Part(s) of the register: RN1: Registered Nurse (sub part 1) Adult (24 February 1975)

Transcription

1 Conduct and Competence Committee Substantive Hearing Wednesday 24 February 2016 Nursing and Midwifery Council, George Street, Edinburgh, EH2 4LH Name of Nurse: NMC PIN: Mrs Nicola Clare Koller 72F1490E Part(s) of the register: RN1: Registered Nurse (sub part 1) Adult (24 February 1975) Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Representation: Nursing and Midwifery Council: Facts proved by way of admission: Facts proved: Facts not proved: Fitness to practise: Sanction: Interim Order: Scotland Lack of competence Mr Ian Luder (Chair/ Lay member) Ms Susan Tokley (Registrant member) Ms Linda Nixon (Lay member) Ms Maria Clarke Miss Bose Kayode Mrs Koller was not present and no representative was present in her absence Represented by Mr Neil Jeffs, counsel, instructed by NMC Regulatory Legal Team All N/A N/A Impaired Suspension order 12 months (By way of consensual panel determination) Interim suspension order 18 months 1

2 Decision on Service of Notice of Hearing: The panel was informed at the start of this hearing that Mrs Koller was not in attendance nor was her representative present. Mr Jeffs informed the panel that notice of this hearing was sent to Mrs Koller on 11 February 2016 by recorded delivery and first class post to her address on the register outlining the date, time and venue of the hearing. Mr Jeffs advised the panel that 28 days had not passed since notice of this proposed hearing had been served upon Mrs Koller. He referred the panel to an from Mrs Koller s representatives, Anderson Strathern LLP which confirms that Mrs Koller explicitly waives her right to 28 days notice as required by Rule 11 of The Nursing and Midwifery Council (Fitness to Practise) Rules Order of Council 2004 (as amended) ( the Rules ). The panel heard and accepted the advice of the legal assessor. Accordingly, the panel considered whether the notice of hearing had been served in accordance with Rules 11 and 34 of the Rules in order to be able to consider proceeding in Mrs Koller s absence. These rules are: 11. (2) The notice of hearing shall be sent to the registrant (b) in every case, no later than 28 days before the date fixed for the hearing. 34. (1) Any notice of hearing required to be served upon the registrant shall be delivered by sending it by a postal service or other delivery service in which delivery or receipt is recorded to, (a) her address in the register The panel had in mind that notice of this hearing was sent to Mrs Koller by first class post and recorded delivery to her address on the register, thereby complying with Rule 34. However, the panel further had in mind that the notice was dated and sent on 11 February 2016, which does not comply with Rule 11. 2

3 The panel had regard to the from Mrs Koller s representatives dated 10 February 2016 which states, We can confirm that we are also content for the hearing to be fixed for 24 February without the usual notice period. In these circumstances, the panel has concluded that Mrs Koller has expressed a clear and settled intention for the case to proceed and provided informed acquiescence in her communications with the NMC. In the light of the above, the panel is satisfied that notice has been served in accordance with the Rules. 3

4 Proceeding in absence: The panel considered whether it should proceed in the absence of Mrs Koller. The panel heard the submissions made by Mr Jeffs, on behalf of the Nursing and Midwifery Council (NMC). It took account of the legal assessor s advice. The panel was mindful that this was a discretion that must be handled with the utmost care and caution. In deciding whether to proceed in the absence of Mrs Koller, the panel weighed its responsibilities for public protection and the expeditious disposal of the case with Mrs Koller s right to a fair hearing. Mr Jeffs, on behalf of the NMC, asked the panel to bear in mind the correspondence from Mrs Koller and her representatives in this case. He informed the panel that there was a proposed agreement for this case to be dealt with by means of a Consensual Panel Determination (CPD), on which he would address the panel in due course. He stated that there is a clear intention by both parties that the case would proceed today in the absence of Mrs Koller and her representatives. He referred the panel to an from Mrs Koller s representatives, Anderson Strathern LLP dated 23 February 2016 in which they state, Further to our correspondence, I can confirm on behalf of the registrant there is no objection to the CPD hearing on 24 February 2016 proceeding in the absence of the registrant in terms of rule 21. The panel was satisfied that Mrs Koller had been sent notice of today s hearing and that she was aware of it. It was the panel s view that she has chosen to voluntarily absent herself from the hearing. Neither Mrs Koller nor her representatives at Anderson Strathern LLP had requested an adjournment and the panel had no reason to believe that an adjournment would result in her attendance. Having weighed the interests of Mrs Koller with those of the NMC and the public interest in an expeditious disposal of this hearing the panel has determined to proceed in Mrs Koller s absence. 4

