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1 Nursing and Midwifery Council Fitness to Practise Committee Substantive Hearing 8-12 January 2018 Nursing and Midwifery Council, 2 Stratford Place, Montfichet Road, London, E20 1EJ Name of registrant: NMC PIN: Chloe Anne Hill 15A1666E Part(s) of the register: RNC, Registered Nurse (sub part 1) Children s (14 September 2015) Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Registrant: Nursing and Midwifery Council: England Misconduct David Newman (Chair, lay member) Susan Field (Registrant member) Colin Sturgeon (Lay member) John Bromley-Davenport Sophie Cubillo-Barsi 8 January not present and not represented 9 January 2018 not present except to give evidence via telephone 10 January 2018 not present and not represented 11 January 2018 present via WebEx 12 January 2018 present via WebEx Represented by Sophie Quinton-Carter, counsel, instructed by NMC Regulatory Legal Team. Facts proved: 5, 6, 7, 8 and 12 Facts proved by admission: 1, 2, 3, 4, 10 and 11 Facts not proved: 9 Fitness to practise: Sanction: Impaired Suspension Order 12 months Page 1 of 38

2 Interim Order: Suspension Order 18 months Page 2 of 38

3 Details of charge (as amended): That you, a registered nurse, 1) On 4 March 2016 recorded that you had taken Patient A s blood pressure and temperature when you had not Charge found proved by way of admission 2) Your actions in charge 1 above were dishonest in that you knew you had not taken these observations Charge found proved by way of admission 3) On 16 March 2016 recorded that you had taken Patient A s blood pressure and temperature when you had not Charge found proved by way of admission 4) Your actions in charge 3 above were dishonest in that you knew you had not taken these observations Charge found proved by way of admission 5) On 6 October 2016 recorded a ventilation reading in relation to Patient B which you had not taken Charge found proved 6) Your actions in charge 5 above were dishonest in that you knew you had not taken a ventilation reading Charge found proved 7) On 6 October 2016 recorded the minute volume alarm settings in relation to Patient B which you did not calculate Charge found proved 8) Your actions in charge 7 above were dishonest in that you knew you had not calculated the minute volume alarm settings Charge found proved 9) During the night shift of 6 October 2016 did not record the fluid balance in relation to Patient B every hour Charge found NOT proved 10)On 6 October 2016 wrongly set the heart rate and oxygen saturation alarms in relation to Patient B Charge found proved by way of admission Page 3 of 38

4 11)On 6 October 2016 ticked the box on the form to indicate that Patient B had a wrist band when you had not checked this; Charge found proved by way of admission 12) Your actions in charge 11 were dishonest in that you knew you had not checked for the wrist band. Charge found proved AND in light of the above, your fitness to practise is impaired by reason of your misconduct. Page 4 of 38

5 Decision on Service of Notice of Hearing The panel was informed at the start of this hearing that Miss Hill was not in attendance and that written notice of this hearing had been sent to Miss Hill s registered address by recorded delivery and by first class post on 5 December Notice of this hearing was signed for on 6 December 2017, and the printed name was Hill. The panel took into account that the notice letter provided details of the allegation, the time, dates and venue of the hearing and, amongst other things, information about Miss Hill s right to attend, be represented and call evidence, as well as the panel s power to proceed in her absence. Ms Quinton-Carter submitted the NMC had complied with the requirements of Rules 11 and 34 of the Nursing and Midwifery Council (Fitness to Practise) Rules 2004, as amended ( the Rules ). The panel accepted the advice of the legal assessor. In light of all of the information available, the panel was satisfied that Miss Hill has been served with notice of this hearing in accordance with the requirements of Rules 11 and 34. It noted that the rules do not require delivery and that it is the responsibility of any registrant to maintain an effective and up-to-date registered address. Decision on proceeding in the absence of the Registrant The panel next considered whether it should proceed in the absence of Miss Hill. The panel had regard to Rule 21 (2) which states: (2) Where the registrant fails to attend and is not represented at the hearing, the Committee Page 5 of 38

6 (a) (b) (c) shall require the presenter to adduce evidence that all reasonable efforts have been made, in accordance with these Rules, to serve the notice of hearing on the registrant; may, where the Committee is satisfied that the notice of hearing has been duly served, direct that the allegation should be heard and determined notwithstanding the absence of the registrant; or may adjourn the hearing and issue directions. Ms Quinton-Carter invited the panel to continue in the absence of Miss Hill on the basis that she had voluntarily absented herself. Ms Quinton-Carter referred the panel to the correspondence between Miss Hill and the NMC. Ms Quinton-Carter informed the panel that Miss Hill s original hearing was due to commence on 4 December 2017, but that the hearing was adjourned at Miss Hill s request, as she was unable to attend due to work commitments. Ms Quinton-Carter submitted that on 5 January 2018 Miss Hill informed the NMC that once again, she would have difficulties in attending today s hearing but that she may be able to attend on 11 and 12 January Ms Quinton-Carter submitted that the allegations in Miss Hill s case are serious in nature and it would be in the public interest to proceed in the absence of the registrant. She further submitted that there was no reason to believe that an adjournment would secure Miss Hill s attendance on some future occasion. Ms Quinton-Carter also informed the panel that Miss Hill had provided two responses to the allegations, which would be available to the panel if the hearing proceeded. The panel accepted the advice of the legal assessor. The panel noted that its discretionary power to proceed in the absence of a registrant under the provisions of Rule 21 is not absolute and is one that should be exercised with the utmost care and caution as referred to in the case of R. v Jones (Anthony William), (No.2) [2002] UKHL 5. The panel further noted the case of R (on the application of Raheem) v Nursing and Midwifery Council [2010] EWHC 2549 (Admin) and the ruling of Mr Justice Holman that: Page 6 of 38

