.

The panel was of the view that your actions did fall significantly short of the standards

expected of a reasonably competent registered nurse, and that your actions did amount

to a breach of the 2015 Code, which are the standards by which every registered nurse

is measured, specifically:

1.2 make sure you deliver the fundamentals of care effectively 1.4 make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay, 2.1 work in partnership with people to make sure you deliver care effectively Practise effectively You assess need and deliver or advise on treatment, or give help (including preventative or rehabilitative care) without too much delay and to the best of your abilities, on the basis of the best evidence available and best practice. You communicate effectively, keeping clear and accurate records and sharing skills,

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knowledge and experience where appropriate. You reflect and act on any feedback you receive to improve your practice.

6 Always practise in line with the best available evidence To achieve this, you must: 6.2 maintain the knowledge and skills you need for safe and effective practice. 9.2 gather and reflect on feedback from a variety of sources, using it to improve your practice and performance 10.1 complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event 10.2 identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need 10.4 attribute any entries you make in any paper or electronic records to yourself, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation

11.2 make sure that everyone you delegate tasks to is adequately supervised and supported so they can provide safe and compassionate care, and 11.3 confirm that the outcome of any task you have delegated to someone else meets the required standard.

18.1 prescribe, advise on, or provide medicines or treatment, including repeat prescriptions (only if you are suitably qualified) if you have enough knowledge of that person’s health and are satisfied that the medicines or treatment serve that person’s health needs

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18.2 keep to appropriate guidelines when giving advice on using controlled drugs and recording the prescribing, supply, dispensing or administration of controlled drugs 18.3 make sure that the care or treatment you advise on, prescribe, supply, dispense or administer for each person is compatible with any other care or treatment they are receiving, including (where possible) over-the-counter medicines 18.4 take all steps to keep medicines stored securely, and

19.1 take measures to reduce as far as possible, the likelihood of mistakes, near misses, harm and the effect of harm if it takes place

The panel bore in mind, when reaching its decision, that you should be judged by the

standards of a reasonably competent Band 5 registered nurse, applicable to the post to

which you had been appointed. The panel considered that its finding of facts showed a

sustained pattern which demonstrated a lack of competence in the areas of patient

assessment, medication administration, accountability and record keeping over a six

month period.

The panel determined that collectively the charges found proved demonstrated a lack of

competence. Your clinical failings were extensive and varied in nature. The numerous

failures in your clinical practice related to basic and fundamental aspects of nursing

care. Further, your failings were of a serious nature which placed patients at risk of

serious harm. In the panel’s judgement, you were given intensive support over a

prolonged period of time, by your supervisors, ward manager and mentor.

The panel noted that you were given specific support to address your clinical

shortcomings in medication administration, accountability and record keeping. There

was no sustained or significant improvement to your practice and you continued to

make fundamental errors despite the on-going measures and support put in place to

improve your performance. In the light of this, the panel concluded that your practice fell

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significantly below the standard expected of a reasonably competent registered nurse.

In all the circumstances, the panel determined that your performance, in respect of the

charges found proved, demonstrated a lack of competence.

Decision on impairment: The panel next went on to decide if as a result of your lack of competence, your fitness

to practise is currently impaired.

The panel was mindful of the need to consider not only whether you continue to present

a risk to members of the public, but also whether the need to uphold proper professional

standards and public confidence in the profession would be undermined if a finding of

impairment were not made in the particular circumstances of this case.

The panel had regard to the guidance given in the judgment of Mrs Justice Cox in the

case of Grant. At paragraph 76 of that judgment, she said:

Do our findings of fact in respect of the doctor’s misconduct,

deficient professional performance, adverse health, conviction,

caution or determination show that his/her fitness to practise is

impaired in the sense that s/he:

a. has in the past acted and/or is liable in the future to act so as to

put a patient or patients at unwarranted risk of harm; and/or

b. has in the past brought and/or is liable in the future to bring the

medical profession into disrepute; and/or

c. has in the past breached and/or is liable in the future to breach

one of the fundamental tenets of the medical profession; and/or

d. […]”

In light of its findings of fact, the panel determined that your actions had engaged the

first three limbs of the guidance in Grant. The panel concluded that you have in the past

acted so as to put patients at unwarranted risk of harm. Furthermore, that your clinical

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failings related to basic and fundamental tenets of nursing practice and demonstrated a

concerning pattern of lack of competence, liable in the future to bring the nursing

profession into disrepute.

The panel was mindful that the issue it had to determine was that of current impairment

as of today. It therefore had to consider whether you are liable in future to act in such a

way as to put patients at unwarranted risk of harm, breach fundamental tenets or bring

the profession into disrepute. The decision about the risk of repetition in this case would

be informed by consideration of the level of insight you have demonstrated and by

whether your lack of competence is capable of being remedied and, if so, whether it has

been remedied.

The panel noted that at the time of the incidents, you had issues surrounding your

health, however the panel was not satisfied that this contributed to your clinical failings,

nor had it been presented with clear independent medical evidence to link your health to

your lack of competence.

The panel considered your insight into your clinical shortcomings and concluded that it

had very little evidence of insight apart from your partial admissions to the charges.