5 Charges: That you, whilst employed as a bank band 5 staff nurse by NHS Lothian, between May 2013 and December 2014, failed to demonstrate the standards of knowledge, skill and judgement required to practise without supervision as a Band 5 Staff Nurse in that: 1. On 2 May 2013, whilst working a shift on Ward 54 at Western General Hospital, you did not undertake and/or document regular checks of Patient B s syringe driver; 2. On 28 May 2013, whilst working a shift on Ward 54 at Western General Hospital: 2.1. You did not ensure that intravenous tazocin was administered to Patient C at 14:00 hours as prescribed; 2.2. You signed for and/or administered an oral dose of co-amoxiclav to Patient D when it was prescribed to be administered intravenously; 3. On 5 June 2013, whilst working a shift on the Acute Receiving Unit at Western General Hospital, in relation to Patient A: 3.1. You did not enter a score in relation to urinary output on the Standardised Early Warning Score documentation; 3.2. You did not commence Patient A s prescribed IV fluids and/or ensure that they were commenced at or around 18:00 hours; 4. On 30 September 2014, whilst working a shift on Ward 72 at Western General Hospital, you did not complete Patient G s admission notes; 5. On 2 December 2014, whilst working a shift on Ward 72 at Western General Hospital, in relation to Patient H: 5.1. You did not ensure that IV amoxicillin was administered at 14:00 hours as prescribed; 5.2. You did not document why IV amoxicillin was not administered; 5.3. You did not document whether Ranitidine was administered at 18:00 hours as prescribed; 5

6 6. You failed to demonstrate that you had met the objectives set in the employee capability action plan dated July 2014 in one or more of the following areas: 6.1. Effective record keeping; 6.2. Effective organisation and time management; 6.3. Safe administration of medication; 6.4. Reflection of patient care; 7. You failed to demonstrate that you had met the objectives set out in the employee capability action plan dated November/December 2014 in one or more of the following areas: 7.1. Demonstrating safe, independent practice; 7.2. Demonstrate progress against the agreed action plan; 7.3. Demonstrate an awareness of evidence based, best practice; 7.4. Demonstrate effective communication and interpersonal skills; 7.5. Demonstrate good nursing practice and decision making skills; And in light of the above, your fitness to practise is impaired by reason of your lack of competence. 6

7 Consensual Panel Determination: The panel heard from Mr Jeffs, on behalf of the Nursing and Midwifery Council (NMC) that a provisional agreement on a consensual panel determination had been reached between Mrs Koller and the NMC. The agreement, which was put before the panel, sets out Mrs Koller s full admission of the facts of all of the charges. She also accepts that her fitness to practise is currently impaired by reason of her lack of competence. It is agreed that an appropriate sanction in this case would be a suspension order for a period of 12 months. The panel has considered the agreement which was signed by Mrs Koller and an officer of the NMC on 23 February 2016 as set out below. The provisional agreement reads as follows: The Nursing and Midwifery Council and Mrs Koller, PIN 72F1490E ( the parties ) agree as follows: 1. Mrs Koller admits the following charges: That you, whilst employed as a bank band 5 staff nurse by NHS Lothian, between May 2013 and December 2014, failed to demonstrate the standards of knowledge, skill and judgement required to practise without supervision as a Band 5 Staff Nurse in that: 1. On 2 May 2013, whilst working a shift on Ward 54 at Western General Hospital, you did not undertake and/or document regular checks of Patient B s syringe driver. 2. On 28 May 2013, whilst working a shift on Ward 54 at Western General Hospital: 2.1 You did not ensure that intravenous tazocin was administered to Patient C at 14:00 hours as prescribed. 2.2 You signed for and/or administered an oral dose of co-amoxiclav to Patient D when it was prescribed to be administered intravenously. 7

