Conduct and Competence Committee Substantive Hearing 4 11 July 2016 Nursing and Midwifery Council, 2 Stratford Place, Montfichet Road, London, E20 1EJ

Transcription

1 Conduct and Competence Committee Substantive Hearing 4 11 July 2016 Nursing and Midwifery Council, 2 Stratford Place, Montfichet Road, London, E20 1EJ Name of Registrant Nurse: Mrs Susan Patricia James NMC PIN: 77J1643E Part(s) of the register: Registered Nurse Adult (Level 2) Nurse Sub part 2 Area of Registered Address: England Type of Case: Misconduct Panel Members: David Kyle (Chair Lay member) Julie Humphreys (Registrant member) Nalini Chavda (Lay member) Legal Assessor: Nicholas Wilcox (Day 1 2 and 4 6) Simon Walsh (Day 3 only) Panel Secretary: Melissa Daysh Mrs James: Nursing and Midwifery Council: Not present or represented. Represented by Mr Conor Kennedy, counsel, instructed by NMC Regulatory Legal Team. Facts proved: 1, 2, 3.1, 3.2, 4.2, 5.1, 5.3, 5.4, 5.5, 6.2, 6.3, 7.3, 8.1, 8.4, 10, 12.1 and 12.4 Facts not proved: 3.3, 4.1, 5.2, 6.1, 7.1, 7.2, 7.4, 8.2, 8.3, 9, 11.1, 11.2, 12.2, 12.3, 13.1, 13.2 and 13.3 Fitness to practise: Impaired by reason of misconduct Sanction: Striking off order Interim Order: Interim suspension order 18 months 1

2 Details of charge (as amended): That you, a Registered Nurse, whilst employed on Ward L2 at Salford Royal NHS Foundation Trust during a night shift commencing 30 June 2013: 1. Left your shift approximately 40 minutes early without authorisation. 2. Did not provide adequate handover for one or more patients. 3. In respect of Patient 1: 3.1. Did not document the start time, duration, and / or rate of a Percutaneous Endoscopic Gastrostomy (PEG) feed; 3.2. Between 18:00 and 06:00 did not complete the fluid balance chart; 3.3. Did not monitor and/or record blood glucose levels. 4. In respect of Patient 2: 4.1. Did not complete a stool chart; 4.2. Between 19:00 and 06:00 did not complete the fluid balance chart. 5. In respect of Patient 3: 5.1. Did not document the number of days the cannula had been inserted; 5.2. Between 18:00 and 06:00 did not adequately complete the fluid balance chart; 5.3. Signed to say that you had administered Zomorph 30mg without a second signatory; 5.4. Delegated the administration of Zomorph to Colleague A; 5.5. Did not administer and/or ensure the administration of Zomorph 30mg. 6. In respect of Patient 4: 6.1. Did not complete a stool chart; 6.2. Between 18:00 and 06:00 did not complete the fluid balance chart; 2

3 6.3. Did not document the start time, duration, and / or rate of a Nasogastric feed. 7. In respect of Patient 5: 7.1. Did not complete a cannula pathway; 7.2. Did not complete a stool chart; 7.3. Did not handover the EWS score; 7.4. Between 22:00 and 06:00 did not complete the fluid balance chart. 8. In respect of Patient 7: 8.1. Between 22:00 and 06:00 did not complete the fluid balance chart; 8.2. Did not complete a stool chart; 8.3. Did not complete a cannula pathway; 8.4. Incorrectly recorded the Early Warning Score (EWS) as In respect of Patient 8, between 00:00 and 06:00 did not complete the fluid balance chart. 10. In respect of Patient 9, between 18:00 and 06:00 did not complete the fluid balance chart. 11. In respect of Patient 10: Did not complete a stool chart; Between 23:00 and 06:00 did not complete the fluid balance chart. 12. In respect of Patient 11: Did not implement a stool chart; Did not complete a cannula pathway; Did not complete a food chart; Between 20:00 and 06:00 did not record fluid intake on the fluid balance chart. 3

4 13. In respect of Patient 13: Did not complete a stool chart; Did not complete a cannula pathway; Did not adequately complete the adult observation chart. AND, in light of the above, your fitness to practise is impaired by reason of your misconduct. 4