7 ...reference by committees or tribunals such as this, or indeed judges, to exercising the discretion to proceed in the person's absence "with the utmost caution" is much more than mere lip service to a phrase used by Lord Bingham of Cornhill. If it is the law that in this sort of situation a committee or tribunal should exercise its discretion "with the utmost care and caution", it is extremely important that the committee or tribunal in question demonstrates by its language (even though, of course, it need not use those precise words) that it appreciates that the discretion which it is exercising is one that requires to be exercised with that degree of care and caution. The panel noted the relevant correspondence from Miss Hill to the NMC regarding today s hearing. The panel has decided to proceed in the absence of Miss Hill. In reaching this decision, the panel has considered the submissions of the case presenter, and the advice of the legal assessor. It has had particular regard to the factors set out in the decision of Jones. It has had regard to the overall interests of justice and fairness to all parties. It noted that: no application for an adjournment has been made by Miss Hill; there is no reason to suppose that adjourning would secure her attendance at some future date; the charges are serious in nature two witnesses have attended today to give live evidence, and two others are due to attend on 9 January 2018; not proceeding may inconvenience the witnesses, their employers and, for those involved in clinical practice, the clients who need their professional services; further delay may have an adverse effect on the ability of witnesses accurately to recall events; there is a strong public interest in the expeditious disposal of the case. There is some disadvantage to Miss Hill in proceeding in her absence. She will not be able to challenge the evidence relied upon by the NMC and will not be able to give evidence on her own behalf. However, in the panel s judgment, this can be mitigated to Page 7 of 38

8 some extent by the panel being able to consider Miss Hill s two statements, and possibly hear from her at a later stage in the hearing. The panel also noted that Miss Hill had posed questions which the witnesses could be asked. The panel can make allowance for the fact that the NMC s evidence will not be tested by cross-examination and, of its own volition, can explore any inconsistencies in the evidence that it identifies. Furthermore, the limited disadvantage is the consequence of Miss Hill s decisions to absent herself from the hearing, waive her rights to attend and/or be represented and to not provide evidence or make submissions on her own behalf. In these circumstances, the panel has decided that it is fair, appropriate and proportionate to proceed in the absence of Miss Hill. The panel will draw no adverse inference from Miss Hill s absence in its findings of fact. Decision and reasons on application to amend the charge The panel heard an application made by Ms Quinton-Carter, on behalf of the NMC, to amend the wording of charge 5, 7, 9 and 10. The proposed amendment was to insert the words in relation to Patient B. It was submitted by Ms Quinton-Carter that the proposed amendment would provide clarity and more accurately reflect the evidence, specifically: 5) On 6 October 2016 recorded a ventilation reading in relation to Patient B which you had not taken; 7) On 6 October 2016 recorded the minute volume alarm in relation to Patient B, which you did not calculate; 9) On 6 October 2016 did not record the fluid balance chart in relation to Patient B, every hour; 10) On 6 October 2016 wrongly set the heart rate and oxygen saturation alarms in relation to Patient B Page 8 of 38

9 The panel accepted the advice of the legal assessor that Rule 28 of the Rules states: 28. (1) At any stage before making its findings of fact, in accordance with rule 24(5) or (11), the Investigating Committee (where the allegation relates to a fraudulent or incorrect entry in the register) or the Fitness to Practise Committee, may amend (a) (b) the charge set out in the notice of hearing; or the facts set out in the charge, on which the allegation is based, unless, having regard to the merits of the case and the fairness of the proceedings, the required amendment cannot be made without injustice. (2) Before making any amendment under paragraph (1), the Committee shall consider any representations from the parties on this issue. The panel was of the view that such amendments, as applied for, were in the interest of justice. The panel was satisfied that there would be no prejudice to Miss Hill and no injustice would be caused to either party by the proposed amendment being allowed. It was therefore appropriate to allow the amendments, as applied for, to ensure clarity and accuracy. Page 9 of 38