8 3. On 5 June 2013, whilst working a shift on the Acute Receiving Unit at Western General Hospital, in relation to Patient A: 3.1 You did not enter a score in relation to urinary output on the Standardised Early Warning Score documentation. 3.2 You did not commence Patient A s prescribed IV fluids and/or ensure that they were commenced at or around 18:00 hours. 4. On 30 September 2014, whilst working a shift on Ward 72 at Western General Hospital, you did not complete Patient G s admission notes. 5. On 2 December 2014, whilst working a shift on Ward 72 at Western General Hospital, in relation to Patient H: 5.1 You did not ensure that IV amoxicillin was administered at 14:00 hours as prescribed. 5.2 You did not document why IV amoxicillin was not administered. 5.3 You did not document whether Ranitidine was administered at 18:00 hours as prescribed. 6. You failed to demonstrate that you had met the objectives set in the employee capability action plan dated July 2014 in one or more of the following areas: 6.1 Effective record keeping. 6.2 Effective organisation and time management. 6.3 Safe administration of medication. 6.4 Reflection of patient care. 7. You failed to demonstrate that you had met the objectives set out in the employee capability action plan dated November/December 2014 in one or more of the following areas: 7.1 Demonstrating safe, independent practice. 8

9 7.2 Demonstrate progress against the agreed action plan. 7.3 Demonstrate an awareness of evidence based, best practice. 7.4 Demonstrate effective communication and interpersonal skills. 7.5 Demonstrate good nursing practice and decision making skills. And in light of the above, your fitness to practise is impaired by reason of your lack of competence. 2. The facts are as follows: a) The NMC received a referral from Ms 1 the Nurse Director at NHS Lothian on 18 December 2013, raising concerns about the registrant s clinical competence. b) The registrant first qualified as a nurse in January At the relevant time she was employed as a band 5 staff nurse through the NHS Lothian Staff Bank from 28 June The registrant worked intermittent bank shifts between 2010 and To join bank nursing staff, nurses undergo an interview process, if successful at that stage they are subject to a 5-day induction which includes 3 days specific to nursing including life support, moving and handling, infection control, medicines management and record keeping. c) In 2013 the registrant began working more consistent bank shifts with NHS Lothian and was primarily based at Western General Hospital ( WGH ). A number of incidents occurred in May and June 2013 which raised concerns about the registrant s general nursing practise. These were: i. Charge 1: On 2 May 2013, the registrant did not undertake and/or document regular checks of Patient B s syringe driver. Patient B was an inpatient on the respiratory ward, the patient was on a sub cutaneous infusion via a syringe pump, receiving Alfebtanil, Metaclopramide, antiemetic and analgesia continuously. Patient B s infusion monitoring chart shows that there were no checks documented between and on 2 May The chart states that the infusion syringe pump should be checked a minimum of every four 9

