Nursing and Midwifery Council: Fitness to Practise Committee Substantive Hearing 12 December 2018

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1 Nursing and Midwifery Council Fitness to Practise Committee Substantive Hearing 12 December 2018 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of registrant: NMC PIN: Part(s) of the register: Area of registered address: Type of case: Panel members: Legal Assessor: Panel Secretary: Registrant: Nursing and Midwifery Council: Anisoara Lazar 15D0551C Registered Adult Nurse Sub part 1 (28 April 2015) Wales Lack of knowledge of English David Boden (Chair, lay member) Janet Leonard (Registrant member) Alice Clarke (Registrant member) Jane Rowley Kathleen Picketts Not present and not represented in absence Represented by Kim Elcoate May, Case Presenter Consensual Panel Determination: Facts proved: Fitness to practise: Sanction: Interim order: Accepted All Impaired Conditions of practice order (18 months) Interim conditions of practice order (18 months) Page 1 of 23

2 Decision on service of Notice of Hearing The panel was informed at the start of this hearing that Ms Lazar was not in attendance and that written notice of this hearing had been sent to Ms Lazar s address by recorded delivery and by first class post on 31 October Furthermore, the panel noted that notice of this hearing had also been sent to Ms Lazar s Royal College of Nursing (RCN) representative on 31 October The panel took into account that the notice letter provided details of the allegation. The panel further noted correspondence, dated 3 December 2018, between the Nursing and Midwifery Council (NMC) and Ms Lazar s RCN representative which stated the time, date and venue of the Consensual Panel Determination (CPD) hearing and, amongst other things, information about Ms Lazar s right to attend, be represented and call evidence, as well as the panel s power to proceed in her absence. Ms Elcoate May submitted that the NMC had complied with the requirements of Rules 11 and 34 of the Nursing and Midwifery Council (Fitness to Practise) Rules 2004, as amended ( the Rules ). The panel accepted the advice of the legal assessor. In the light of all of the information available, the panel was satisfied that Ms Lazar has been served with notice of this hearing in accordance with the requirements of Rules 11 and 34. It noted that the rules do not require delivery and that it is the responsibility of any registrant to maintain an effective and up-to-date registered address. Decision on proceeding in the absence of the Registrant The panel next considered whether it should proceed in the absence of Ms Lazar. The panel had regard to Rule 21 (2) which states: Page 2 of 23

3 (2) Where the registrant fails to attend and is not represented at the hearing, the Committee (a) (b) (c) shall require the presenter to adduce evidence that all reasonable efforts have been made, in accordance with these Rules, to serve the notice of hearing on the registrant; may, where the Committee is satisfied that the notice of hearing has been duly served, direct that the allegation should be heard and decided notwithstanding the absence of the registrant; or may adjourn the hearing and issue directions. Ms Elcoate May invited the panel to continue in the absence of Ms Lazar on the basis that she had voluntarily absented herself. The panel was informed of the CPD Agreement which stated: Ms Lazar is aware of the CPD hearing. Ms Lazar does not intend to attend the hearing and is content for it to proceed in her and her representative s absence. Ms Lazar and her representative will endeavour to be available by telephone should any clarification on any point be required. Furthermore, the panel had sight of an dated 12 December 2018 from the RCN which stated: I can confirm that Ms Lazar is aware that the CPD hearing is due to take place today and is content for the matter to proceed in her absence. The panel accepted the advice of the legal assessor. The panel noted that its discretionary power to proceed in the absence of a registrant under the provisions of Rule 21 is not absolute and is one that should be exercised with the utmost care and caution as referred to in the case of R. v Jones (Anthony William), (No.2) [2002] UKHL 5. The panel further noted the case of R (on the application of Page 3 of 23