Even in your contemporaneous reflective feedback forms, when your shortcomings

were highlighted, you simply expressed a resolve to do better rather than any

meaningful understanding of the implications of your failings. When shortcomings were

discussed at the time of the incidents, you at times sought to blame others rather than

accept the deficiencies in your own practice. During your oral evidence you continued to

blame others for your clinical shortcomings, rather than take responsibility for them.

With regard to remediation, the panel formed the view that clinical failings relating to a

lack of competence are remediable. The panel considered the testimonials submitted on

your behalf which spoke to your good, compassionate nature and professionalism,

however it noted that none of these directly addressed the issues related to your clinical

failings. The panel therefore determined that it had not been presented with any real

evidence of remediation, noting that you have not practised as a nurse since 2016. The

panel also considered that despite the intensive and significant support provided to you

at the Trust, you were unable to remediate your clinical shortcomings. The panel

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concluded that your lack of competence has not been remedied and, consequently,

there is a real risk of repetition. Therefore, the panel concluded that a finding of

impairment on the grounds of public protection is necessary.

The panel also heard from both counsel, who addressed the panel in respect of a

breach of your interim order, which required you to work in a health care setting under

indirect supervision. The panel was informed by Ms Shafton, on your behalf, that this

had occurred on three occasions and that this matter had now been referred to the

NMC as a new referral. Whilst it noted that you had, had resigned your position from the

post at the healthcare setting, the panel was concerned that in continuing to work in

breach of your interim order on the 2nd and 3rd occasions, you had continued to

demonstrate a lack of insight into your failings.

The panel bore in mind the overarching objective of the NMC: to protect, promote and

maintain the health safety and well-being of the public and patients and the wider public

interest which includes promoting and maintaining public confidence in the nursing and

midwifery professions and upholding the proper professional standards for members of

those professions. In the judgement of the panel, irrespective of the risk of repetition,

public confidence in the profession and the regulator would be undermined if a finding of

impairment was not made in the particular circumstances of your case.

Having regard to all of the above, the panel was satisfied that your fitness to practise is

currently impaired by reason of your lack of competence.

Determination on sanction:

The panel decided to make a suspension order for a period of 12 months. The effect of

this order is that the NMC register will show that your registration has been suspended.

In reaching this decision, the panel has had regard to all the evidence that has been

adduced in this case, together with the submissions of Mr Cholerton on behalf of the

NMC and Ms Shafton, on your behalf.


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The panel has borne in mind that any sanction imposed must be appropriate and

proportionate and, although not intended to be punitive in its effect, may have such

consequences. The panel had careful regard to the new Sanctions Guidance (“SG”)

published by the NMC. It recognised that the decision on sanction is a matter for the

panel, exercising its own independent judgement.

The panel first considered the aggravating and mitigating factors in this case.

The panel identified the following as aggravating factors in this case:

• Your lack of competence related to numerous, wide-ranging failings over a

prolonged period of time whilst under direct supervision;

• Your actions, in relation to clinical errors, placed patients at unwarranted risk of

harm;

• You did not remediate, in a sustained manner, the deficiencies in your practice

despite additional support during the practice programme;

• Your lack of meaningful cooperation with the supervisory and capability

procedures put in place to improve your practice;

• Your continued lack of insight.

The panel identified the following as mitigating factors in this case:

• You have been a registered nurse for a substantial period of time, with no

previous referrals to your regulator;

• [PRIVATE]

• There are positive testimonials and references in support of your good character

and practice;

• There is some evidence of adequate practice whilst at Woodlands Care Home;

• You made partial admissions to the charges and have engaged with these

proceedings.

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The panel then turned to the question of which sanction, if any, to impose. It considered

each available sanction in turn, starting with the least restrictive sanction and moving

upwards.

The panel first considered whether to take no action. The panel bore in mind that it had

identified at the impairment stage that these were substantial failings and that there

remained a risk of repetition in this case. Any repetition would bring with it a risk of harm

to patients. To take no action would therefore not provide protection to the public. In

addition, the panel considered that to take no further action would be inadequate to

mark the seriousness of the lack of competence in this case. It would not be in the

public interest in declaring and upholding standards and maintaining public confidence

in the profession.

Next, in considering whether a caution order would be appropriate in the circumstances,

the panel took into account the SG, which states that a caution order may be

appropriate where ‘the case is at the lower end of the spectrum of impaired fitness to

practise and the panel wishes to mark that the behaviour was unacceptable and must

not happen again.’ The panel considered that your lack of competence was not at the

lower end of the spectrum and that a caution order would be inappropriate in view of the

wide-ranging clinical shortcomings identified. A caution order would offer no protection

to the public and the panel decided that it would be neither proportionate nor in the

public interest to impose a caution order given its findings at the impairment stage.