10 Background A referral was received by the NMC on 21 July 2016 from the Matron of the Paediatric Critical Care Unit, Sheffield, Children s NHS Foundation Trust ( the Trust ). Miss Hill started working for the Trust in September 2015 on the Paediatric Critical Care Unit ( PCCU ). She was a newly qualified nurse and was completing her preceptorship programme at the time of the allegations. It is alleged that on 4 March 2016 Miss Hill was caring for Patient A, a child in a high dependency bed on the PCCU. Patient A was on six hourly observations. At 14:00, her observations were due. Miss Hill failed to take Patients A s blood pressure and temperature and made false recordings on the patient s chart to indicate that she had done so. It is further alleged that on 16 March 2016, Miss Hill failed again to take Patient A s observations of blood pressure and temperature. Patient A was on a day trip when Miss Hill entered false information onto Patient A s chart. Following a disciplinary investigation, Miss Hill was given a final written warning on 11 June Miss Hill commenced a phased return to work on the same ward on 5 September She restarted her preceptorship programme and also had a period of supernumerary status. All shifts she worked were supervised and Miss Hill was supported by a small team of senior nurses. However, on 6 October 2016, Miss Hill made a number of further recording errors when caring for Patient B. Miss Hill was being supported and supervised by a member of staff on this date as part of her supervised practice programme. The allegations in relation to Patient B are set out in charges 5 to 12. Following a further disciplinary investigation into these events, Miss Hill was dismissed from the Trust. Page 10 of 38

11 Decision on the findings on facts and reasons The panel was aware that the burden of proof rests on the NMC, and that the standard of proof is the civil standard, namely the balance of probabilities. This means that the facts will be proved if the panel was satisfied that it is more likely than not that the incidents occurred as alleged. The panel heard and accepted the advice of the legal assessor. The panel has drawn no adverse inference from the non-attendance of Miss Hill. In reaching its decisions on the facts, the panel took into account all the oral and documentary evidence in this case, together with the submissions made by Ms Quinton- Carter. The panel heard oral evidence from four witnesses called on behalf of the NMC: Witness 1 (W1), Support Worker; Witness 2 (W2), Clinical Manager for Critical Care Services at the time of the first incident and Matron at the time of the second incident; Witness 3 (W3), Support Worker; Witness 4 (W4), Band 6 Staff Nurse and Clinical Nurse Educator. W2 stated that it was normal practice for newly qualified nurses to work within an intensive care unit after qualifying and that there were mechanisms in place to assist with any concerns the nurse may have. She further stated that following the first investigation W2 undertook in relation to the incident in March 2016, Miss Hall recommenced her preceptorship training and was supernumerary. In relation to charge 5, W2 stated that she asked Miss Hill about the ventilation recording and that Miss Hill responded by stating that she could not see the ventilation machine due to people being around the patient s bed. W2 stated that she would have Page 11 of 38

12 expected Miss Hill to politely request the people to move so that she could view the machine, in order to ensure patient safety. In relation to charge 7, W2 informed the panel that the minute volume is the amount of air that is delivered to the patient by the ventilator over a minute. The alarms are set for upper and lower limits to alert staff should there be an adverse change in these volumes. In relation to charge 9, W2 stated that every hour a record is made of fluid input and output and a balance is calculated. In relation to charge 11, W2 stated that it is best practice to identify a patient by checking their wristband. W2 stated that Miss Hill accepted that she did not check the wristband. W4 stated that it was her responsibility to supervise Miss Hill on allocated shifts during Miss Hill s recommencement on her preceptorship. In relation to charge 5, W4 stated that on 6 October 2016 Miss Hill took the lead in caring for Patient B, a stable patient who was ventilated and nursed on a one to one basis, whilst W4 supervised Miss Hill in doing so. In relation to the ventilation reading, W4 informed the panel that Miss Hill had made a recording of 16/10 when the machine showed that the actual recording was 18/10. W4 stated that she raised the issue of the recording with Miss Hill and Miss Hill informed her that she was unable to see the machine to make an accurate record and so documented the pressure from the previous hour. W4 stated that Miss Hill did not provide an explanation as to why she could not see the machine. W4 stated that this led her to conclude that Miss Hill had knowingly made the record incorrectly. In relation to charge 7, W4 stated that she noticed that the record Miss Hill had made on the ventilation checklist was, in her clinical opinion, not appropriate for a patient of that weight. W4 informed the panel that she asked Miss Hill about the record and Miss Hill informed W4 that she was going to go back and check it later. W4 stated that Miss Hill should have asked her for help if she was unsure. Page 12 of 38

13 W4 stated that she spoke with Miss Hill in the presence of another colleague in relation to the incidents on the nightshift of 6 October 2016 and W4 expressed her concerns. W4 stated that, during this meeting, Miss Hill stated that she had not cared for ventilated a patient for a long time. W4 stated that she felt that Miss Hill failed to appreciate the seriousness of the mistakes she had made. When questioned in relation to charge 9, W4 informed the panel that the fluid balance chart needs to be completed every hour. W4 informed the panel that you should always sign the chart once the fluid balance has been calculated and checked. However, when referred to the fluid balance chart by the panel, W4 accepted that some nurses might complete the relevant calculations but forget to sign that they had been checked. W4 stated that completing the chart fully is very important as it could affect the drugs and fluids that may need to be prescribed for the patient. W4 stated that at the beginning of the shift on 6 October 2016, Miss Hill appeared happy and confident in taking the lead. However, W4 stated that at the end of the shift, after discussing the concerns raised, Miss Hill appeared defeated. Further application to amend the charge After hearing evidence from the NMC witnesses, the panel heard a further application made by Ms Quinton-Carter on behalf of the NMC, to further amend the wording of charge 7 and 9. The proposed amendment in relation to charge 7 was to insert the word settings, specifically: 7) On 6 October 2016 recorded the minute volume alarm settings, in relation to Patient B, which you did not calculate The proposed amendment to charge 9 was to insert the words During the night shift of and remove the word chart from the charge, specifically: Page 13 of 38