4 Raheem) v Nursing and Midwifery Council [2010] EWHC 2549 (Admin) and the ruling of Mr Justice Holman that:...reference by committees or tribunals such as this, or indeed judges, to exercising the discretion to proceed in the person's absence "with the utmost caution" is much more than mere lip service to a phrase used by Lord Bingham of Cornhill. If it is the law that in this sort of situation a committee or tribunal should exercise its discretion "with the utmost care and caution", it is extremely important that the committee or tribunal in question demonstrates by its language (even though, of course, it need not use those precise words) that it appreciates that the discretion which it is exercising is one that requires to be exercised with that degree of care and caution. The panel has decided to proceed in the absence of Ms Lazar. In reaching this decision, the panel has considered the submissions of the case presenter, and the advice of the legal assessor. It has had particular regard to the factors set out in the decision of Jones. It has had regard to the overall interests of justice and fairness to all parties. It noted that: no application for an adjournment has been made by Ms Lazar; Ms Lazar has expressly agreed for this hearing to proceed in her absence; there is a strong public interest in the expeditious disposal of the case. The panel was of the view that it would be in the NMC s interests and in the public interest to proceed and dispose of this matter expeditiously. For all the reasons referred to above, the panel decided to proceed in the absence of Ms Lazar. Page 4 of 23

5 Consensual Panel Determination The panel considered the agreement for a CPD that had been reached with regard to this case between Ms Lazar and the NMC. The agreement, which was put before the panel, sets out Ms Lazar s admission of the charge, and her acceptance that her fitness to practise is currently impaired by reason of her lack of knowledge of English. It is further proposed in the Agreement that the appropriate and proportionate sanction in this case would be a conditions of practice order for a period of 18 months. The agreement was signed by Ms Lazar s RCN representative on her behalf on 11 December The panel was referred to the agreement reached by the parties. That agreement reads as follows: The CPD agreement: Ms Lazar is aware of the CPD hearing. Ms Lazar does not intend to attend the hearing and is content for it to proceed in her and her representative s absence. Ms Lazar and her representative will endeavour to be available by telephone should any clarification on any point be required. The Nursing and Midwifery Council and Ms Anisoara Lazar, PIN 15D0551C ( the parties ) agree as follows: 1. Ms Lazar admits the following charges: That you, a registered nurse: 1. Do not have the necessary knowledge of the English language to practise safely and effectively. And in light of the above, your fitness to practise is impaired by reason of your lack of knowledge of English. Page 5 of 23

6 Facts 2. The facts are as follows: 2.1 Ms Lazar worked for Abertawe Bro Morgannwg University Health Board (ABMU) in the following roles: (i) July 2016 to June Band 5 Staff Nurse at Singleton Hospital (ii) November 2015 to June 2016 Band 5 Staff Nurse at Princess of Wales Hospital 2.2 Colleague 1, the Ward Manager at Singleton Hospital was responsible for supervising Ms Lazar. She did not feel that Ms Lazar s English language was of a sufficient standard and this was evidenced by Ms Lazar not fully understanding or double checking when she had been given instructions. Ms Lazar would then not follow through on instructions. Colleague 2, the Matron of Integrated Medicine & Unscheduled Care at Singleton Hospital, noted that it was evident Ms Lazar did not understand what was being asked of her during drug rounds. 2.3 Ms Lazar resigned from ABMU on 31 May In 2016, Ms Lazar applied to join Direct Nursing Services Limited and became a live member of the agency on 30 June She was recruited as a Band 5 Staff Nurse, experienced both within the NHS and within nursing homes. She attended six shifts over three different Trusts for the agency. 2.5 On a nightshift from August 2017, Ms Lazar worked at Glangwili Hospital on the Preseli Ward, which is a surgical ward. Colleague 3, the nurse in charge of the shift, who worked alongside Ms Lazar, was concerned about her standard of work and wrote a statement of events to the charge nurse. Page 6 of 23

7 2.6 It was recorded that Ms Lazar displayed communication difficulties during the shift. She struggled to understand basic instructions and her language difficulties impacted on her ability to provide effective care. 2.7 Following this shift, Ms Lazar undertook further training, which included promoting effective communication skills in nursing practice (August 2017), how to introduce yourself to patients (September 2017) and maintaining best practice in record keeping and documentation (September 2017). 2.8 After receiving a referral from ABMU in August 2017, the NMC made enquiries with Direct Nursing Services Limited, who provided details of a complaint made by Hywel Dda Health Board in relation to Ms Lazar s practice following the night shift that she had undertaken on August On 23 October 2017, the NMC wrote to Ms Lazar requiring her to undertake a language assessment Ms Lazar s nationality is Romanian and this is her first language Ms Lazar took the International English Language Testing System (IELTS) assessment on 2 December She received an overall band score of 4.0, with a breakdown as follows: (i) Listening: 3.5 (ii) Reading 4.0 (iii) Writing: 3.5 (iv) Speaking The results are reported as band scores on a scale from 1 (the lowest) to 9 (the highest). The NMC expects all nurses and midwives on the register to achieve a minimum score of 7.0 in each of the four Page 7 of 23