10 hours. As a result, Patient B was without pain medication which would have caused unnecessary pain and discomfort. After the incident the registrant stated that she did not think that it was her responsibility to carry out checks on the syringe pump and presumed that someone else would check this. The registrant had previously worked on the respiratory ward and had completed syringe driver training. ii. Charge 2.1: On 28 May 2013, the registrant did not ensure that intravenous tazocin was administered to Patient C at hours as prescribed. This was due to the registrant failing to put the patient s notes in the treatment room thereby failing to ensure the antibiotics were administered on time, causing treatment to be delayed and a requirement for two stat doses to be administered. A stat dose of tazocin was administered at on 28 May 2013 and a further stat dose was administered on 29 May 2013 at The registrant had previously followed the correct procedure and therefore was deemed to have known what the procedure was. The registrant offered no explanation for this incident when questioned. iii. Charge 2.2: On 28 May 2013, the registrant correctly administered an oral dose of co-amoxiclav to patient D at 0800 hours, however, during the mid-morning medical round, Patient D s co-amoxiclav prescription route was changed from 625mg to IV 1.2 grams. At 1400 hours the registrant signed the prescription chart to show the administration of the medication under the IV prescription but administered the oral dose. She did not check the correct dose and the correct route on Patient D s records. During an investigation meeting on 24 September 2013, the registrant was reminded that she was present during the prescription change. The registrant was not able to recall this incident. iv. Charge 3.1: Patient A was an inpatient on the acute receiving unit and the registrant was allocated care of the patient from 0800 hours on 5 June 2013, the registrant was undertaking a 12-hour shift. Patient A had recorded a low score on urine output and was deteriorating in health, the patient had not passed urine since 0300 hours and had a fluid balance chart to monitor her fluid input and output. At 1700 hours the registrant completed the Standardised Early Warning 10

11 System ( SEWS ) documentation but did not enter a score in relation to urinary output for the 1700 hours recording. The registrant had completed SEWS training prior to this incident. v. Charge 3.2: At 1800 the same day the patient was prescribed IV fluids, however, this was not commenced by the registrant, although the registrant had received some IV training she had not been signed off as competent to undertake IV administration unsupervised and therefore should have sought assistance and/or brought the 1800 hours prescription to the attention of senior staff. The registrant did not and in addition did not mention this issue at hand over. It was not until 2130 hours the nightshift staff realised the 1800 hours IV fluids had not been administered and action was taken. vi. Patient A went into peri-arrest and required critical intervention as she was hypovolaemic- namely, she had low blood volume, low output and her blood pressure was low. This outcome may have occurred whether or not fluids were given when prescribed, however, it remains that the registrant placed the patient at unwarranted risk of harm by not completing the SEWS documentation or taking the appropriate action in relation to the 1800 hours fluid prescription. vii. When questioned the registrant acknowledged that IV fluids were prescribed and stated that she must have been distracted before she had an opportunity to escalate Patient A s condition. The registrant informed the investigation team that she didn t know it was her responsibility to take any action, that she should it was someone else s responsibility and that she had whilst she had qualifications on paper, her experience was lacking. d) Ms 2, the Bank Staff Manager, was instructed to carry out an investigation in relation to the incidents above and into general concerns raised by staff about the registrant s competence. The registrant s bank status was deactivated on 10 June 2013, pending the investigation. This was reviewed on 18 July 2013 and the registrant was temporarily downgraded from a band 5 to a band 2 care assistant until the investigation was concluded. In mitigation the registrant explained that she had worked in South 11

12 Africa as a nurse where the doctors would complete all of the care requirements and advise the nurses of what they needed to do. e) On 22 October 2013 a disciplinary hearing took place and the registrant accepted most of the allegations against her. She denied that she required a lot of support and supervision. The registrant was unable to offer any mitigation and was issued with a first written warning [PRIVATE] f) The registrant remained downgraded to a band 2 care assistant until a full OHS assessment was carried out. She was also restricted to working shifts on non-acute wards. g) On 9 April 2014, Dr 3, Consultant Occupational Physician, provided an OHS assessment. This indicated that the registrant tended to ignore aspects of written information, however within a competency period, she could work back up to band 5 level. This letter is attached at appendix 1. It shows that the registrant has a tendency to ignore certain aspects of visual information in written or printed format, however, it states this can be overcome by double checking and by undertaking advised activities. [PRIVATE]. Ward 72 action plans h) An action plan was developed by Ms 2 and put in place for 12 weeks in July The registrant was restricted to working on ward 72 at WGH. This is a purpose built ward for the elderly and is less acute than a general medical ward. The intention in placing the registrant on this ward was to offer the level of support required by the registrant, without placing additional pressure on the ward. There would also be three nurses readily available to provide additional support. The following objectives were included in the action plan: i. To meet weekly with her designated Practice Education Facilitator ( PEF ) ii. To demonstrate an awareness of personal accountability in practice iii. To demonstrate effective record keeping iv. To discuss care delivered to three patients in her care per shift worked; and 12