14 9) On During the night shift of 6 October 2016 did not record the fluid balance chart, in relation to Patient B, every hour It was submitted by Ms Quinton-Carter that the proposed amendment would provide clarity and more accurately reflect the evidence. Miss Hill was spoken to on the telephone and informed the panel that she did not oppose the proposed amendments. The panel accepted the advice of the legal assessor that Rule 28 of the Rules states: 28. (1) At any stage before making its findings of fact, in accordance with rule 24(5) or (11), the Investigating Committee (where the allegation relates to a fraudulent or incorrect entry in the register) or the Fitness to Practise Committee, may amend (a) (b) the charge set out in the notice of hearing; or the facts set out in the charge, on which the allegation is based, unless, having regard to the merits of the case and the fairness of the proceedings, the required amendment cannot be made without injustice. (2) Before making any amendment under paragraph (1), the Committee shall consider any representations from the parties on this issue. When drafting its reasons, the panel noted that no amendment had been prosed to charge 8 in order to make it compatible with the amendment which had been proposed for charge 7. The panel considered that charge 8 should be amended by the addition of the word settings after the word alarm, in line with the proposed amendments in charge 7: 8) Your actions in charge 7 above were dishonest in that you knew you had not calculated the minute volume alarm settings Page 14 of 38

15 The panel was satisfied that there would be no prejudice to Miss Hill and no injustice would be caused to either party by the proposed amendments being allowed. It was therefore appropriate to allow the amendments, as applied for, to ensure clarity and accuracy. Continued decision on the findings on facts and reasons On the afternoon of 9 January 2018, Miss Hill gave evidence to the panel by telephone under affirmation. Miss Hill informed the panel that she did not have any of the hearing documents with her. Miss Hill was asked if she was happy to proceed and Miss Hill concurred that she was happy to proceed in those circumstances. Miss Hill referred the panel to her written submissions dated 1 December 2017 and 5 January 2018 and informed the panel that the content of those submissions were true to the best of her knowledge and belief. Miss Hill stated that she has reflected on her actions in respect of the admitted charges. In relation to charge 5, Miss Hill stated that she did check the ventilation reading but misread the number. Miss Hill stated that she was prevented from obtaining good visibility of the ventilation reading by people around the bed of the patient. Miss Hill further stated that she now realises she should have checked more carefully to ensure the accuracy of the reading and that she did not act dishonestly or maliciously in failing to do so. In relation to charge 7, Miss Hill stated that she did not intentionally fail to calculate the minute volumes but that she simply forgot to do so due to her feeling flustered and not concentrating properly. Page 15 of 38

16 In relation to charge 9, Miss Hill stated that because of another colleague administering medication for her, she was unable to complete the fluid balance chart until the she was informed of the of volume medication administered. Miss Hill stated that she takes responsibility for her actions but that there were a number of issues within the Ward. Miss Hill provided examples to the panel including the Trust failing to arrange an occupation health review for her and feeling unsupported on certain shifts which resulted in Miss Hill internalising her problems. In addition, she did not feel comfortable in the presence of W4. Miss Hill stated that W4 made her feel under pressure, particularly as she was aware of Miss Hill s health condition. Miss Hill stated that she felt she did not have anyone she could speak to and, as a result, began panicking and subsequently making mistakes. The panel found all the NMC witnesses to be honest, credible and professional in their evidence. The panel found their evidence to be consistent with the documents provided to the panel and with each other. The panel found the witnesses to be frank when they did not have a clear recollection of accounts and demonstrated that they were clinically credible. The panel noted that Miss Hill provided evidence by telephone and it was therefore unable to fully assess Miss Hill s demeanour. However, the panel found that Miss Hill was confident in the answers she provided and that she accepted when she could not remember certain details relating to the charges. The panel found Miss Hill to be consistent in her oral evidence but it noted inconsistencies between her oral evidence and what she is reported to have said during interviews conducted by the Trust. The panel found that this affected her credibility in regards to certain matters. At the start of this hearing, the panel considered Miss Hill s written and signed submissions dated 1 December Ms Quinton-Carter invited the panel to find that the submissions before it, amount to formal admissions in relation to charges 1, 2, 3 4, 10 and 11. The panel determined that the written submissions did amount to admissions and therefore found charges 1, 2, 3, 4, 10 and 11 proved, by admission. Miss Hill was Page 16 of 38

