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

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1 Nursing and Midwifery Council Fitness to Practise Committee Substantive Order Review Hearing 2 November 2017 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of registrant: NMC PIN: Mrs Rosamma James 06A0091O Part(s) of the register: Registered Nurse Sub Part 1 Adult (January 2006) Area of Registered Address: Panel Members: Legal Assessor: Panel Secretary: Mrs James: Nursing and Midwifery Council: Order being reviewed: Outcome: England Deborah Jones (Chair, lay member) Alister Campbell (Registrant member) Anne Phillimore (Lay member) Andrew Lewis Siobhán Hamill Present and represented by Ms Shirley Forbes of Royal College of Nursing. Represented by Ms Feryal Ertan counsel, instructed by NMC Regulatory Legal Team. Conditions of Practice Order (3 months) Conditions of Practice Order varied and extended (12 months) to come into effect at the end of 10 December 2017 in accordance with Article 30 (1)

2 Decision and reasons on review of the current order: The panel decided to vary and extend the conditions of practice order for a period of 12 months. This order will come into effect at the end of 10 December 2017 in accordance with Article 30 (1) of the Nursing and Midwifery Order 2001 (as amended) (the Order). This is the second review of a conditions of practice order, originally imposed by a panel of the Conduct and Competence Committee on 1 August 2014 for 3 years. The order was reviewed by a panel on 3 August 2017 and the order was continued for a further 3 months. The current order is due to expire at the end of 10 December The panel is reviewing the 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, whilst employed by Southend University Hospital NHS Trust ( the Trust ) and working on the Surgical Assessment Unit: Whilst employed by the Trust as a Band 5 Registered Nurse between 16 February 2011 and 16 December 2011, failed to demonstrate the standards of knowledge, skill and judgment required to practise without supervision as a Band 5 Registered Nurse: 1. were unable to safely administer medication to patients without supervision in that you afield adult drug assessments on: a. 16 February b. 7 April On 15 August 2011, in response to clinical indications that Patient A was acutely unwell:

3 a. Failed to take adequate and/or prompt steps to escalate the matter; b. Failed to take appropriate action in response; On 16 December 2011, were unable to correctly answer when asked by Sister Churchill what would happen to a patient s pulse if they were bleeding; 5. Did not complete your period of performance supervision on the Surgical Assessment Unit. Whilst employed by the Trust as a Band 5 Registered Nurse: 6. On or around 14 December 2011, provided incorrect information to Sister Churchill regarding the care required by Patient B, including: a. Whether the patient had sutures; 7. On 16 December 2011, failed to carry out adequate observations of patient in Bay B of the Unit, despite informing Sister Churchill that you had done so; On 16 December 2011, breached the confidentiality of Patient C by discussing his or her personal details on front of other patients. AND in light of the above your fitness to practise is impaired by reason of your lack of competence in relation to charge(s) 1 to 5, and by reason of your misconduct in relation to charge(s) 6 to 9.

4 The first reviewing panel determined the following with regard to impairment: The panel has 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 has carried out a comprehensive review of the order in light of the current circumstances. It has noted the decision of the last panel. However, it has exercised its own judgment as to current impairment. The panel has had regard to all of the documentation before it, including the NMC bundle and the bundle provided by you, which contained 2 reflective pieces, references from your two current employers, and a significant number of training certificates. It has taken account of the submissions made by Ms Richardson on behalf of the NMC and by Ms Constantine on your behalf. Ms Richardson submitted that your fitness to practice remained impaired. While she accepted that you have complied with the current conditions of practice order, she submitted that you have nevertheless provided insufficient evidence to demonstrate that you have addressed the specific concerns identified by the previous panel. She submitted that a nurse who is only able to practise safely in a limited area of nursing practice is not a nurse who is able to practise without restriction. She invited the panel to impose a conditions of practice order which specifically addresses the concerns identified by the substantive panel. Ms Constantine, on your behalf, submitted that your fitness to practise is no longer impaired. She submitted that the current conditions of practice order has addressed the issues with your practice, as you have worked without any issues for the past three years, as evidenced by the references from your employers. She drew the panel s attention to your reflective piece, in which you explain where you have drawn on your previous difficulties in an acute setting in your current practice in nursing homes. She submitted that you have fully complied