13 v. To demonstrate effective management and awareness of deteriorating patients. i) Charge 4: The registrant undertook a mandatory training update and a 12 week evaluation period was arranged. For the first six weeks of this evaluation period, the registrant was directly supervised by senior nurses. During this time, there were no concerns. At the six week stage the registrant was allocated to a small number of patients. During her first formal review on 7 November 2014, Ms 2 discussed with the registrant that she had not completed the admission notes for Patient G, the admission notes had been later picked up and completed by night shift staff, although this task had not been delegated to the nightshift by the registrant. During the meeting the registrant stated that she believed it was the other nurses responsibility to complete patient records. She was not able to provide any mitigation for the omission. j) Charge 6: The review concluded that the registrant had not met the actions set out in her capability plan, specifically: effective record keeping, organisational and time management skills, safe administration of drugs and completion of reflective sessions. k) A new plan of action was agreed which included more supportive shifts for the registrant. The registrant was informed that if she did not achieve the objectives of the plan then the matter could proceed to a formal capability hearing. l) The registrant returned to work on ward 72 for two shifts a week. She was provided with a six week time frame to complete the objectives. It was also agreed that the registrant would meet weekly with her PEF and fortnightly on ward 72 with Ms 2. The objectives in the second plan were: i. To demonstrate progress against the agreed action plan ii. To demonstrate an ability to reflect upon her practice and complete action plans for future iii. To demonstrate professional values such as safe, independent practise and awareness of evidence based best practise iv. To demonstrate communicate and interpersonal skills v. To demonstrate good nursing practice and decision making skills; and vi. To demonstrate leadership, management and team working skills. 13

14 m) Charge 5: On 2 December 2014 the registrant did not provide Patient H with antibiotics at as prescribed. Furthermore the registrant did not document why it was not administered or whether or not ranitidine was administered at as prescribed. The registrant was not able to explain why she had missed Patient H s antibiotics. This was realised by another member of staff at approximately and as a result of the omission, Patient H had to have two stat doses of amoxicillin at and in order to get the patient back on their cycle. n) During her investigation, Ms 2 noticed that Patient H s ranitidine was also not signed for at by the registrant therefore it was not clear whether this had been administered as prescribed. o) Charge 7: The further issues on ward 72 were viewed as repetitious behaviour, despite the support provided and Ms 2 decided to discontinue the second capability programme after the incidents of 2 December 2014 as it was felt the registrant was putting patients at risk of unwarranted harm. The registrant had completed 2 shifts under the second capability action plan before it was discontinued and as such was deemed to have failed to have met the objectives set out as noted, above. p) On 22 December 2014, Ms 2 held a second formal capability meeting. The registrant could not explain why she was still making omissions in patient care but stated that she had a head injury. She did not provide any further detail about the injury but stated she was hoping to have tests in January 2015 to find out more; the registrant stated that it could be a coincidence that all her problems were with IV medication and that she seemed to have a problem processing written things and that she felt she needed to be working with another qualified member of staff 100% of the time. The registrant could not think of any other support she could have been given. She acknowledged that she was placing not only herself, but patients at risk. q) The registrant indicated that she would like to remain employed by NHS Lothian Staff Bank as a band 2 care assistant, which was agreed by Ms 2. The formal capability proceedings were discontinued as a result of this agreement. 14

15 r) The registrant asked if she could change her mind about the decision to downgrade to band 2 as she wished to go back to working as a registered nurse. The registrant was informed that she could appeal against the decision and that the matter would then proceed to stage three of the capability proceedings a formal hearing. The registrant has not appealed and remains on the NHS Lothian Bank Staff roster as a band 2 care assistant. 3. Impairment 3.1. The Registrant accepts that her fitness to practice is impaired by reason of her lack of competence because she currently lacks the standards of knowledge, skill and judgment required to practise safely as a nurse without supervision Following the guidance set down by Dame Janet Smith in her fifth report to the Shipman enquiry, which has been endorsed in Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC297 (Admin), the Registrant accepts that she: 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 Has in the past brought and/or is liable in the future to bring the professions into disrepute; and/or Has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the professions; 3.3. The Registrant was provided with ongoing support and supervision from senior colleagues within the Trust and was moved to a ward where she was afforded support in a less acute area. Action plans were established to highlight the areas requiring improvement and whilst there was improvement shown in the 6 weeks whilst she was under direct supervision, as soon as that supervision was relaxed and the registrant given the care of a small number of patients, errors were 15