17 informed of this at the start of the telephone call with her on 9 January 2018, and accepted those findings. The panel then went on to consider the remaining charges. The panel considered each charge in turn and made the following findings: Charge 5: 5) On 6 October 2016 recorded a ventilation reading in relation to Patient B which you had not taken This charge is found proved In reaching this decision, the panel took into account all the evidence before it. The panel noted the evidence within the minutes of the investigation meeting held on 8 December 2016, between Miss Hill, W2 and a Human Resources representative, in which it is reported that Miss Hill had stated: I went to look at the ventilation machine but I could not see it as there were a few people around the patient s bed They were in the middle of a conversation therefore I did not want to disturb them The minutes state that Miss Hill was asked whether the people around the patient s bed were family or staff, to which Miss Hill responded that they were staff. The minutes further state: The ventilation setting had been handed over to me by the previous nurse. The panel noted that when asked whether this was normal practice to take the word of another nurse, Miss Hill responded stating: Page 17 of 38

18 No I would usually check the ventilation readings. When asked However, you did not on this occasion. Is that correct?, Miss Hill responded Yes. The panel found that the minutes of the investigation meeting are corroborated, to some extent, by the typed notes, dated 6 October 2016, prepared by W4, based on hand written notes she had made of a meeting with the registrant and a Band 7 nurse during the night shift commencing on 6 October That typed note states: The ventilator observations documented on the ICU chart for were documented as 16/10 when they were actually set at 18/10 (they had been documented as 16/10 from the previous shift). Discussed this with Chloe and she stated that she could not see the ventilator so documented the pressures that had been written down for the previous hour. The panel also noted W4 s oral evidence in which she informed the panel that there is a large amount of space around each bed, which is necessary for equipment and in the event of any emergency. Accordingly, W4 stated that the presence of other staff would not have stopped Miss Hill from recording a reading. The panel noted that Miss Hill s written submission of 1 December 2017 states: With this allegation, I have denied intentionally falsifying the document on this date. I did check the patient s ventilation reading from the end of the bed space. I believed it was 16/10 rather than 18/10. I was also handed over by a previous nurse as 16/10 who had also documented their readings incorrectly as 16/10. I mention this because when I thought the ventilator read 16/10, I had no other evidence to make me believe this was wrong. I understand now that I should have moved closer to the ventilator to double (sic), and this is something I will take with me into the future. Page 18 of 38

19 In her oral evidence, Miss Hill stated that she had difficulty seeing the reading on the ventilator because of people around the patient s bed. She stated that she thought she saw 16/10, which was the same as the previous reading in Patient A s record, and she therefore made an entry of 16/10. The panel noted that Miss Hill had not stated at the meeting held on the nightshift of 6 October 2016 that she had been unable to see the ventilator reading because of other people being present. Miss Hill also did not mention this in her statement to the NMC on 1 December At the investigation meeting of 8 December 2017, Miss Hill agreed, when specifically asked by W2, Miss Hill agreed that she did not check the ventilation readings. In light of the inconsistencies in Miss Hill s accounts and taking into account the evidence of W2 and W4, the panel determined that Miss Hill recorded a ventilation reading that she had not taken. The panel therefore found this charge proved. Charge 6 6) Your actions in charge 5 above were dishonest in that you knew you had not taken a ventilation reading This charge is found proved. In reaching this decision, the panel considered its findings on charge 5. The panel determined that Miss Hill had recorded a reading in the patient s records in order to give the impression that she had taken a reading, when she had not done so. The panel carefully considered the background circumstances relating to the case, what Miss Hill knew at the time of the incident, and what was expected of her. The panel concluded that the entry had been made to convey the impression that she had taken the reading, when she had not done so. The panel concluded that such an action was dishonest by the standards of reasonable and honest people. The panel therefore found this charge proved. Page 19 of 38

20 Charge 7 7) On 6 October 2016 recorded the minute volume alarm settings, in relation to Patient B, which you did not calculate This charge is found proved In reaching this decision, the panel took into account all of the evidence before it. The panel noted the evidence within the minutes of the investigation meeting held on 8 December 2016, between Miss Hill, W2 and a Human Resources representative, in which it is reported that Miss Hill had stated: I forgot about the calculation as I had not had a ventilated patient for a while. Therefore I wrote the number down which was on the ventilator The panel further noted the typed notes of the minutes of the meeting on the nightshift which commenced on 6 October 2016, prepared by W4 that states: When completing and signing the ventilation safety check chart the minute volumes were incorrect. I asked Chloe if she was aware of how to calculate Minute Volumes and she then calculated them correctly and stated that she was going to calculate them correctly later on. The panel determined that collectively, the evidence suggests Miss Hill did record the minute volume setting without calculating it properly. This is corroborated in both Miss Hill s oral and written submissions in which latter she states: I did not originally calculate the minute volumes. This is because I simply forgot to do the calculation. Once I was reminded to do the calculation, I was then able to calculate this. I do apologise for the mistake I made, however, I did not intentionally do this. Page 20 of 38

