Nursing and Midwifery Council Fitness to Practise Committee Substantive Meeting 22 March 2019

Transcription

1 Nursing and Midwifery Council Fitness to Practise Committee Substantive Meeting 22 March 2019 Nursing and Midwifery Council, 2 Stratford Place, London E20 1EJ Name of registrant: NMC PIN: Part(s) of the register: Claire Crouch 10F0016W Registered Nurse Adult Nursing Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Wales Misconduct Florence Mitchell (Chair, registrant member) Anna Ferguson (Registrant member) Sarah Tozzi (Lay member) Ben Stephenson Kathleen Picketts Consensual Panel Determination: CPD Accepted Sanction: Conditions of Practice Order (6 months) Interim Order: Interim Conditions of Practice Order (18 months) Page 1 of 17

2 Decision on Service of Notice of Meeting The panel was informed at the start of this meeting that Miss Crouch was not in attendance and that written notice of this meeting had been sent to Miss Crouch s registered address by recorded delivery and by first class post on 22 January The panel took into account that the notice letter provided details of the allegation, the time and dates of the meeting. The panel accepted the advice of the legal assessor. In the light of all of the information available, the panel was satisfied that Miss Crouch has been served with notice of this meeting in accordance with the requirements of Rules 11A 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. Consensual Panel Determination The panel considered the Agreement for a CPD that had been reached with regard to this case between Miss Crouch and the NMC. The Agreement, which was put before the panel, sets out Miss Crouch s admission of charge 1, and her acceptance of her fitness to practise being currently impaired by reason of her misconduct. 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 6 months. The agreement was signed by Miss Crouch on 21 March The panel was referred to the Agreement reached by the parties. That Agreement reads as follows: Page 2 of 17

3 The CPD Agreement: Miss Crouch ( the Registrant ) is aware of the CPD meeting and content for the case to be disposed of in this way. Preliminary matters Offering no evidence 1. The Nursing and Midwifery Council (hereafter the NMC ) offer no evidence in respect of charge 2. This matter is the subject of a factual dispute between the parties. 2. In line with the ratio in X, the facts are fully set out below for the panel s consideration. 3. Without prejudice to the NMC s position that there is a case to answer in respect of the facts of the above referenced charge (the Rule 24(7) consideration) and without it being conceded that if the facts of the charge were found proved it would be a matter supportive of a finding of impairment (the Rule 24(8) consideration), it is the NMC s position that this charge add nothing to the overall seriousness of the case in circumstances where all other aspects are proved by way of admission. 4. In the circumstances articulated above, it would not serve the public interest to hold a hearing to determine this discrete point. Indeed, to do so would be wholly contrary to the public interest, in that, it would represent an unnecessary expenditure of registrants fees and be oppressive to the Registrant. It is in accordance with the NMC s published guidance for an offer of no evidence to be made where there is no longer a public interest in continuing with a part of an allegation. Agreement Page 3 of 17

4 The NMC and the Registrant, PIN 10F0016W, (collectively the parties ) agree as follows: Charges 5. The Registrant faces the following allegation: That you, a registered nurse: 1) On 16 January 2017, ordered OxyContin and morphine sulphate tablets for Patient A when there was no clinical reason for doing so. 2) On 30 January 2017, dispensed Laxido to Patient B when doing so was clinically inappropriate. AND in light of the above, your fitness to practise is impaired by reason of your misconduct The Registrant admits charge 1. Charge 2 is denied. 6. The facts are as follows: Background 6.1. The Registrant was first admitted to the register of nurses and midwives maintained by the NMC on 17 November The Registrant is registered as a Registered Nurse Adult The Registrant s practice has previously been the subject of regulatory intervention Whilst the facts of the earlier case are not relevant to the instant matter it is relevant to note that at the time of the instant allegations the Registrant was subject to an interim conditions of practice order which, inter alia, Page 4 of 17