16 repeatedly made; an increase in support whilst on shift in a second action plan did not result in safer practice and mistakes were again made with the effect that the second action plan was terminated due to concerns over patient safety. The ongoing concerns in respect of the registrant s clinical competence demonstrate an inability to maintain the required standard of safe practise and as such the registrant is shown to have both placed patients at risk of unwarranted harm and given the lack of remediation in the identified areas, there remains such a risk to the public if she were allowed to practise without restriction Whilst some improvements were noted and the Registrant s medication administration and care improved under direction there were significant concerns raised in letting her practise without supervision. In practising whilst not competent to do so the Registrant acted in a manner which placed patients at unwarranted risk of harm and therefore served to bring the professions into disrepute 3.5. Despite this support, the Registrant failed to demonstrate that she was competent in a variety of areas of knowledge and skill that were fundamental to the role she had undertaken. The Registrant s unsafe practice put her patients at unwarranted risk of harm and had it not been for the actions of her supervisors and/or colleagues may have caused them actual harm The registrant has failed to maintain the knowledge and skills needed for safe and effective practise and not worked within the limits of her competency and as such could be said to have breached a fundamental tenet of the profession There is further a public interest in a finding of impairment being made, the public have the right to expect a registered nurse to be capable of safe and effective practice and to deliver a service that is capable, safe, knowledgeable, understanding and completely focused on the needs of the people in their care; given the persistent failure of the registrant to demonstrate the necessary standards of knowledge, skill and judgement to practise as a registered nurse, a finding of impairment is necessary to protect the reputation of the profession by ensuring professional standards are maintained and upheld. 16

17 3.8. The registrant has submitted a number of documents attached to this agreement at appendix 2. [PRIVATE]. 3.9 The remaining documents in exhibit 2 include a positive reference in relation to the registrant s work as a band 2 bank staff and as a staff nurse; these ought to be taken in to consideration by the panel as evidence that the registrant is accomplished in a band 2 role and there are some positive comments in regard to her work as a staff nurse, however, given the admitted facts and acceptance of current impairment, these references can only serve to have limited weight in relation to the case as a whole as a risk of repetition remains extant The registrant has chosen not to submit a reflective statement in this case and has not worked as a registered nurse since In all the circumstances and particularly considering Dame Janet Smith s guidance, it is agreed by the parties that the Registrant s fitness to practise is currently impaired. 4. The appropriate sanction in this case is a 12-month suspension order. The parties have considered the NMC s Indicative Sanctions Guidance to Panels ( ISG ) and have taken account of the key principles contained therein 4.1. The parties acknowledge that the public interest must be at the forefront of any decision on sanction, which includes the particular need to protect patients, the collective need to maintain the confidence of the public in the profession and the NMC and the declaring and upholding of proper standards of conduct and behaviour The parties also acknowledge that a sanction must be proportionate and as such, is a balancing exercise between the Registrant s interests and the public interest The parties have considered the potential aggravating and mitigating features of the case. In terms of the potential aggravating features: - The Registrant s failings were wide-ranging and affected numerous patients; - They related to fundamental aspects of nursing; 17

