Nursing and Midwifery Council: Fitness to Practise Committee. Substantive Order Review Hearing. 25 August 2017

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1 Nursing and Midwifery Council Fitness to Practise Committee Substantive Order Review Hearing 25 August 2017 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of registrant: NMC PIN: Nancy Thando Blessings 00J1308E Part(s) of the register: Registered Nurse Sub part 1 Adult Nursing September 2004 Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Miss Blessings: Nursing and Midwifery Council: Order being reviewed: Outcome: England Lack of competence Martyn Griffths (Chair, Lay member) Mary McCartney (Registrant member) Kay Grindell (Lay member) Ian Ashford-Thom Jonathan Storey Present and represented by Jessie Robinson, instructed by the Royal College of Nursing Represented by Nazmeen Imambaccus, Case Presenter, instructed by NMC Regulatory Legal Team. Suspension order (6 months) Conditions of practice order (12 months) to come into effect at the end of 10 October 2017 in accordance with Article 30 (1) of the Nursing and Midwifery Order

2 Decision and reasons on review of the current order The panel decided to impose a conditions of practice order for 12 months. This order will come into effect at the end of 10 October 2017 in accordance with Article 30 (1) of the Nursing and Midwifery Order 2001 (as amended) (the Order). This is the seventh review of a substantive order to which you are subject. On 29 June 2012, a panel of the Conduct and Competence Committee made you the subject of a conditions of practice order. This was reviewed on 23 December 2013 where the panel extended the order for a further two months. This was reviewed on 17 February 2014 where the panel amended and extended the order for a further 12 months. This was reviewed on 13 March 2015 where the panel varied and extended the order for 6 months. This was reviewed on 2 September 2015 where the panel replaced the order with a suspension order for a period of 12 months. This was reviewed on 1 September 2016 where the panel imposed a 6 month suspension order. This was reviewed on 8 March 2017 where the panel imposed a 6 month suspension order. The current order is due to expire at the end of 10 October The panel is reviewing the current order pursuant to Article 30 (1) of the Order. The charges found proved which resulted in the imposition of the substantive order were as follows: That you, while employed at Basingstoke and North Hampshire Hospital as a Band 5 Staff Nurse: 1. On or around 28 th August 2007, incorrectly primed a patient s intravenous line with mannitol rather than heparinised saline and / or 2. On or around 27 th February 2008, administered an incorrect dose of intravenous adrenaline to a patient, more particularly ten times the required amount in that you administered 10mls of 1 in 10,000 rather than 1 mil of 1 in 10,000 and / or 2

3 3. Whilst undergoing an informal period of supervised practice at the Basingstoke and North Hampshire Hospital in the Emergency Department, between around March and May 2008, you failed to demonstrate that you were capable of working safely and competently without supervision, in that: a) on or around 28 th March 2008, you incorrectly labelled a patient s blood sample and / or b) on or around 14 th April 2008, you incorrectly cannulated / attempted to cannulate a patient who had lymphoedema and / or c) on or around 23 rd April 2008, you scored 66% in a drug calculation assessment, where the passmark was 100% and / or d) on or around 28 th April 2008, you scored 70% in a drug calculation assessment, where the passmark was 100% and / or 4. After the formal performance management period commenced on around 4 th July 2008, you failed to demonstrate that you were capable of working safely and competently without supervision, in that: a) On or around 8 th July 2008, during a series of assessments: i) you required a lot of prompting in order to identify the pulseless electrical activity (PEA) rhythm and / or ii) you were unsure of the drug dosage for atropine and / or iii) you required prompting in order to identify what to do for the management of asystole (no cardiac electrical activity) and /or iv) you failed to confidently communicate when, during a role play, the assessor played the wife of a patient with a fractured femur and asked if the patient was going to die and / or v) you were unable to identify several of the carpal bones and / or vi) you required prompting during an assessment on the application of a plaster of paris backslab for a patient with a Colles fracture and / or 3

4 b) On or around 17 th July 2008, you scored 96% in a drug calculation assessment, where the passmark was 100% and / or c) On or around 18 th July 2008, during a clinical scenario assessment you: i) [ ] ii) failed to request information regarding patients, even though you had not been present at handover and / or iii) indicated that you wanted paracetamol to be prescribed to a patient, even though the patient had overdosed on paracetamol and / or c) During a teaching assessment on or around 22 nd July 2008, you: i) required prompting whilst you were teaching the skill of setting up an arterial line and / or ii) required prompting whilst you were teaching the skill of setting up a Bi- Level Positive Airway Pressure ( BiPAP ) and / or 5. After the second stage of the formal performance management policy was introduced on or around 1 st August 2008 and / or whilst undergoing a period of supervised practice at the Basingstoke and North Hampshire Hospital in the fracture clinic between around August 2008 and November 2008, you failed to demonstrate that you were capable of working safely and competently without supervision, in that: a) On or around 27 th October 2008, during a drug round assessment i) you failed to ensure that a patient was wearing a name band and / or allergy band and / or you indicated that you had checked there was an allergy band in place when there was not and / or ii) you failed to adequately clarify what the nature of a patient s allergic reaction to penicillin was and /or 4