5 required her to be under the indirect supervision of another registered nurse when practising and to create and work towards the completion of a personal development plan aimed at developing her record keeping, communication and noting and escalating care of deteriorating patients At the time of the instant allegations the Registrant was employed as a nurse at Tycoch Care Home ( the Home ). The Registrant joined the nursing team at the Home on 16 November Charge On 16 January 2017, the Registrant worked a day shift with Kerry Thomas, Senior Nurse The Registrant was present at the morning handover when the night nurse and Ms Thomas discussed a change in medication for Patient A. Patient A had previously been prescribed morphine sulphate tablets as analgesia but was now prescribed OxyContin. Ms Thomas describes OxyContin as a more potent alternative to morphine sulphate tablets Ms Thomas later told the Registrant about Patient A s change in medication with the Registrant later the same day and at c hours explained that Patient A s OxyContin would soon be out of stock and that a prescription was required to cover the interim period before more stock became available. Ms Thomas asked the Registrant to fax Patient A s GP to discontinue the morphine sulphate and request a new prescription of OxyContin In error, the Registrant requested prescriptions for both morphine sulphate tablets and OxyContin from Patient A s GP. This error was noted and corrected by Ms Thomas later the same day Ms Thomas explained this error to the Registrant whom she describes as being concerned and apologetic. Page 5 of 17

6 Charge The NMC has also received evidence to suggest that, on 30 January 2017, the Registrant was working a day shift at the Home and dispensed medication (Laxido) for Patient B when it was clinically inappropriate to do so due to Patient B having loose stools The Registrant is said to have been informed that Patient B had loose stools by Patient B s daughter. It is also said that Patient B s daughter questioned why the Registrant was dispensing Laxido in these circumstances but that she nonetheless dispensed the medication and left Patient B to take this. There was no issue with Patient B consuming this medication unsupervised. Conclusion Ultimately, these issues led to the Registrant failing her probationary period at the Home on the basis that it was felt she could not work safely without supervision. Misconduct 7. The Registrant accepts that the facts admitted at charge 1 amount to miconduct In particular, the Registrant accepts that her misconduct breached the following parts of the Code: 18. Advise on, prescribe, supply, dispense or administer medicines within the limits of your training and competence, the law, our guidance and other relevant policies, guidance and regulations Page 6 of 17

7 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 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 7.2. The Registrant further accepts that her actions at charge 1 can properly be characterised as a basic medication error and that it is significant that this occurred despite her practice being the subject of enhanced supervision requirements In all the circumstances the Registrant s actions are sufficiently serious as to amount to misconduct. Impairment 8. The Registrant admits that her fitness to practise is impaired by reason of her misconduct With reference to the factors outlined by Dame Janet Smith in the 5 th Shipman Report the Registrant accepts that she has: in the past acted and/or is liable in the future to act as so to put a patient or patients at unwarranted risk of harm; and/or in the past brought and/or is liable in the future to bring the [nursing] profession into disrepute; Page 7 of 17

8 8.2. Fortunately, the Registrant s mistake was noticed and corrected by Ms Thomas before any actual harm could arise. Nonetheless, the parties agree that the Registrant s actions could, potentially, have placed Patient A at unwarranted risk due to the confusion that could have arisen as to what medication he was to be administered and the potential for an overdose which therefore arose The Registrant s actions have also brought the profession into disrepute. With regard to Patient A, the Registrant failed to fully inform herself about the drugs she was requesting before communicating with the GP. She invited the GP to do something clinically inappropriate and, in so doing, it can be assumed, caused him to lose confidence in her and the profession more generally The Registrant accepts that in circumstances whereby she continued to make medication errors despite concerns about this aspect of her practice being extant and despite being supported and supervised by virtue of the requirements of an interim conditions of practice order it cannot be said that the risk of her repeating her misconduct in future is low. Rather, the parties agree, there is a real risk and therefore a finding of current impairment is required on the grounds of public protection The parties note that this case relates solely to clinical errors and agree, therefore, that whilst a finding of current impairment is required on public interest grounds, in that the public would expect a nurse about whom serious concerns exist as to her medication management to have her practice restricted, this is wholly parasitical on the unresolved public protection issues in this case. Sanction 9. The appropriate sanction in this case is a 6 month conditions of practice order with review. Page 8 of 17