18 - The Registrant received extensive support from the Trust, however she failed to demonstrate the necessary competencies expected of a nurse working with patients who were prone to rapid deterioration; 4.4. In terms of the potential mitigating features: The Registrant has shown a degree of insight into her failings and accepts the charges against her and current impairment. Admissions were made to the majority of the allegations as far back as 22 October 2013 The registrant has submitted testimonials that speak of how she was regarded in the workplace The registrant has submitted information pertaining to her finances and the impact of regulatory proceedings 4.5. The parties agree that taking no further action or imposing a caution order would not be appropriate in this case. The Registrant s lack of skill and knowledge were fundamental to her position as a Band 5 Staff Nurse on an acute ward and taking no further action or imposing a caution order would be insufficient to protect the public. The Registrant is not able to practise safely without supervision and to allow her to do so without restriction would place patients at an unwarranted risk of harm A conditions of practice order has been considered and the guidance at paragraphs of the ISG however, whilst there are identifiable areas of the registrant s practise that are capable of remediation, the registrant was not capable of remediating those failing despite supported an supervised practise; further, given that the registrant has not practised as a nurse since 2014 and there is no evidence of remedial re-training before the panel, there remains a risk to patient safety if the registrant were permitted to practise even with conditions A suspension order would serve to sufficiently protect patients and the public interest; the only issue in this case relates to the registrant s lack of competence and it is agreed that there would be a risk to patient safety if the registrant were allowed to practise even with conditions. 18

19 4.8. An order for 12 months is deemed necessary in the circumstances based upon the severity and the wide ranging nature of the failings demonstrated by the registrant, this would allow the registrant sufficient time to consider and to undertake necessary remediation; the panel are invited to take into account the guidance set out at paragraph 68 of the ISG and to consider setting out any expectations it has to assist a reviewing panel prior to the expiry of the order. 5. Interim order 5.1. It is also necessary for the protection of the public and otherwise in the public interest for there to be an interim suspension order of 18 months in the same terms as the substantive order. This is in order to cover the appeal period and the life of any appeal should there be one. Such an interim order shall enable consistency of approach and ensure that the purpose of the substantive order is given immediate effect The Parties understand that this provisional agreement cannot bind a panel, and that the final decision on findings of 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 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. 19

20 Panel decision: The panel heard and accepted the advice of the legal assessor, who reminded it that the issue of impairment and sanction remained matters for the professional judgment of the panel. In this case, Mrs Koller has admitted all of the facts and the panel therefore confirms that all of the charges are found proved by admission. She has also admitted that her fitness to practise is impaired by reason of her lack of competence. The panel took into consideration that in every case this is a matter of judgement for the panel. The panel acknowledges that there is merit in cases being resolved by consent if appropriate. Whilst the panel accepted that in this case the admission of impairment demonstrates some insight on Mrs Koller s part, it notes that she has not provided any evidence of reflection or any information as to her understanding of the impact that her actions could have had on patients with whom she came into contact. Instead at times, she stated that she believed that other nurses were responsible for completing specific patient related tasks rather than herself, which the panel considers is evidence of an attitudinal issue. The panel has borne in mind its responsibility regarding public protection and the public interest which includes the maintenance of public confidence in the profession, and the declaring and upholding of proper standards of conduct and behaviour amongst members of the profession and confidence in the regulatory process. Mrs Koller s failings were wide ranging and related to her general nursing practise which is fundamental to her role as a registered nurse. Despite having received extensive support over a prolonged period and supervision on least two occasions, she was unable to demonstrate the standards of nursing practice required of a Band 5 registered nurse. The panel noted that during the first six weeks of an evaluation period in which Mrs Koller was directly supervised by senior nurses, there were no concerns. However, during her first formal review on 7 November 2014, concerns were raised with regard to the completion of patient admission notes. In addition, the review concluded that Mrs Koller had not met the actions set out in her capability plan. 20