5 with the order and there is nothing to suggest that you present an ongoing risk of harm to the public. She also submitted that public confidence would not be undermined if you were found not to be impaired, as members of the public would not think it fair for you to be held accountable for any deficiencies in a previous substantive order when you have worked hard to demonstrate compliance. 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. In considering whether your fitness to practise remains impaired, the panel had careful regard to all the documentation before it, including the findings of the previous panel, particularly paragraph 22 of the previous decision, in which the panel listed the deficiencies it had identified. These were medicines administration, including intravenous medication, recognising and responding to an acutely ill patient, including the need to escalate and communication with colleagues That panel considered that your deficiencies in these areas of clinical practice were the source of the risk of harm to the public, which had not been remediated, and which motivated a finding of impairment and the imposition of the current order. The panel carried out its own independent risk assessment in light of the all the information it had been provided. However, it was unable to find any meaningful evidence that these specific areas of concern had been addressed in your reflective pieces or in the training you had undertaken. It noted that neither of your managers had commented on your competence in these areas. It was therefore unable to conclude that you had developed sufficient insight into the clinical failings in your practice or whether they had been remediated by you.

6 Without such evidence, the panel was unable to safely conclude that there was not a continuing risk of repetition if you were to practice in any other clinical setting. It therefore concluded that your fitness to practice remains impaired on the grounds of public protection. The panel also determined that there was a public interest in a finding of current impairment, as it would undermine public confidence in the profession and the NMC if a panel were to determine that a nurse was able to practice without restriction when it had insufficient evidence to do so. The panel therefore determined that your fitness to practice is currently impaired. The first reviewing panel determined the following with regard to 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 noted that its powers are set out in Article 29 of the Order. The panel has also taken into account the NMC s Indicative Sanctions Guidance (ISG) and has borne in mind that the purpose of a sanction is not to be punitive, though any sanction imposed may have a punitive effect. Having been unable to satisfy itself that you no longer present a risk of harm to the public, the panel determined that it would be inappropriate to allow the current order to lapse upon expiry, or to impose a caution order. It considered that some restriction on your practice was necessary to safeguard the public and to maintain public confidence in the profession and in the NMC. The panel next considered the imposition of a conditions of practice order. The panel determined that it would be appropriate to continue the conditions of practice order in its current form until such time as you can demonstrate that the ongoing risk of harm to the public has been addressed. It accepted that to make the conditions more onerous would not take account of your past three years

7 working without incident, and might require you to seek work in an area which you no longer wish to practice in, which would be disproportionate. Accordingly, the panel determined, pursuant to Article 30(1) (c) of the Nursing and Midwifery Order 2001, to extend the current conditions of practice order for a period of 3 months, which will come into effect on the expiry of the current order. 1. You must notify the NMC within fourteen 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. 2. You must confine your nursing practice to nursing or care home settings. 3. You must inform the NMC of 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. You must within fourteen 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. 5. You must within fourteen 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 inform 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:

8 (i) any organisation or person employing, contracting with, or using you to undertake nursing or midwifery work, (ii) any agency you are registered with or apply to be registered with (at the time of application), (iii) any prospective employer (at the time of application), (iv) 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 panel considered that an extension of the order for 3 months would allow you time to gather evidence demonstrating that you have remediated the identified failings in your practice, practically, through relevant training and/or through your own insight, and present it to the next reviewing panel. In light of the evidential deficiencies noted by this panel, any future reviewing panel may inevitably require the following: A report from your manager(s) which specifically addresses your practice in relation to: o Medicines management o Intravenous medication o Recognising and responding to the needs of acutely ill patients o Accurate and effective communication of clinical concerns with colleagues. Evidence of any specific training undertaken in relation to the above 4 areas. A further reflective piece, using a recognised model of reflection such as the Gibbs reflective cycle, which focuses on how your practice has improved in relation to the above 4 areas.