8 components, save for in writing where from 5 December 2018 this was reduced to 6.5. The minimum overall score remains as As part of the referral to the NMC, other concerns were raised about Ms Lazar, which have not been pursued. Ms Lazar was subject to restrictions on her practice by way of an interim conditions of practice order, which ceased on 30 November Ms Lazar s response 3. On 23 October 2018, Ms Lazar s representative confirmed to the NMC that they were interested in resolving the case by way of CPD. Upon receipt of further documentation, CPD was agreed between the parties on 30 November In her reflective piece (undated but provided to the NMC on 30 November 2018) Ms Lazar acknowledges that she needs to improve her knowledge of English in order to help and support her patients. 5. Ms Lazar confirms that she has independently taken steps to improve her English language by enrolling onto an English language course and also intends to undertake additional English lessons. 6. In her reflective piece, Ms Lazar explains why she considers that it is important to have a good understanding of English: I understand that I have to have good communication in English because as a Nurse I always make the right decisions in order not to put the life of the patients at risk. As an example every time during the shift I m very close to my patients and I explain clearly what the procedure is and give them all the necessary attention to make them feel safe. I respect my patients and I have a good communication with them. When I administer drugs to my patients, I clearly explain to them what the drugs are and what their benefits are. If a Page 8 of 23

9 patient has a chest infection, UTI etc... I call the DOCTOR GP to give the details of the patient (name, date of birth, disease history) why I called and I follow all the procedures and advice that I advice. [sic] Working as a nurse also helps me to improve my skills as I have communication with patients, colleagues, families, doctors etc. I understand that I have to have good communication in English because I work in UK as a Nurse and it is very important to make the right decisions. 7. Ms Lazar is supported by her current employers, who are aware of the NMC fitness to practise proceedings. They have confirmed that they will continue to support and employ her if restrictions are placed on her registration. Ms Lazar has two employers (April Court Care Home and Hengoed Court Care Home). 8. In a letter dated 13 November 2018, the Manager of April Court Care Home confirmed that: Ms Lazar has been employed as a nurse since 18 July 2018 working 11 hours per week, but previously completed work there as a bank nurse from 23 August 2016 to 8 July The home intends to continue to employ Ms Lazar at this time. There have been no issues with Ms Lazar s practice during her employment. She is willing to support Ms Lazar if she were made subject to a conditions of practice order and will be able to assist in improving Ms Lazar s communication skills in relation to English language. 9. In a letter dated 20 November 2018, the General Manager of Hengoed Court Care Home confirmed that: Ms Lazar has been employed as a registered nurse since 22 June The home intends to continue to employ Ms Lazar at this time. Page 9 of 23

10 No concerns have been raised regarding Ms Lazar s practice during her employment. Ms Lazar updates care plans and her writing skills do not reflect any concerns that require addressing currently. That the company cannot take responsibility for a condition requiring Ms Lazar to improve her English language, but will support attendance on English language courses, including ensuring where possible that night shifts do not impact upon attendance at study days. 10. Ms Lazar has provided a number of documents (Appendix 1) including: Reflective piece (undated) References from her current employers (referred to above) Previous reference from Hengoed Care Home dated 6 April 2018 Testimonial from a colleague dated 5 April 2018 Impairment 11. Ms Lazar accepts that her fitness to practise is currently impaired by reason of her lack of knowledge of English, adopting the formulation set out by Mrs Justice Cox in CHRE v (1) NMC and (2) Grant [2011] EWHC 927 (Admin) and the four questions posed specifically by Dame Janet Smith in her Fifth Report to The Shipman Inquiry. Ms Lazar acknowledges that a consideration of current fitness to practise looks backwards as well as forwards and accepts that she: (i) 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; (ii) Has in the past brought and/or is liable in the future to bring the profession into disrepute; (iii) Has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the professions. (iv) Page 10 of 23