21 The panel recognises the matters Mrs Koller raised with regard to her health. However, the panel had regard to the letter from Dr 4 [PRIVATE]. The panel has therefore given limited weight to Mrs Koller s health matters. Mrs Koller was a nurse with more than thirty years experience, yet despite having been given ample opportunities through the support and supervision failed to reach the standard expected of a Band 5 nurse. She failed to do so. On one or more occasions, Mrs Koller s unsafe practice put patients at unwarranted risk of harm and had the potential to cause actual harm had it not been for the actions of her colleagues. The panel found that the first three limbs of the test laid out by Dame Janet Smith were engaged in this case. It also asked itself the questions posed by Silber J in Cohen v General Medical Council [2008] EWHC 581 (Admin), namely, is the conduct remediable, has it been remediated and is there a risk of repetition in the future, and determined that the answers were, yes, no and yes. Accordingly, the panel concluded that Mrs Koller s failings amounted to a lack of competence and that her fitness to practice is currently impaired. The panel considered the proposed order in light of the Indicative Sanctions Guidance (ISG). It also took into account the principle of proportionality and the need to balance Mrs Koller s interest with the public interests. The panel considered that to take no further action in the circumstances of this case and given the wide ranging nature of Mrs Koller s lack of competence would not be proportionate or sufficient to protect the public or in the public interest, either in relation to the maintenance of public confidence in the profession and the regulatory process or in declaring and upholding proper standards of conduct and behaviour. The panel then considered whether to make a caution order. The panel recognised that a caution order would not restrict Mrs Koller s practice, and had concerns as to the risk of repetition. It therefore concluded that such an order would not sufficiently protect the public, nor would it satisfy the public interest. 21

22 The panel then went on to consider imposing a conditions of practice order. This case relates to Mrs Koller s lack of competence in relation to basic and essential elements of general nursing practise. The panel had little information as to the nature of Mrs Koller s current employment(s) and her performance therein. However, it noted that she remains on the NHS Lothian Bank Staff roster as a band 2 care assistant and that she appears to be seeking employment outside nursing. The panel has also been provided with three references contained within the bundle, all of which make mention of having knowledge of these NMC proceedings and speak of Mrs Koller as hard working, conscientious and willing to learn. The panel also noted that whilst the referrer in this case had been informed of the proposed sanction, no response had been received. The panel had serious concerns about the extent of the basic and essential areas of nursing to which Mrs Koller s lack of competence related. It considered that without the ability to put into practice her learning and development, Mrs Koller cannot practise safely as a registered nurse. Moreover, the incidents had continued to occur notwithstanding extensive support and supervised practice. Mrs Koller had not indicated that she wished to comply with a conditions of practice order and the panel did not consider that conditions could be devised which were practicable and workable in this case. The panel was satisfied that her lack of competence was such that nothing less than a period of suspension would sufficiently protect the public and satisfy the public interest in this case, given her failings in relation to basic and essential areas of nursing. The panel was satisfied that a suspension order for twelve months would reflect the fundamental nature of Mrs Koller s failings and would adequately protect the public. Further, this will provide a sufficient period for her to reflect further upon the panel s findings and to undertake remediation. For the reasons given above, the panel decided to make the order as agreed to by the parties. 22

23 Towards the end of the period of suspension another panel will review the order. At the review hearing the panel may revoke the order, confirm the order or replace the order with another order. Whilst this panel cannot bind any subsequent reviewing panel, it considers that it would assist a reviewing panel if Mrs Koller were to attend the review hearing and to provide the following: o Up to date references and testimonials from any work, paid or unpaid; o A written reflective statement regarding her deficiencies, the issues which led to the referral including the issue of accountability, and what she would do differently in the future to reduce the risk of repetition; o Evidence of how Mrs Koller has kept her nursing knowledge up to date and of any training undertaken; and o An up to date [PRIVATE] report [PRIVATE] The suspension order will come into effect 28 days after the service of the notification of the panel s decision upon Mrs Koller. If she chooses to appeal the decision, this order will not take effect until the appeal has been concluded. Given the panel s findings, it concurs with the provisional agreement that it is necessary for the protection of patients and is otherwise in the public interest to impose an interim suspension order for a period of 18 months to cover the appeal period. If no appeal is made against the panel s substantive decision then the interim order will cease to have effect upon the expiry of the applicable appeal period or, if an appeal is made, when the appeal is withdrawn or otherwise finally disposed of. The panel accordingly makes that interim order. This decision will be confirmed to Mrs Koller in writing. That concludes this determination. 23