9 Your attendance at the review hearing. Decision on current fitness to practise The panel has 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 has carried out a comprehensive review of the order in light of the current circumstances. It has noted the decision of the last panel. However, it has exercised its own judgment as to current impairment. The panel has had regard to all of the documentation before it, including the substantive order review bundle and the documentation provided by you which consisted of 9 training certificates, 3 reflective statements and references from two current employers. It has taken account of the submissions made by Ms Ertan, on behalf of the NMC and those made by Ms Forbes, on your behalf. Ms Ertan, on behalf of the NMC, outlined the chronology of your case. She submitted that that your fitness to practice remains impaired as there is still a risk of repetition. She accepted you had engaged with the NMC proceedings and have complied with the conditions imposed upon you; however, there is still a risk of repetition. She told the panel that the findings of fact found proved demonstrated that you lacked certain basic nursing skills expected of a band 5 nurse. She submitted that if the panel found current impairment, the decision on sanction is one for its professional judgment. Ms Forbes, on your behalf, outlined the background of your case and detailed the concerns raised by the previous panel. She explained that those concerns were that you had demonstrated a lack of remediation and insight and therefore there was a risk of repetition. She explained to the panel that since the imposition of the order, you had taken strides to ensure you have reflected and accepted your errors, including basic errors.

10 She drew the panel s attention to the reflective statements, where you say that if you were faced with similar circumstances again, you would know how to handle them differently, which was one of the concerns outlined by the original substantive panel. Ms Forbes referred the panel to the references you adduced which show your understanding of the need to communicate effectively. In relation to the concern of repetition, as outlined by the NMC, she submitted that you have not faced any regulatory concerns before or since, you are of good character, you have engaged with the NMC proceedings, which have been lengthy. You have provided positive references from your employers, who comment on your clinical ability and communication skills. You have complied with the order imposed and have addressed the areas of concern. She submitted that you are not currently impaired and the concerns of repetition and the risk to the wider public if you were to practise unrestricted are no longer relevant. She submitted that you have complied with the conditions of practise order imposed on you and have successfully addressed any deficiencies identified in your practice. She invited the panel to revoke the current order with immediate effect. 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. In considering whether your fitness to practise remains impaired, the panel had careful regard to all the documentation before it, including the findings of the previous reviewing panel on 3 August 2017, which outlined the deficiencies that you were yet to address successfully, these were medicines administration, including intravenous medication, recognising and responding to an acutely ill patient, including the need to escalate and communication with colleagues. These clinical concerns resulted in the finding of impairment and the continuation of the order.

11 The panel carried out its own independent risk assessment in light of the all the information it had been provided. The panel had sight of your three reflective pieces, in which you had demonstrated further insight into your clinical skills deficiencies and the importance of addressing them and acknowledged that you had attended and completed a number of training courses in the areas of concern. The panel also accepted that since the last reviewing panel, your employers have commented on your clinical competence and this has been provided to the panel. The panel particularly noted the reference from Ms 1, Home Manager in which she stated, I can confirm that I observe Rosamma during her shifts and I am involved in her supervisions and that she is responsive to the needs of our residents and makes effective communication with her colleagues in relation to the clinical needs of our residents. The panel however were aware that you have been working in a care home setting and that concerns were raised about your ability to undertake your role safely and effectively in an acute hospital setting. The panel therefore were not satisfied that you had been afforded the opportunity to address the concerns raised in relation to this particular clinical environment. The panel however did accept that the conditions imposed on your practise previously did not allow you the opportunity to do this and restricted your practise to a care home setting only; the panel therefore concluded that this was no fault of yours. The panel determined, as you have been unable to fully demonstrate competence and insight in all the areas of concern, especially in an acute hospital setting, a restriction of your practice is still necessary on the grounds of public protection. The panel was satisfied that there currently remains a real risk of repetition of deficiencies in this area, if you were to practice in an acute hospital setting. The panel bore in mind the overarching objective of the NMC: to protect, promote and maintain the health safety and well-being of the public and patients and the wider public interest which includes promoting and maintaining public confidence in the nursing and midwifery professions and upholding the proper professional standards for members of