11 12. By virtue of her admission to the charge, Ms Lazar accepts that she does not have the necessary knowledge of the English language to practise safely and effectively. 13. There is no evidence of patient harm in this case. However, if Ms Lazar fails to improve her knowledge of English, then the parties agree that she is liable in the future to act so as to put patients at an unwarranted risk of harm. Effective communication with patients and colleagues is fundamental to safe practice. It is also important that Ms Lazar is able to understand all medical documentation that she is reviewing and completing. 14. The parties agree that members of the public would expect Ms Lazar to be able to communicate effectively in her role as a nurse. There have been previous concerns raised about her ability to do so. Therefore, her language impairment has in the past brought and is liable in the future (in the absence of improvement) to bring the profession into disrepute. 15. Ms Lazar s language impairment has in the past breached and is liable in the future (in the absence of improvement) to breach one of the fundamental tenets of the profession, namely to be able to practise safely and effectively in caring for patients. 16. In assessing the likely risk of repetition in this case, the parties are mindful that Ms Lazar has not yet completed an English language course and that it is an NMC requirement to achieve a specific level on the IELTS test. Therefore, at this time there remains a risk that Ms Lazar is unable to demonstrate safe and effective practice due to lacking the necessary knowledge of the English language. This gives rise to public protection concerns. 17. Ms Lazar is taking remedial steps to address her language deficiencies, which the parties agree is required. While this is ongoing, the risk of repetition can be managed by the support and oversight of the registrant s employers. They have confirmed that there have been no issues with Ms Lazar s practice during the time she has been employed with them. Page 11 of 23

12 18. Ms Lazar confirms that she has enrolled onto an English language course of her own volition. This is a college course at Gower College Swansea, which started on 27 November 2018 and is due to last until July Ms Lazar has demonstrated through her reflective piece that she understands why a good standard of English is required to practise as a nurse and she has demonstrated insight into the risks that language deficiencies can pose to patients in her care. 20. The level of Ms Lazar s English in December 2017 is as reflected in her overall score of 4.0 in the IELTS assessment, which is considerably below the score of 7.0, which the NMC requires. The parties agree that the registrant is unfit to practise without restriction at this time. 21. In order to uphold the reputation of the profession and to declare and uphold proper professional standards, as well as maintain confidence in the NMC as regulator, the parties agree that it is also in the public interest for Ms Lazar s fitness to practise to be found currently impaired. 22. The parties invite a finding of impairment on both public protection and public interest grounds. 23. While the parties agree that Ms Lazar s fitness to practise is currently impaired by reason of lack of knowledge of English, this remains a matter for the panel s own professional judgement. Sanction 24. The parties agree that the appropriate and proportionate sanction in this case is a conditions of practice order for a period of 18 months with a review. In reaching this decision the following factors have been taken into account: Aggravating features Particularly low score on IELTS test Page 12 of 23

13 Mitigating features Supported by employers who are aware of the concerns Insight and willingness to improve English language demonstrated No evidence of patient harm 25. The parties have borne in mind that a sanction imposed in these proceedings is not intended to be punitive, although its impact may be and that the intention in imposing any sanction is to ensure that the NMC s overarching objective of public protection is met. The parties are also mindful that the least restrictive sanction which properly addresses the public protection and public interest concerns should be imposed and that any sanction imposed must be proportionate to the regulatory concerns, when weighed against the impact of the sanction on the registrant. 26. The parties agree that it would be inappropriate and disproportionate to take no action and to take such a course would be inconsistent with the parties agreed position on impairment. 27. The parties also consider that it would be inappropriate and disproportionate to impose a caution order. This would not adequately meet the public protection concerns in a case of this nature and would not restrict Ms Lazar s ability to practise. 28. The parties agree that the proper sanction in this case is a conditions of practice order and that the minimum length of the order properly to reflect the regulatory concern in this case is 18 months. The parties agree that a review is required before the order expires. In reaching that conclusion, the parties have carefully considered the NMC Sanctions Guidance and in particular that conditions will be sufficient to protect patients and address any concerns about public confidence or proper professional standards and conduct. Page 13 of 23