21 In light of the evidence before it, the panel determined that Miss Hill did record the minute volume setting without calculating it and therefore found this charge proved. Charge 8 8) Your actions in charge 7 above were dishonest in that you knew you had not calculated the minute volume alarm settings This charge is found proved In reaching this decision, the panel considered its findings on charge 7. The panel carefully considered the background circumstances relating to this charge, what Miss Hill knew at the time of the incident and what was expected of her. The panel referred to the typed notes of the minutes of the meeting dated 6 October 2016, which state: Discussed that I found it most concerning that she understood how to calculate them but had not done so. The panel further considered Miss Hill s written submission of 1 December 2017 which states: As I did not intentionally falsify this document, or intentionally not do the calculation. Therefore, I do not feel I was dishonest in my actions. Again, I admit that this was careless of me to forget. Miss Hill gave evidence that she had intended to return to calculate the settings at a later time. The panel considered that the alarm settings would be an important part of patient safety checks and noted that the alarm settings in the patient s record had changed over a period of time. The panel therefore determined that it would be unlikely that Miss Page 21 of 38

22 Hill would forget that the settings needed to be calculated, rather than merely to repeat the previous setting. Further, the panel determined that as Miss Hill stated that she knew how to calculate properly, this undermined her argument that she had forgotten to complete the calculations. In light of the evidence before it, the panel considered that it was not credible that Miss Hill was going to return and amend the recording she had already made and that undermined her contention that she had not acted dishonestly in recording the minute volume alarm settings, which she had not calculated. The panel concluded that her actions were dishonest by the standards of reasonable and honest people and therefore found this charge proved. Charge 9 9) During the night shift of 6 October 2016 did not record the fluid balance, in relation to Patient B, every hour This charge is found NOT proved In reaching this decision, the panel took into account all of the evidence before it, in particular, Patient B s fluid balance chart. The panel noted Miss Hill s written submission of 1 December 2017 in which she accepts that: I had not added the fluid balance chart together and ensured it had been filled in completely. The panel noted that the relevant fluid balance figures are recorded on the chart every hour, although for one of the hours during that shift, there was no tick or signature next to the balance. It noted that no suggestion was made by any of the witnesses that any of the fluid recordings, including the balance recording, were not made by Miss Hill. Page 22 of 38

23 Despite considering W4 s evidence that it is best practise to sign the recording, the panel determined that in light of the evidence before it, the fluid balance had been recorded every hour. The panel therefore found this charge not proved. Charge 12 12) Your actions in charge 11 were dishonest in that you knew you had not checked for the wrist band. This charge is found proved In reaching this decision, the panel took into account all of the evidence before it. The panel carefully considered the background circumstances relating to this charge, what Miss Hill knew at the time of the incident and what was expected of her. The panel noted the typed notes, dated 6 October 2016, prepared by W4, based on hand written notes she had made of a meeting with the registrant and a Band 7 nurse during the night shift commencing on 6 October That typed note states: When we went to give the patient medication there was no wrist label present. Chloe had ticked on the safety checks that the patient had a wrist label in situ. When I asked Chloe about this she stated that she was going to check for a wrist label later in the shift during cares. The panel considered Miss Hill s oral evidence that she ticked the box by mistake and intended to tick the box above. However, the panel found that there was no such box above. [PRIVATE] It found that it is not credible that Miss Hill would have returned to the patient to check for the wrist band later on in the shift, as she asserted. In light of the inconsistences in Miss Hill s evidence, the panel determined that she should not have recorded that she had made the check, when she had not done so. It Page 23 of 38

24 concluded that her action was dishonest by the standards of reasonable and honest people. The panel therefore found this charge proved. Page 24 of 38

25 Submission on misconduct and impairment: Having announced its finding on all the facts, the panel then moved on to consider, whether the facts found proved amount to misconduct and, if so, whether Miss Hill s fitness to practise is currently impaired. There is no statutory definition of fitness to practise. However, the NMC has defined fitness to practise as a registrant s suitability to remain on the register unrestricted. Miss Hill gave evidence to the panel via WebEx under affirmation. She referred the panel to her written submissions dated 10 January Miss Hill stated that she has taken responsibility for her actions and has learnt from the mistakes that she made when she was working in the PCCU and expressed remorse for her failings. Miss Hill stated that she wants to improve in her practice and, despite not working in a clinical setting since her dismissal from the Trust, Miss Hill informed the panel that she continues to read medical journals in her spare time to keep her knowledge up to date. Miss Hill stated that she does wish to practise as a nurse again in the future and that should she find herself in a similar situation to that which resulted in the charges, she would now be able to speak clearly about her thoughts and feelings to colleagues and managers. [PRIVATE] When questioned, Miss Hill informed the panel that, overall, the support she received from the Trust was good. However, Miss Hill stated that when she tried to express that she was feeling overwhelmed, she did not feel she got the support she needed. Miss Hill stated that at the time of the allegations, she was not thinking clearly and was under a lot of pressure and was not fit to be at work. Miss Hill further stated that she understands that making incorrect recordings risked causing harm to the patients in her care. In her submissions, Ms Quinton-Carter invited the panel to take the view that Miss Hill s actions amounted to breaches of The Code: Professional standards of practice and behaviour for nurses and midwives (2015). She then directed the panel to specific Page 25 of 38