9 9.1. The parties have considered the NMC s Sanctions Guidance in arriving at the above sanction The parties further note that the Registrant is subject to a conditions of practice order in respect of the earlier case referenced at paragraph 6.4 which is due to be reviewed before 23 October The parties agree that, taking no further action or imposing a caution order for any length would be inappropriate. There is a continuing risk arising from the Registrant s unrestricted practise which would not be managed by either disposal The concerns in this case are exclusively clinical. A conditions of practice order will allow for appropriate restrictions to be placed on the Registrant s practice; protecting the public whilst also allowing the Registrant to develop her skills and remediate. With reference to the NMC s sanctions guidance the following features of this case indicate a conditions of practice order is the appropriate sanction; there is no evidence of harmful deep-seated personality or attitudinal problems, there are identifiable areas of the Registrant practice (namely medication management) in need to assessment and retraining and there is no evidence of general incompetence The conditions should be as follows: 1. At any time that you are employed or otherwise providing nursing or midwifery services, you must place yourself and remain under the supervision of a workplace line manager, mentor or supervisor nominated by your employer, such supervision to consist of working at all times on the same shift as, but not necessarily under the direct observation of, a registered nurse who is physically present in or on the same ward, unit, floor or home that you are working in or on. Page 9 of 17

10 2. You must work with your line manager, mentor or supervisor (or their nominated deputy) to create a Personal Development Plan designed to address the concerns about the following areas of your practice: a. Medication management and administration. b. Communication 3. You must meet with your line manager, mentor or supervisor (or their nominated deputy) at least every month to discuss the standard of your performance and your progress towards achieving the aims set out in your Personal Development Plan. 4. You must send a report from your line manager, mentor or supervisor (or their nominated deputy) setting out the standard of your performance and your progress towards achieving the aims set out in your Personal Development Plan to the NMC before any NMC review hearing or meeting. 6. You must tell the NMC within 7 days of any nursing appointment (whether paid or unpaid) you accept within the UK or elsewhere, and provide the NMC with contact details of your employer. 7. 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. 8. You must within 7 days of accepting any post or employment requiring registration with the NMC, or any course of study connected with nursing or midwifery, provide the NMC with the name/contact details of the individual or organisation offering the post, employment or course of study; Page 10 of 17

11 9. 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; 10. 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 (9) above, to them: (a) Any organisation or person employing, contracting with, or using you to undertake nursing work; (b) Any agency you are registered with or apply to be registered with (at the time of application) to provide nursing services; (c) Any prospective employer (at the time of application) where you are applying for any nursing appointment; and (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) The conditions of practice order should run for 7 6 months to allow it to be reviewed at the same time as the substantive order to which the Registrant is currently subject Temporary or permanent removal would be disproportionate in this case. With particularly regard to a suspension order the following features of the case suggest such an order would be inappropriate; there are no harmful deep-seated personality or attitudinal problems and a lesser sanction is sufficient to protect the public. Interim Order Page 11 of 17

12 10. It is necessary for the protection of the public and otherwise in the public interest for there to be an interim conditions of practice order of 18 months and in the terms described above to cover the appeal period 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. Decision and reasons on the consensual panel determination: In reaching its decision, the panel accepted the advice of the legal assessor and bore in mind that in reviewing the Agreement the panel should have regard to the law and guidance in respect of misconduct, impairment and sanction. The panel should consider whether the 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 for nurses. A panel will normally make a decision about a provisional CPD on the basis that the registrant has made full admissions to both the factual allegations as set out in the charges, and to impairment. It is then for the panel to exercise its own judgment as to impairment and sanction. The panel first considered a preliminary matter application by the NMC to offer no evidence in respect of charge 2 in the Agreement. While the panel noted that there appears to be evidence to support charge 2, it is disputed by Miss Crouch. The panel accepted that this charge adds nothing to the overall seriousness of the case, and it would not be in the public interest to hold a hearing to determine this charge on its own. The panel therefore endorsed paragraphs 1 to 4 of the Agreement and accepted that the NMC offers no evidence in respect of charge 2. Page 12 of 17