5 Decision on Service of Notice of Hearing: The panel was informed at the start of this hearing that Mrs James was not in attendance and has not engaged with the NMC leading up to these proceedings. Since 4 February 2014, no registered address for Mrs James has been on the Register and a note had been placed on the Register stating do not mail. Mr Kennedy, on behalf of the NMC, informed the panel that written notice of this hearing had been sent to Mrs James last registered address by recorded delivery and by first class post on 2 June Royal Mail Track and Trace documentation confirmed that the notice of hearing was sent to Mrs James last registered address by recorded delivery on that date. The notice was returned to the NMC stating that Mrs James had gone away. Mr Kennedy also informed the panel that the NMC had engaged Beaumont Consultants Limited to investigate Mrs James current address. While a different address to that on the Register was identified as a result of the Speedtrace Report, the notice of hearing was not sent to this different address for Mrs James. Mr Kennedy stated there was insufficient certainty from the NMC that Mrs James resides at this address and this is the reason the written notice of this hearing was not posted to this address, but rather posted to her last registered address as listed on the Register. Mr Kennedy 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 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 Mrs James right to attend, be represented and call evidence, as well as the panel s power to proceed in her absence. The panel accepted the advice of the legal assessor. In the light of all of the information available, the panel determined that Mrs James was likely to be aware of the NMC proceedings being taken against her, even though it was 5

6 unlikely that she will have seen the formal notice of hearing required to be served under Rule 11 of the Rules. It is apparent that for some time the NMC has had reason to believe that Mrs James was no longer living at the address as last listed on the Register. Since at least October 2015, the NMC had been sending correspondence, including the Notice of Referral dated 26 January 2016 containing the Standard Directions Form and charges Mrs James faced, to the address advised by Beaumont Consultants Limited. It was only the notice of hearing, dated 2 June 2016, that was sent to Mrs James address as listed on the register. The panel determined that the NMC knew that it was more than likely that Mrs James would not receive the notice of hearing at this address. Despite sending other correspondence to Mrs James address as identified by Beaumont Consultants Limited, they failed to send the notice of hearing to this address, even with the knowledge that someone by the name of James had signed for correspondence from the NMC sent to this address in October The NMC therefore had failed to send the notice of hearing to the address at which Mrs James was most likely residing. In accordance to the judgement of Hill v Institute of Chartered Accountants EWCA Civ 555 [2013] the right question to ask of any procedure adopted should therefore not be whether it is permitted but whether it is prohibited It must, of course, still be fair and that is the critical issue. The judgement of GMC v Adeogba [2016] EWCA Civ 162, states the first question that had to be addressed in any regulatory disciplinary case was whether all reasonable efforts had been taken to serve a practitioner with notice. That had to be considered against the background of the requirement on the part of the practitioner to provide an address for the purposes of registration along with the methods used by the practitioner to communicate with the (GMC) and the relevant tribunal during the investigative and interlocutory phases of the case. 6

7 The panel takes the view that Rule 34 is not mandatory but directory, in that failure to comply with Rule 34 does not of itself mean that hearing cannot continue. Rule 34 states: 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, or by leaving it at (a) (b) her address in the register; or where this differs from, and it appears to the Council more likely to reach her at, her last known address, the registrant s last known address. The NMC has served notice on Mrs James address as last listed in the Register, despite having reason to believe that she was residing elsewhere and sending other correspondence to this address. The NMC has therefore failed to comply with the terms of Rule 34. However, despite at least one letter being received by someone of the name James in October 2015 at the address indicated by Beaumont Consultants Limited, Mrs James has herself failed to comply with her obligation as a Registered Nurse, in that she has not responded to any correspondence sent to either address by the NMC and indeed has not apparently engaged with the NMC from the outset of these proceedings. In particular, she has not given the NMC details of an effective current registered address. The panel concluded that Mrs James is likely to be aware of the investigation into her fitness to practise and the proceedings brought against her by the NMC. The Rules do not require proof of delivery of the notice of hearing. It is the responsibility of any registrant to maintain an effective and up-to-date registered address. The panel concluded that Mrs James has failed to discharge her obligation in this respect. It has therefore in reality been difficult, if not impossible, for the NMC to know where to send the notice of hearing with any expectation of it being seen by Mrs James. 7

8 Having regard to relevant case law, the panel has determined that Rule 34 is not mandatory and that accordingly a breach of this Rule is not of itself fatal to the hearing continuing. There is a substantial public interest in the timely hearing of fitness to practise allegations. Mrs James failure to provide the NMC with details of a current effective address and to engage with the NMC in connection with these proceedings has led the panel to determine that any unfairness to her resulting from non-compliance by the NMC with Rule 34 is outweighed by the public interest in the hearing continuing. Decision on proceeding in the absence of the Registrant: The panel had regard to Rule 21 (2) (b) which states: Where the registrant fails to attend and is not represented at the hearing, the Committee...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... Mr Kennedy invited the panel to continue in the absence of Mrs James on the basis that she has had some notification that she is facing charges before the NMC. She has not engaged with the NMC since the outset of its investigation and, as a consequence, there was no reason to believe that an adjournment would secure her attendance on some future occasion. 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 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 and GMC v Adeogba [2016] EWCA Civ