26 paragraphs and identified where, in the NMC s view, Miss Hill actions amounted to misconduct. Ms Quinton-Carter then moved on to the issue of impairment, and addressed the panel on the need to have regard to protecting the public and the wider public interest. This included the need to declare and maintain proper standards and maintain public confidence in the profession and in the NMC as a regulatory body. Ms Quinton-Carter referred the panel to the judgement of Mrs Justice Cox in the case of Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin). In reaching her decision, in paragraph 74 she said: In determining whether a practitioner s fitness to practise is impaired by reason of misconduct, the relevant panel should generally consider not only whether the practitioner continues to present a risk to members of the public in his or her current role, but also whether the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular circumstances. Mrs Justice Cox went on to refer to paragraph of Dame Janet Smith in her Fifth Report from Shipman, where she identified the following as an appropriate test for panels considering impairment. Do our findings of fact in respect of the doctor s misconduct, deficient professional performance, adverse health, conviction, caution or determination show that his/her fitness to practise is impaired in the sense that s/he: a. 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 b. has in the past brought and/or is liable in the future to bring the medical profession into disrepute; and/or Page 26 of 38

27 c. has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the medical profession; and/or d. has in the past acted dishonestly and/or is liable to act dishonestly in the future. Ms Quinton-Carter submitted that all four limbs of the test are engaged. Ms Quinton-Carter submitted that there is a risk of repetition of the concerns found proved. She invited the panel to consider that at the time of the allegations Miss Hill was a newly qualified nurse. However, Ms Quinton-Carter submitted that despite disciplinary proceedings having been conducted in relation to the incidents in March 2016, similar incidents were repeated in October Ms Quinton-Carter submitted that this repetition demonstrated Miss Hill s failure to appreciate the seriousness of her failings in March Ms Quinton-Carter submitted that Miss Hill has not worked within a clinical setting since her suspension in October 2016 and there is no evidence before the panel to demonstrate that Miss Hill has sought to improve her practice or undertake any training in relation to nursing. In relation to insight, Ms Quinton-Carter submitted that Miss Hill has demonstrated limited insight. She further submitted that although Miss Hill accepts responsibility for her failures, she seeks to deflect responsibility for her actions onto other factors. The panel has accepted the advice of the legal assessor, which included reference to a number of judgments which are relevant. These included: Grant [2011] EWHC 927 (Admin), Ronald Jack Cohen v General Medical Council [2008] EWHC 581 (Admin), Roylance v General Medical Council (No 2) [2000] 1 A.C. 311 and Nandi v GMC [2004] EWHC 2317 (Admin). The panel adopted a two-stage process in its consideration, as advised. First, the panel must determine whether the facts found proved amount to misconduct. Secondly, only if the facts found proved amount to misconduct, the panel must decide whether, in all the Page 27 of 38

28 circumstances, Miss Hill s fitness to practise is currently impaired as a result of that misconduct. Page 28 of 38

29 Decision on misconduct When determining whether the facts found proved amount to misconduct the panel had regard to the terms of The Code: Professional standards of practice and behaviour for nurses and midwives (2015). The panel, in reaching its decision, had regard to the public interest and accepted that there was no burden or standard of proof at this stage and exercised its own professional judgement. The panel was of the view that Miss Hill s actions did fall significantly short of the standards expected of a registered nurse, and that her actions amounted to a breaches of the Code. Specifically: 1 Treat people as individuals and uphold their dignity 1.2 make sure you deliver the fundamentals of care effectively 10 Keep clear and accurate records relevant to your practice 10.3 complete all records accurately and without any falsification 13 Recognise and work within the limits of your competence 13.3 ask for help from a suitably qualified and experienced healthcare professional to carry out any action or procedure that is beyond the limits of your competence 16 Act without delay if you believe there is a risk to patient safety or public protection 16.2 raise your concerns immediately if you are being asked to practise beyond your role, experience and training Page 29 of 38

30 19 Be aware of, and reduce as far as possible, any potential for harm associated with your practice 19.1 take measures to reduce as far as possible, the likelihood of mistakes, near misses, harm and the effect of harm if it takes place 20 Uphold the reputation of your profession at all times 20.1 keep to and uphold the standards and values set out in the code 20.2 act with honesty and integrity at all times 20.9 maintain the level of health you need to carry out your professional role The panel appreciated that breaches of the Code do not automatically result in a finding of misconduct. However, the panel determined that the facts found proved, taken individually and collectively, are serious in nature. The panel was informed that no actual harm occurred. However, it determined there was a real risk of harm to patients in Miss Hill s care because of her failings. The panel found that Miss Hill s actions did fall seriously short of the conduct and standards expected of a nurse and amounted to misconduct. Page 30 of 38