14 29. As per the Sanctions Guidance, the relevant factors that make a conditions of practice order appropriate in this case are as follows: 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 and willingness to respond positively to retraining patients will not be put in danger either directly or indirectly as a result of the conditions the conditions will protect patients during the period they are in force conditions can be created that can be monitored and assessed. 30. The parties have arrived at the conclusion that a conditions of practice order is the appropriate sanction due to the particular circumstances of this case, which can be summarised as follows: 30.1 Ms Lazar is supported by her current employers who are aware of the concerns in this case and intend to continue to employ her. Furthermore, the employers have not raised concerns with Ms Lazar s practice during the time she has been employed by them and there have been no restrictions on her registration since 30 November There will be restrictions imposed on Ms Lazar s registration, which will ensure that her employers (who it is intended will remain consistent throughout the 18 month period) can continue to monitor Ms Lazar s progress with improving her English, in full knowledge of the fitness to practise proceedings and what is required of her Ms Lazar has demonstrated insight into the need for her level of English to improve and she is willing to work under conditions while she takes steps to do this Ms Lazar will be required to improve her English through completion of an English language course. She has already enrolled onto and commenced a course, which demonstrates her intended compliance with this. Page 14 of 23

15 30.5 At a review hearing, the panel would be able to assess Ms Lazar s progress through her re-taking the IELTS assessment and making her score available to a reviewing panel. 31. The parties consider that with the above safeguards in place, the public will be adequately protected. Furthermore, the parties consider that an 18 month period is sufficient for Ms Lazar to demonstrate the necessary improvement in her English language. 32. The conditions agreed by the parties are as follows: 1. You must confine your nursing practice to April Court Care Home and Hengoed Court Care Home. 2. You must complete an English language course within 12 months of the date on which these conditions become effective, and send a copy of your results to the NMC within 14 days of you receiving them. 3. You must re-take the International English Language Testing System (IELTS) assessment before a review of this order and provide the results to the NMC at least 14 days before a review hearing. 4. You must tell the NMC about any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 7 days of you receiving notice of them. 5. a) You must within 7 days of accepting any course of study connected with nursing or midwifery, provide the NMC with the name and contact details of the individual or organisation offering the or course of study. b) You must within 7 days of entering into any arrangements required by these conditions of practice provide the NMC with the name and Page 15 of 23

16 contact details of the individual/organisation with whom you have entered into the arrangement. 6. You must immediately tell the following parties that you are subject to a conditions of practice order under the NMC s fitness to practise procedures, and disclose the conditions listed at (1) to (5) above, to them. a) April Court Care Home; b) Hengoed Court Care Home; c) Any agency you are registered with to provide nursing services; d) Any educational establishment at which you are undertaking a course of study connected with nursing or midwifery, or any such establishment to which you apply to take such a course (at the time of application) 33. The parties agree that the seriousness of this case is not such as to require temporary removal from the register. It is not necessary for Ms Lazar s registration to be suspended to protect patients and the public interest. Ms Lazar has been practising without restriction for over a year and her employers have confirmed that they are willing to support her in addressing her language difficulties. Ms Lazar has identified steps she can take to achieve this. The parties agree that a suspension order would, therefore, be disproportionate to the seriousness of the regulatory concerns in this case. 34. It is also in the public interest to retain the services of an otherwise competent nurse. 35. For the same reasons, the parties agree that a striking-off order would be disproportionate and in any event, is not an available sanction at this time under Article 29(6) of The Nursing and Midwifery Order Page 16 of 23

17 Interim order 36. It is also necessary for the protection of the public and otherwise in the public interest for there to be an interim conditions of practice order for 18 months to cover the appeal period. The interim conditions of practice should be as per the proposed conditions for sanction, set out above. Both parties understand that if no appeal is made, the interim order will cease to have effect 28 days after the notice of the decision on sanction is served. The parties understand that this provisional agreement cannot bind a panel, and that the final decision on findings impairment and sanction is a matter for the panel. The parties understand that, in the event that a panel does not agree with this provisional agreement, the admissions to the charges set out at section 1 above, and the agreed statement of facts set out at section 2 above, may be placed before a differently constituted panel that is determining the allegation, provided that it would be relevant and fair to do so. Page 17 of 23