9 The panel has decided to proceed in the absence of Mrs James. In reaching this decision, the panel has considered the submissions of Mr Kennedy, and the advice of the legal assessor. It has had regard to the overall interests of justice and fairness to all parties. It took into account that: Mrs James has not engaged with the NMC and has not responded to any of the letters sent to her about this hearing; There is no reason to suppose that adjourning would secure her attendance at some future date; Three witnesses have attended today to give evidence and another two witnesses are due to give evidence tomorrow; Further delay may have an adverse effect on the ability of witnesses to recall events; There are multiple, serious charges to be heard at these proceedings; There is a strong public interest in the expeditious disposal of the case. There is some disadvantage to Mrs James in proceeding in her absence. Although the evidence upon which the NMC relies will have been sent to her at her registered address, she has made no response to the allegations. 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. 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 weaknesses in the evidence which it identifies. Furthermore, the limited disadvantage is the consequence of Mrs James choice not to engage with the NMC in connection with its investigation and the resulting fitness to practise proceedings. In these circumstances, the panel has decided that it is fair, appropriate and proportionate to proceed in the absence of Mrs James. The panel will be careful to ensure that it does not draw any adverse inference based solely on Mrs James absence in its findings of fact. 9

10 Decision and reasons on application to amend charge: The panel heard an application made by Mr Kennedy, on behalf of the NMC, to amend the wording of charge 6.3 and 9. Mr Kennedy submitted that the proposed amendments would provide clarity and more accurately reflect the evidence without any prejudice to Mrs James. 6. In respect of Patient 4: Did not document the start time, duration, and / or rate of a Percutaneous Nasogastric Endoscopic Gastrostomy (PEG) feed. 9. In respect of Patient 8, between 00:00 and 06:00 did not complete the fluid balance [chart]. 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 (i) the Conduct and Competence Committee, may amend (a) the charge set out in the notice of hearing unless, having regard to the merits of the case and the fairness of the proceedings, the required amendment cannot be made without injustice. 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 Mrs James and no injustice would be caused to either party by the proposed amendments being allowed. It 10

11 was therefore appropriate to make the requested amendments to ensure clarity and accuracy. Decision and reasons on application pursuant to Rule 31: The panel heard an application made by Mr Kennedy under Rule 31 of the Rules to allow the written statement of Ms 6 into evidence. He told the panel that Ms 6 was not present at this hearing as Ms 6 is not the sole witness to give evidence in relation to charge 2. She was not present at the time of the incidents. Mr Kennedy reminded the panel that Mrs James made the decision not to attend this hearing. On this basis, Mr Kennedy advanced the argument that there was no lack of fairness to Mrs James in allowing Ms 6 s written statement into evidence. In reaching its decision, the panel took into account that Ms 6 s statement had been prepared in anticipation of being used in these proceedings and contained the paragraph This statement of two pages is true to the best of my information, knowledge and belief and was signed by her. The panel considered whether Mrs James would be disadvantaged by the change in the NMC s position of moving from reliance upon the oral evidence of Ms 6 to that of a written statement. As the panel had already determined to proceed in Mrs James absence, she would not be in a position to cross examine this witness in any event. The panel considered that there was also a potential disadvantage in that the NMC would be deprived, as would the panel, of the oral evidence of this witness and the opportunity of questioning and probing that testimony. 11

12 Having taken and accepted the legal assessor s advice, the panel came to the view that it should accept into evidence Ms 6 s written statement. It is relevant to proof of some of the allegations and it is consistent with other evidence heard by the panel. She is not the sole or decisive witness called by the NMC in relation to charge 2. The panel accordingly determined that it would not be unfair to admit Ms 6 s statement in evidence. The panel would give appropriate weight to that evidence once it had heard and evaluated all the evidence before it. Background: The charges arose while Mrs James was employed as a Registered Nurse on Ward L2 at Salford Royal NHS Foundation Trust. Ward L2 is a 24 bed acute medical ward specialising in gastroenterology. It is alleged that during a night shift commencing 30 June 2013, in which Mrs James was the nurse in charge, she left her shift early at approximately 06:20 on 1 July 2013 without permission when she was due to finish at 07:30. This put patients at risk as it left the only other registered nurse, Ms 2, in sole charge of 24 patients, some of whom were very ill. When the day staff, namely Ms 4 and Mr 1, arrived on duty they discovered that Mrs James was not on the ward to provide them with a verbal handover and had left written handover notes for them instead. These were alleged to have been of poor quality. Subsequently, this matter was escalated to Ms 5. This matter was investigated by Ms 5, who was the Ward Manager at the time of the allegations. During the course of her investigation, Ms 5 came to the conclusion that Mrs James had not adequately completed a range of documentary records relating to the care of patients allocated to her, including fluid balance and observations charts, such as stool and food charts. It is also alleged that Mrs James did not document the start time, duration and rate of Percutaneous Endoscopic Gastrostomy (PEG) feed for 12