13 The panel noted Miss Crouch s admission to the remaining charge in this case. The panel looked at the Agreement in respect of misconduct and impairment. In considering misconduct, the panel considered that it is unlikely that charge 1 would amount to misconduct if considered in isolation. However, it bore in mind that this charge arose while Miss Crouch was subject to a conditions of practice order arising from a separate matter, and was under indirect supervision. In these circumstances, the panel endorsed paragraph 7.2 of the Agreement and was satisfied that this basic medication error, in context, amounted to misconduct. In considering current impairment, the panel noted that Miss Crouch has admitted that her fitness to practise is currently impaired. The panel noted that Miss Crouch has demonstrated remorse. However, it did not have any information before it demonstrating insight from Miss Crouch. The panel agrees for the reasons given in paragraphs 8.2 to 8.5 of the Agreement that a finding of impairment is required on the grounds of public protection and is otherwise in the public interest. Having found Miss Crouch 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 has considered this case carefully and has decided to confirm that a conditions of practice order is an appropriate sanction. The panel first considered whether to take no action or impose a caution order 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 or impose a caution order. Page 13 of 17

14 The panel next considered whether placing conditions of practice on Miss Crouch 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 took the view that Miss Crouch s misconduct is remediable, and determined that the risk is mitigated by the restrictions imposed by the specific conditions in the proposed Agreement.The panel considered the specific condition regarding supervision and was satisfied that indirect supervision is appropriate, as proposed in the Agreement. The panel accepted that Miss Crouch 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, the panel decided that the appropriate and proportionate sanction is that of a conditions of practice order. The panel considered the imposition of a suspension order and 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 Miss Crouch s case. It considered that the seriousness of this case does not require removal from the register, nor would it be in the public interest. The panel noted paragraph 9.6 of the Agreement which proposed a conditions of practice order for a period of 7 months, contrary to paragraph 9 which gives a length of 6 months. Upon further enquiries, the panel was made aware that this discrepancy was brought to the NMC s attention by the RCN prior to the Agreement being signed by Miss Crouch, and a length of 6 months for a conditions of practice order had been agreed by the parties. The panel noted the s between the parties dated 14 March 2019 which demonstrate that Miss Crouch had signed an amended Agreement that proposed a 6 month order in paragraph 9.6. The panel was therefore satisfied that the correct proposed length of the conditions of practice order in paragraph 9.6 was 6 months. Page 14 of 17

15 The panel, in fully accepting the Agreement, confirmed that the following conditions, as set out in the Agreement, are appropriate and proportionate in this case: 1. At any time that you are employed or otherwise providing nursing services, you must place yourself and remain under the supervision of a workplace line manager, mentor or supervisor nominated by your employer, such supervision to consist of working at all times on the same shift as, but not necessarily under the direct observation of, a registered nurse who is physically present in or on the same ward, unit, floor or home that you are working in or on. 2. You must work with your line manager, mentor or supervisor (or their nominated deputy) to create a Personal Development Plan designed to address the concerns about the following areas of your practice: a. Medication management and administration. b. Communication 3. You must meet with your line manager, mentor or supervisor (or their nominated deputy) at least every month to discuss the standard of your performance and your progress towards achieving the aims set out in your Personal Development Plan. 4. You must send a report from your line manager, mentor or supervisor (or their nominated deputy) setting out the standard of your performance and your progress towards achieving the aims set out in your Personal Development Plan to the NMC before any NMC review hearing or meeting. 6. You must tell the NMC within 7 days of any nursing appointment (whether paid or unpaid) you accept within the UK or elsewhere, and provide the NMC with contact details of your employer. 7. 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. Page 15 of 17

16 8. You must within 7 days of accepting any post or employment requiring registration with the NMC, or any course of study connected with nursing or midwifery, provide the NMC with the name/contact details of the individual or organisation offering the post, employment or course of study; 9. 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; 10. 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 (9) above, to them: (e) Any organisation or person employing, contracting with, or using you to undertake nursing work; (f) Any agency you are registered with or apply to be registered with (at the time of application) to provide nursing services; (g) Any prospective employer (at the time of application) where you are applying for any nursing appointment; and (h) 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 6 months Before the end of the period of the order, a panel will hold a review hearing to see if Miss Crouch s misconduct has been remediated. 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 Page 16 of 17

17 The panel, in full agreement with the Agreement, 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 risk arising from 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 Miss Crouch is sent the decision of this hearing in writing. That concludes this determination. Page 17 of 17