5 iii) you started preparing oral medications for a patient who had had a bronchoscopy and was nil by mouth for an hour after the operation and / or failed to check whether the patient was nil by mouth or not and / or iv) you failed to adequately communicate with patients and / or v) you failed to identify that a patient s bottles of medication needed to be locked away and / or b) On or around 31 st October 2008, you needed prompting during a paediatric assessment: i) [ ] ii) in order to identify a possible fractured femur and / or iii) in order to use a formula for estimating the child s weight, rather than weighing it and / or iv) in order to reach the correct value following a weight calculation and / or v) in order to consider EMLA and / or intranasal diamorphine for pain relief And in light of the above your fitness to practise is impaired by reason of your lack of competence The sixth reviewing panel determined the following with regard to impairment: This panel considers that you have demonstrated your ongoing commitment in undertaking further training. The panel was encouraged by the content of your reflective piece as showing evidence of your developing awareness and insight into your failings. However, it placed limited weight on the reading log, some of which was undertaken some time ago, and it noted that you have not provided any references. The panel is also encouraged by the limited but developing insight you have shown in accepting that your fitness to practise remains impaired and that a conditions of practice order is necessary. 5

6 The panel is of the view that there remains a risk of repetition given that the concerns in your practice have not yet been fully addressed. The panel was mindful that one of the original incidents which led to the imposition of a conditions of practice order had led to actual patient harm. There is no material before the panel from which it could conclude that your fitness to practise is no longer impaired. Given that you have yet to demonstrate that you have remedied your shortcomings, the panel concluded that there are ongoing concerns and in consequence your fitness to practise remains impaired. The sixth reviewing panel determined the following with regard to sanction: The panel went on to consider whether to extend the suspension order. You have expressed remorse and a degree of insight into your lack of competence. However, the panel has been provided with no evidence that you have taken sufficient steps to remedy your lack of competence to a point where you would be fit to practise safely even under supervision. The panel was not satisfied today that you have sufficiently remedied your shortcomings during the suspension period. In all the circumstances of this case the panel concluded that it is necessary and proportionate to impose a further six month suspension. This will give you a further opportunity to gain work in a caring role and to reflect on, and produce evidence to the next panel of, the seriousness and impact of your lack of competence on public protection and on the reputation of the nursing profession as well as public confidence in it. It may also enable you to produce evidence of your satisfactory performance in a caring environment. The panel considered that there may come a point when your continued lack of remediation will lead to a position (which might be on the occasion of the next review) where the situation is incompatible with ongoing registration. However, for the reasons already set out, the panel was not satisfied that that position had 6

7 quite been reached yet, although the matter was very finely balanced. In those circumstances a striking-off order would be disproportionate at this time and was not necessary to protect the public or to serve the wider public interest. Decision on current fitness to practise The panel considered carefully whether your fitness to practise remains impaired. Whilst there is no statutory definition of fitness to practise, the NMC has defined fitness to practise as a registrant s suitability to remain on the register without restriction. In considering this case, the panel carried out a comprehensive review of the order in light of the current circumstances. It noted the decision of the last panel. However, it exercised its own judgment as to current impairment. The panel had regard to all of the documentation before it, including your collection of training certificates, testimonials and reflections. It has taken account of the submissions made by Ms Imambaccus on behalf of the NMC, and those made by Ms Robinson, on your behalf. Ms Robinson submitted that you concede that your fitness to practice remains impaired, but invited the panel to replace the current suspension order with a conditions of practice order. Ms Robinson submitted that you have been working as a healthcare assistant at Woodlands House since April 2017 where you undertake three 12-hour shifts a week, and referred the panel to two references from colleagues (one of whom works on occasion as the nurse in charge at Woodlands House). Ms Robinson listed to the panel the 20+ online training courses that you have undertaken from RCN Learning and Boots in July and August With regard to insight and remediation, Ms Robinson submitted that your consistent engagement with these proceedings, as well as a commitment to your further development and independent learning, displays considerable insight into your clinical shortcomings. Further, Ms Robinson submitted that, were you made subject to a conditions of practice order, you would receive the appropriate level of support in order 7