13 one patient and made the same omissions in relation to a Nasogastric feed for another patient allocated to her during her night shift. Finally it is alleged that she did not record and/or monitor blood glucose levels for Patient 1. It is further alleged that Mrs James signed the controlled drug register to say that she had administered Zomorph 30mg to Patient 3 without the required second signatory and also did not ensure that this medication was administered by a Registered Nurse as required. Mrs James is also alleged to have instructed Ms 3, a Clinical Support Worker, to administer the Zomorph to Patient 3, which Ms 3 did after Mrs James had left the ward. To date, Mrs James has not engaged in the NMC proceedings and therefore it has not been possible to ascertain Mrs James current employment status. Evidence adduced by the NMC: Opening the case for the NMC, Mr Kennedy took the panel through the charges and identified the evidence that would assist the panel with its determination on facts. The panel read and considered all the written evidence put before it. The panel also heard oral evidence and/or read statements from the following witnesses who had been employed by the Trust: - Mr 1, who was employed as a Staff Nurse on the Gastroenterology Medical Ward (L2) at Salford Royal NHS Foundation Trust. - Ms 2, who was employed as a Staff Nurse on Ward L2 at Salford Royal NHS Foundation Trust. - Ms 3, who was employed as a Clinical Support Worker on Ward L2 at Salford Royal NHS Foundation Trust. - Ms 4, who was employed as a Staff Nurse on Ward L2 at Salford Royal NHS Foundation Trust. 13

14 - Ms 5, who was employed as the Ward Manager on Ward L2 at Salford Royal NHS Foundation Trust. - Ms 6, who was employed as a Staff Nurse on Ward L2 at Salford Royal NHS Foundation Trust. The above titles refer to the individuals positions at the time of the charges. Decision on the findings on facts and reasons: In reaching its decisions on the facts, the panel considered all the evidence adduced in this case together with the submissions made by Mr Kennedy, on behalf of the NMC. The panel heard and accepted the advice of the legal assessor. 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 would be proved if the panel was satisfied that it was more likely than not that the events occurred as alleged. The panel approached its fact finding on the basis that where Mrs James has been charged as did not, the panel did not have to determine if Mrs James was required to do the task alleged and had failed to do it. It merely had to determine if she did or did not perform the task alleged. The panel has drawn no adverse inference from the non-attendance of Mrs James. The panel was of the view that Mr 1 was a credible witness. He was nervous in giving his evidence and vague at times in recalling the event in question, but he endeavoured to assist the panel as best he could. He was candid in reflecting upon his limited nursing experience at the time. His evidence was relevant to charges 1 and 2. 14

15 Ms 2 was considered to be an honest and credible witness. She had a good recollection of events during the night shift commencing 30 June 2013 and presented her evidence to the panel in a clear and straight-forward way. The panel found Ms 3, a clinical support worker on shift with Mrs James, to be open and honest during her oral evidence. She provided evidence to the panel primarily in relation to charges 1 and 5 and the panel was of the view that she was a credible witness. Ms 4 s evidence was primarily in relation to charge 2 and the panel was of the view that she presented her evidence with credibility and found that she had a good recollection of events. She was an honest and reliable witness. The panel found Ms 5 to be of great assistance to it, especially when identifying the correct documentary evidence for each patient against the corresponding charges. Her evidence was consistent, reliable and credible. Ms 6 s witness statement was read by the panel. While her evidence was largely consistent with the oral evidence of the other witnesses, the panel placed more reliance on the oral evidence than on the written hearsay evidence of Ms 6. While the panel found all witnesses to be credible, there were some small inconsistencies within their evidence. However, the panel was of the view that overall the witnesses were reliable and doing their best to assist the panel. The panel did not consider that there were any inconsistencies of such significance as to affect the reliability of any individual witness. Mrs James night shift commencing on 30 June 2013 started at 19:00 and ended at 07:30 the following morning. Some of the charges allege a time period commencing at 18:00. In those instances, the panel has not made any adverse findings against Mrs James prior to 19:00. 15