18 Decision and reasons on the CPD The panel decided to accept the CPD. The panel heard and accepted the legal assessor s advice. She reminded the panel that they could accept, or outright reject the provisional agreement reached between the NMC and Ms Lazar, or suggest amendments with the agreement of the parties. Further, the panel should consider whether the provisional agreement would be in the public interest. This means that the outcome must ensure an appropriate level of public protection, maintain public confidence in the profession and the regulatory body, and declare and uphold proper standards of conduct and behaviour. The panel noted that Ms Lazar admitted the facts of the charge. In this respect, the panel endorsed paragraphs 2 to 10 of the provisional agreement. Accordingly, the panel was satisfied that the charge is found proved as set out in the signed provisional agreement before the panel. The panel then went on to consider whether Ms Lazar s fitness to practise is currently impaired. Whilst acknowledging the agreement between the NMC and Ms Lazar, the panel exercised its own independent judgement in reaching its decision on impairment. The panel considered whether Ms Lazar s fitness to practise is currently impaired by reason of her lack of knowledge of English. The panel decided that Ms Lazar s fitness to practise is currently impaired. In this respect the panel endorsed paragraphs 11 to 23 of the provisional agreement. The panel bore in mind that Ms Lazar has admitted current impairment. It was mindful that the concerns were raised in August 2017, and that improvement appears to have been made in the intervening time, according to a professional reference dated 5 April The panel considered Ms Lazar s reflective piece and found her to have sufficient insight. No concerns had been raised from the two care homes Ms Lazar has been working at. The panel was of the view that Ms Lazar is motivated and is actively taking steps to improve her English language skills. The panel had sight of a confirmation form that Ms Lazar enrolled on an English language course that began on 27 November Page 18 of 23

19 2018, but noted that this was one year after the language concerns had been raised. This course consists of two, 2 hour sessions per week. The panel also considered the 2 December 2017 results of Ms Lazar s International English Language Testing System (IELTS) and was of the view that she has not fulfilled the requirements of a registered nurse. In light of this, the panel accepted the provisional agreement in that three limbs of Grant are engaged in this case. It considered whether Ms Lazar had remediated her practice and, in the light of Ms Lazar s IELTS score, determined that her English language skills have not been sufficiently remediated. However, the panel acknowledged the steps that Ms Lazar is taking to improve her English language skills. Therefore a finding of current impairment is required. The panel concluded that Ms Lazar s fitness to practise is currently impaired on both public protection and public interest grounds. Having found Ms Lazar s fitness to practise currently impaired, the panel went on to consider what sanction, if any, it should impose in this case. The panel has borne in mind that any sanction imposed must be appropriate and proportionate. The purpose of any sanction is not intended to be punitive even though it may have a punitive effect. The panel had careful regard to the Sanctions Guidance (SG). Decision on sanction is a matter for the panel exercising its own independent judgement. The panel considered the aggravating and mitigating circumstances as set out in the provisional agreement. The panel was of the view that no evidence of patient harm was not a mitigating circumstance. However, it considered the positive testimonials from the two care homes that Ms Lazar works at to be a strong mitigating circumstance. Specifically, the panel noted a reference from the general manager at Hengoed Court Care Home dated 6 April 2018 which stated: Ms Lazar has very strong clinical skills Page 19 of 23

20 The panel noted a further reference from the general manager at Hengoed Court Care Home dated 20 November 2018 which stated: at this time no concerns have been raised from families, residents or colleagues [Ms Lazar] updates care plans and her writing skills do not reflect any concerns Furthermore, the panel noted a reference from an employee from Hengoed Court care Home dated 5 April 2018 which stated: I have noticed [Ms Lazar s] communication skills improving each week The panel has considered this case very carefully and has decided to confirm that a conditions of practice order is an appropriate sanction, as set out in the provisional consensual panel determination, except for one suggested amendment. The panel was mindful that the conditions of practice order confines Ms Lazar to working at the two stated care homes where she is currently employed. Therefore, it is unnecessary to impose the proposed condition 6c as she is not permitted to work for an agency under the terms of condition 1. Before this decision was handed down, this alteration was agreed with each of the parties. The effect of this order is that Ms Lazar s name on the NMC register will show that she is subject to a conditions of practice order and anyone who enquires about her registration will be informed of this order. The panel first considered whether to take no action but concluded that this would be inappropriate in view of the finding of current impairment and the continuing risk to patients. The panel decided that it would be neither proportionate nor in the public interest to take no further action. 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. The panel considered that a caution order would be inappropriate in this case, and would not address the risk which arises from Ms Lazar s current lack of knowledge Page 20 of 23