The panel next considered whether placing conditions of practice on your registration

would be a sufficient and appropriate sanction. The panel was mindful that any

conditions imposed must be proportionate, measurable and workable. The panel took

into account the Sanctions Guidance regarding when conditions of practice may be

appropriate, in particular:

• no evidence of harmful deep-seated personality or attitudinal problems;

• identifiable areas of the nurse or midwife’s practice in need of assessment and/or

retraining;

• no evidence of general incompetence;

• potential willingness to respond positively to retraining;

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• the nurse or midwife has insight into any health problems and is prepared to

agree to abide by conditions on medical condition, treatment and supervision;

• patients will not be put in danger either directly or indirectly as a result of

conditional registration;

• the conditions will protect patients during the period they are in force;

• it is possible to formulate conditions and to make provision as to how conditions

will be monitored.

The panel acknowledged that your lack of competence was capable of remediation and

that there were identifiable areas of your practice which required assessment or

retraining. However, the panel noted that over a six month period you had been subject

to intensive support and supervision to address your shortcomings, but you failed to

improve your practice. In the panel’s judgement, this was indicative of a general lack of

competence. Given your continued lack of insight, the panel was not satisfied that you

would be willing or able to comply with this order. On the contrary, the panel has heard

that you have, in addition, breached your interim conditions of practice order, and that

there is an open referral with the NMC in respect of this. [PRIVATE]. Accordingly and

additionally, the panel did not feel that a conditions of practice order would be in your

own interests.

In these circumstances, the panel concluded that placing conditions on your registration

would not adequately protect the public, satisfy the public interest or address the

seriousness of the facts found proved.

The panel then went on to consider whether a suspension order would be an

appropriate and proportionate sanction. The panel considered that your lack of

competence related to numerous failings, which were repeated over a prolonged period

of time, and were wide-ranging and fundamental in nature. The panel found that at the

time of the incidents, you lacked insight into your clinical shortcomings and that there

was insufficient evidence of remediation. The panel has found that you continue to lack

insight into your failings and in the panel’s view, this highlighted deep seated attitudinal

issues. Therefore there is a risk of repetition and the consequent risk of harm to patients

if you were allowed to continue to practice even under restrictions. The panel concluded

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that the seriousness of your lack of competence requires your temporary removal from

the register and that such an outcome would adequately protect the public and address

the public interest considerations of this case.

The panel therefore decided to impose a suspension order. It was satisfied that this

would protect the public while in force and would mark the seriousness of your lack of

competence. The panel considered that this order is necessary to mark the importance

of maintaining public confidence in the profession, and to send to the public and the

profession a clear message about the standard of practice required of a registered

nurse.

The panel considered that you would need to show a significant improvement regarding

your level of insight and remediation in order to demonstrate that you are no longer

impaired. The panel therefore decided to impose a suspension order for a period of 12

months. The panel concluded that an order of this length was necessary to mark the

seriousness of this case and to afford you a further opportunity to reflect on the

incidents, demonstrate insight into the failings regarding your practice and their potential

impact on patients, colleagues and the profession, and begin to remediate your

practice.

The panel directs a review of this suspension order prior to its expiry. This is a case

which raises both public protection and public interest concerns therefore it would not

be appropriate or in the public interest to allow this order to lapse on the expiry without

any assessment of your current fitness to practice.

At the end of the period of suspension, another panel will review the order. At the review

hearing the panel may revoke the order, or it may confirm the order, or it may replace

the order with another order.

The panel was of the view that a future reviewing panel may be assisted by:

• Your attendance at the review hearing

• A detailed reflective piece with regards to insight

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• Evidence of up to date and relevant training in the areas identified

• Up to date and relevant testimonials

• Evidence that you have kept your clinical practice up to date

The panel noted that the sanction of a strike off was not available at this stage.

Determination on Interim Order: Mr Cholerton, on behalf of the NMC, submitted that an interim suspension order should

be imposed on the basis of protection of the public and otherwise in the public interest.

He submitted that the interim suspension order, which would take immediate effect,

should be for a period of 18 months to cover the possibility of an appeal being lodged by

you in the 28 day appeal period.

Ms Shafton, on your behalf, did not oppose this application.

The panel heard and accepted the advice of the legal assessor.

The panel had regard to the circumstances of the case and the reasons set out in its

decision for imposing a suspension order.

The panel decided to make an interim suspension order for a period of 18 months. The

reasons for the interim suspension order are as follows:

The panel had particular regard to its earlier finding that there remained a risk of

repetition of the significant and numerous failings identified in your clinical practice. It

also bore in mind the seriousness of the matters which it has found proved and

concluded that in light of its earlier decisions on impairment and sanction, that an

interim order was necessary for the protection of the public and otherwise in the public

interest in order to uphold professional standards and maintain public confidence in the

profession. For the reasons already set out in detail in the decision on sanction, the

panel considered that workable interim conditions of practice could not be formulated to

address the concerns in this case and protect the public pending any appeal. The panel

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therefore concluded that it is necessary for your registration to be subject to an interim

suspension order on the grounds of public protection and in the public interest. To do

otherwise would be inconsistent with its earlier findings.

The period of this order is for 18 months to allow for the possibility of an appeal to be

made and determined.

If no appeal is made, then the interim order will be replaced by a 12 month suspension

order 28 days after you are sent the decision of this hearing in writing.

That concludes this determination.

nursing and midwifery council fitness to practise ......2017/11/07 · fitness to practise...

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