8 to facilitate your return to unrestricted practice, which would uphold the wider public interest. The panel heard and accepted the advice of the legal assessor. In reaching its decision, the panel was mindful of the need to protect the public, maintain public confidence in the profession and to declare and uphold proper standards of conduct and performance. The panel considered whether your fitness to practise remains impaired. The panel considered the documents provided to it and appreciated the considerable effort you have undertaken to remediate your practice and develop your insight since the last review hearing. The panel was impressed by the wide-ranging subject matters of the training you have recently completed, and considered your reflective piece to be comprehensive. Although impressed by your increased insight and remediation since the last review hearing, the panel noted that you have been working as a healthcare assistant since April 2017 and, as such, have not been able to able to address issues surrounding medicine administration, or implement your theoretical skills in a practical setting. In light of this, the panel determined that there remains a risk of repetition. The panel therefore decided that a finding of current impairment is necessary on the grounds of public protection. The panel had borne in mind that its primary function was to protect patients and the wider public interest which includes maintaining confidence in the nursing profession and upholding proper standards of conduct and performance. Although you have remediated as much as you can, the panel determined in this case, given your current period of suspension, a finding of current impairment on public interest grounds is also required. For these reasons, the panel finds that your fitness to practise remains impaired. 8

9 Determination on sanction Having found your fitness to practise currently impaired, the panel then considered what, if any, sanction it should impose in this case. The panel also took into account the NMC s Sanctions Guidance (SG) and bore in mind that the purpose of a sanction is not to be punitive, though any sanction imposed may have a punitive effect. The panel first considered whether to take no action or to impose a caution order but concluded that either option would be inappropriate in view of the risk of repetition identified and seriousness of the case. The panel decided that it would be neither proportionate nor in the public interest to take no further action or impose a caution order. The panel considered substituting the current suspension order with a conditions of practice order. The panel considered you have developed your insight, undertaken a significant amount of training, and have expressed a genuine desire to return to nursing. Further the panel considered that it would be possible to formulate practicable and workable conditions, that if complied with, may lead to your unrestricted return to practice and would serve to protect the public and the reputation of the profession in the meantime. The panel decided that the public would be suitably protected as would the reputation of the profession by the implementation of the following conditions of practice: 1. You must notify the NMC within seven days of any nursing appointment which requires you to be registered as a nurse (whether paid or unpaid) that you accept within the UK or elsewhere, and provide the NMC with contact details of your employer. 2. You must immediately inform the following parties that you are subject to a conditions of practice order under the NMC s fitness to practise procedures, and disclose all these conditions to them: 9

10 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). c. Any prospective employer (at the time of application). 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). 3. You must tell the NMC about any professional investigation started against you and/or any professional disciplinary proceedings taken against you within seven days of you receiving notice of them. 4. 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: a. 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; and b. monthly meetings to discuss your clinical caseload and performance and progress. 5. At any time that you are employed or otherwise providing nursing or midwifery services you must send a report from your line manager, mentor or supervisor or their nominated deputy (who must be a registered nurse) setting out the standards of your performance and improvements in your numeracy skills in relation to your clinical practice. This must be sent to the NMC at least 14 days before any NMC review hearing or meeting. 6. In order to prepare you for the drug calculation assessment referred to in condition 7 below, you must successfully complete and pass a certified basic numeracy course within four months of this order coming into effect. Evidence of 10

11 this must be sent to the NMC at least 14 days before any NMC review hearing or meeting. 7. Before you undertake unsupervised administration of medications, you must successfully complete and pass a comprehensive workplace assessment in medicine administration which includes the calculations routinely required of a registered nurse involved in the administration of medicine. You must forward a copy of a satisfactory completion certificate of this assessment within 14 days before any NMC review hearing or meeting. 8. You must successfully complete a practical course in IV infusions (which may be a realistic simulation that does not involve real patients) and pass the relevant assessments. Until then, you must not undertake any IV administration or infusion, save under the direct supervision of a registered nurse deemed competent and qualified to assess or mentor you as part of your completion of the practical element of an IV drug administration and therapy course. Evidence of this must be sent to the NMC at least 14 days before any NMC review hearing or meeting. The panel determined that a period of 12 months under these conditions will give you time to find work as a nurse and make progress on the conditions specified. The panel considered that you have done everything possible in your current circumstances to remediate your clinical shortcomings and that, in order to fully remediate your clinical shortcomings, you need to prove yourself competent in a practical setting. As such, the panel determined that the imposition of a further period of suspension would not serve any useful purpose. This conditions of practice order will come into effect at the end of 10 October 2017, when the current suspension order expires. This decision will be confirmed to you in writing. 11

12 That concludes this determination. 12

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