21 of English. The panel decided that it would be neither proportionate nor in the public interest to impose a caution order. The panel next considered whether placing conditions of practice on Ms Lazar s registration would be a sufficient and appropriate response. The panel was mindful that any conditions imposed must be proportionate, measurable and workable. The panel considered the evidence before it and was of the view that it had nothing before it to indicate a current level of high risk. In the light of the references provided, the panel was satisfied that the risk that arises in this case is addressed by the support that Ms Lazar s employers are providing to her. The panel considered the specific proposed conditions and determined that the risk is mitigated by the restrictions imposed, in particular by confining Ms Lazar s practice to the current two care homes where she is currently employed. The panel accepted that Ms Lazar would be willing to comply with conditions of practice, as evidenced by her agreement to the provisional consensual panel determination. The panel therefore decided that it would be possible to formulate appropriate and practical conditions, which would address the concerns highlighted in this case. Balancing all of these factors, and after having taken into account both the aggravating and mitigating features of this case, the panel decided that that the appropriate and proportionate sanction is that of a conditions of practice order. The panel was of the view that to impose a suspension order would be wholly disproportionate and would not be a reasonable response in the circumstances of Ms Lazar s case. It considered that the seriousness of this case does not require removal from the register. The panel considered the public interest in keeping an otherwise good nurses in practice and was of the view that, in this case, there is a strong public interest in Ms Lazar continuing to practice. Having regard to the matters it has identified, the panel has concluded that a conditions of practice order will mark the importance of maintaining public confidence in the profession and is the appropriate response in this case. Page 21 of 23

22 The panel, in fully accepting the provisional consensual panel determination, confirmed that the following conditions, as set out in the proposed consensual panel determination, are appropriate and proportionate in this case: 1. You must confine your nursing practice to April Court Care Home and Hengoed Court Care Home. 2. You must complete an English language course within 12 months of the date on which these conditions become effective, and send a copy of your results to the NMC within 14 days of you receiving them. 3. You must re-take the International English Language Testing System (IELTS) assessment before a review of this order and provide the results to the NMC at least 14 days before a review hearing. 4. You must tell the NMC about any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 7 days of you receiving notice of them. 5. a) You must within 7 days of accepting any course of study connected with nursing or midwifery, provide the NMC with the name and contact details of the individual or organisation offering the or course of study. b) You must within 7 days of entering into any arrangements required by these conditions of practice provide the NMC with the name and contact details of the individual/organisation with whom you have entered into the arrangement. 6. You must immediately tell the following parties that you are subject to a conditions of practice order under the NMC s fitness to practise procedures, and disclose the conditions listed at (1) to (5) above, to them. a) April Court Care Home; Page 22 of 23

23 b) Hengoed Court Care Home; c) Any educational establishment at which you are undertaking a course of study connected with nursing or midwifery, or any such establishment to which you apply to take such a course (at the time of application) The period of this order is for 18 months Before the end of the period of the order, a panel will hold a review hearing to see if Ms Lazar s knowledge of English language has improved. At the review hearing the panel may revoke the order or any condition of it, it may confirm the order or vary any condition of it, or it may replace the order for another order. Determination on interim order The panel, in full agreement with the provisional CPD, confirmed that an interim conditions of practice order was necessary for the protection of the public and is otherwise in the public interest. The panel had regard to the seriousness of the facts found proved and the reasons set out in its decision for the substantive order in reaching the decision to impose an interim order. To do otherwise would be incompatible with its earlier findings. The conditions for the interim order will be the same as those detailed in the substantive order. The period of this order is for 18 months to allow for the possibility of an appeal to be made and decided. If no appeal is made, then the interim order will be replaced by the conditions of practice order 28 days after Ms Lazar is sent the decision of this hearing in writing. That concludes this determination. Page 23 of 23

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