31 Decision on impairment The panel next went on to decide if, as a result of this misconduct, Miss Hill s fitness to practise is currently impaired. Nurses occupy a position of privilege and trust in society and are expected at all times to be professional. Patients and their families must be able to trust nurses with their lives and the lives of their loved ones. To justify that trust, nurses must be honest, open and act with integrity. They must make sure that their conduct at all times justifies both their patients and the public s trust in the profession. In this regard, the panel considered the judgement of Mrs Justice Cox in the case of Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin). The panel determined that all four limbs of the test set out by Dame Janet Smith in her Fifth Shipman Report are engaged. Miss Hill has put patients at an unwarranted risk of harm, and has brought the nursing profession into disrepute. The panel further determined that Miss Hill has breached a fundamental tenet of the nursing profession as a result of her misconduct and that she has acted dishonestly. Regarding insight, the panel accepted Miss Hill s evidence that she has taken significant steps to address her health condition. [PRIVATE] Nevertheless, the panel determined that Miss Hill has failed to demonstrate full insight, in either her submissions or her oral evidence, as to how her misconduct may have affected vulnerable patients in her care, their families, her colleagues and the nursing profession. In considering whether Miss Hill has remedied her practice, the panel determined that the record keeping errors found proved are capable of remediation, but that there was no evidence before it to demonstrate Miss Hill has remediated these concerns. With regards to the five dishonesty allegations found proved, the panel was concerned about the repetition of the dishonesty, in particular after Miss Hill had been suspended and given a final written warning by the Trust after the first two incidents. [PRIVATE] The panel was therefore of the view that there is a risk of repetition of the clinical Page 31 of 38

32 shortcomings in the record keeping incidents and of the dishonesty. A finding of impairment is therefore required for the protection of the public. The panel bore in mind that the overarching objectives of the NMC are to protect, promote and maintain the health, safety and well-being of the public and patients, and to uphold/protect 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 those professions. The panel determined that, in this case, a finding of impairment on public interest grounds is also required. Having regard to all of the above, the panel was satisfied that Miss Hill s fitness to practise is currently impaired. Page 32 of 38

33 Determination on sanction: Miss Hill participated in this stage of the hearing by WebEx. Submissions on sanction were made by Ms Quinton- Carter on behalf of the NMC and by Miss Hill. The panel has considered this case very carefully and has decided to make a suspension order for a period of 12 months. The effect of this order is that the NMC register will show that Miss Hill s registration has been suspended. In reaching this decision, the panel has had regard to all the evidence that has been adduced in this case. The panel accepted the advice of the legal assessor. The panel has borne in mind that any sanction imposed must be appropriate and proportionate and, although not intended to be punitive in its effect, may have such consequences. The panel had careful regard to the Sanctions Guidance ( SG ) published by the NMC. It recognised that the decision on sanction is a matter for the panel, exercising its own independent judgement. The panel took into account its findings on impairment. The panel considered that the following were aggravating and mitigating factors: Aggravating factors The charges relate to repeated incidents of clinical errors and dishonesty, both before and after a suspension, disciplinary hearing and a final written warning following the incidents in March 2016; Miss Hill s failures relate to basic nursing care; Miss Hill s misconduct put vulnerable paediatric patients at unwarranted risk of harm on more than one occasion; Miss Hill has demonstrated limited insight into the effect her misconduct could have had on patients, their families, colleagues and the reputation of the nursing profession; Page 33 of 38

34 Mitigating factors Miss Hill has made full admissions in relation to charges 1 to 4, 10 and 11 and accepted certain aspects of the incidents giving rise to the other charges found proved; [PRIVATE] The panel considered the nature of the misconduct in Miss Hill s case. [PRIVATE] Miss Hill thereby put vulnerable patients at an unwarranted risk of harm and attempted to deceive her supervisor that she had followed the correct procedure to obtain accurate figures for patient observations. The panel determined that Miss Hill s misconduct of repeated dishonesty demonstrated a pattern of behaviour and a tendency to be dishonest in certain situations. Miss Hill has continued to demonstrate limited insight in this respect. The panel first considered whether to take no action but concluded that this would be inappropriate in view of the seriousness of the case. Next, in considering whether a caution order would be appropriate in the circumstances, the panel took into account the SG, which states that a caution order may be appropriate where the case is at the lower end of the spectrum of impaired fitness to practise and the panel wishes to mark that the behaviour was unacceptable and must not happen again. The panel considered that Miss Hill s misconduct was not at the lower end of the spectrum and that a caution order would neither protect the public or satisfy the public interest concerns in this case. The panel next considered whether placing conditions of practice on Miss Hill s registration would be a sufficient and appropriate response. The panel is mindful that any conditions imposed must be proportionate, measurable and workable. The panel determined that conditions may be workable and appropriate in relation to the clinical errors in Miss Hill s case, but determined that such conditions would not be practicable after taking into account the fact that the charges found proved, which included Page 34 of 38

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