12 those professions. The panel determined that a finding of continuing impairment on public interest grounds is required. For these reasons, the panel finds that your fitness to practise remains impaired. 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 noted that its powers are set out in Article 29 of the Order. The panel has also taken into account the NMC s Sanctions Guidance (SG) and has borne in mind that the purpose of a sanction is to protect the public and not to be punitive, though any sanction imposed may have a punitive effect. Because you have been unable to satisfy the panel that you no longer present a risk of harm to the public, the panel determined that it would be inappropriate to allow the current order to lapse upon expiry, or to impose a caution order. It considered that some restriction on your practice was necessary to safeguard the public and to maintain public confidence in the profession and in the NMC. The panel went on to consider whether a suspension order was necessary. It determined that as you had complied with the conditions and had made some progress in the areas of concerns and you are currently practising safely within the existing conditions, therefore it concluded that a suspension order would be unnecessary at this time. The panel next considered the imposition of a conditions of practice order. The panel determined that it would be appropriate to vary and extend the conditions of practice order until such time as you can demonstrate that you have fully addressed the concerns raised regarding your practise in an acute hospital setting and able to show you no longer pose a risk of harm to the public. The panel accepted your compliance with the conditions imposed upon you for the last three years and noted that condition 2

13 in particular did not allow you the opportunity to work within an acute clinical setting and address the concerns that were raised. Accordingly, the panel determined, pursuant to Article 30(1) (c) of the Nursing and Midwifery Order 2001, to extend and vary the current conditions of practice order for a period of 12 months. 1. You must notify the NMC within fourteen 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. 2. At any time that you are employed or otherwise providing nursing services within an acute hospital setting, you must place yourself and remain under the supervision of a workplace line manager, mentor or supervisor nominated by your employer. You should work at all times on the same shift as but not necessarily under the direct observation of, a registered nurse of band 6 or above who is physically present in or on the same ward, unit, floor or home that you are working on. 3. If working in an acute hospital setting, you must work with you 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 practise: a) Medicines management skills; b) Intravenous medication administration; c) Recognising and responding to the needs of acutely ill patients d) Accurate and effective communication of clinical concerns with colleagues. 4. If working in an acute hospital setting, you must meet with your line manager, mentor or supervisor (or their nominated deputy) monthly to discuss the standard of your performance and your progress towards

14 achieving the aims set out in your personal development plan. 5. You must inform the NMC of any professional investigation started against you and/or any professional disciplinary proceedings taken against you within seven days of you receiving notice of them. 6. You must within fourteen 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. 7. You must within fourteen 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. 8. 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 the conditions listed at (1) to (5) above to them: (i) any organisation or person employing, contracting with, or using you to undertake nursing or midwifery work, (ii) any agency you are registered with or apply to be registered with (at the time of application), (iii) any prospective employer (at the time of application), (iv) 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).

15 In light of the evidential deficiencies noted by this panel, any future reviewing panel may inevitably require the following: a) A report from your line manager, mentor, supervisor or (or their nominated deputy) detailing your achievements in the clinical skills expected of a band 5 nurse working in an acute hospital setting in the areas of concerns, specifically: medicines management skills, intravenous medication administration, recognising and responding to the needs of acutely ill patients and accurate and effective communication of clinical concerns with colleagues. b) A further reflective piece, using a recognised model of reflection such as the Gibbs reflective cycle, which focuses on how your practice has improved in relation to the above 4 areas; c) Your attendance at the review hearing. This order will be reviewed before its expiry in accordance with Article 30(1) of the Order. At the review the panel may revoke the order, allow it to lapse, extend it, vary any condition of it, or impose a different order. This decision will be confirmed to you in writing. That concludes this determination.

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