16 The panel considered each charge and made the following findings: Charge 1: 1. Left your shift approximately 40 minutes early without authorisation. This charge is found proved. In reaching this decision, the panel took into account the evidence of Ms 2 and Ms 3 that Mrs James left her night shift approximately 40 minutes early on the morning on 1 July Mr 1 and Ms 4 confirmed that Mrs James was not present to give them a verbal handover when they came on shift. Ms 5 told the panel of the procedure for nurses who may need to leave a shift in an emergency. She told the panel that Mrs James would have been aware that she needed to advise staff on the ward of her need to leave her shift early. Ms 5 said that Mrs James also had a responsibility to inform the hospital s site coordinator of her intention to leave her shift early. This would allow the site coordinator to give Mrs James authority to leave her shift and for other arrangements to be put in place, such as relocating a nurse to the affected ward from another part of the hospital. It was confirmed by Ms 2, the second registered nurse on the night shift, that Mrs James had in fact told other staff that she was intending on leaving the ward early as she was having car troubles. However, Mrs James did not seek authorisation from the Site Coordinator to leave her shift early. Ms 5 informed the panel that car problems would not be regarded as an emergency situation and the Site Coordinator would not have granted Mrs James permission to leave early had she asked. The panel determined that it was more likely than not that Mrs James left her shift on 1 July 2013 early without authorisation from the Site Coordinator. It concluded that Mrs James would have known that if she had sought permission from the Site Coordinator 16

17 she would not have been granted authorisation to leave her shift early. Therefore, the panel concluded that Mrs James chose not seek permission and left the ward at least 40 minutes early if not longer, leaving Ms 2 as the only other Registered Nurse responsible for 24 patients, some of whom were very ill. The panel therefore found charge 1 proved. Charge 2: 2. Did not provide adequate handover for one or more patients. This charge is found proved. The panel had regard to the evidence of Mr 1, who told the panel that the hand written note that Mrs James left him at the commencement of his day shift on 1 July 2013 was not adequate. He told the panel that being an inexperienced nurse he particularly required a verbal handover from night staff so he could ask questions about each individual patient s care and have a solid understanding of what their care requirements were for his shift. It was Ms 5 s evidence that it was protocol for nurses to update the electronic handover list throughout the course of their shift. The electronic handover given to Ms 4 on the morning of 1 July 2013 had been printed from the system at 18:01 on 30 June It is evident that Mrs James did not update the electronic records of her patients during her shift. Furthermore, there is no evidence to suggest that the ward was busy during the night shift which might have prevented Mrs James from updating the electronic handover notes. Ms 5 went on to say that if a nurse cannot update the electronic handover notes, it is the responsibility of the nurse handing over her patients to pass relevant information about a patient s care, treatment and condition verbally. In this case, Mrs James had left the 17

18 ward 40 minutes early and was not present on the ward at the time of handover to give a verbal handover to Mr 1 and Ms 4 of this essential patient information. Furthermore, Ms 5 told the panel that if a nurse has to leave the ward prior to the end of their shift, it is expected that they give a detailed written handover for the day staff nurses. While Mrs James left a separate handwritten handover note for Mr 1 and made handwritten entries on the electronic record for Ms 4, these were not sufficiently detailed for the purpose of ensuring that Mr 1 and Ms 4 had the essential information about the patients for whose care they were taking over responsibility. Ms 4, to whom Mrs James was to hand over her patients, told the panel that because of Mrs James inadequate handover, Patient 13 received delayed monitoring. She told the panel that if an adequate handover had been given by Mrs James, Ms 4 would have been aware that Patient 13 was due for observations at the commencement of the day shift. It was hospital policy that patients with an EWS of 0-1 were required to have observations about every eight hours. Instead, Patient 13 s observations were not done until nearer the end of the day shift. Mrs James had not advised Ms 4 in her handwritten notes that Patient 13 had observations taken at 23:10 and required them to be taken again during the day shift. Ms 5 provided the panel with an example of Mrs James inadequate handover. She pointed out that the handwritten note left for Mr 1 in relation to Patient 1 states the following 42 units insulin given. No other details were handed over to Mr 1. Ms 5 told the panel that an adequate handover should have included the need for another blood sugar reading to be taken after a large dose of insulin had been administered to ensure the patient s diabetes was under control and for this to be handed over to Mr 1. Mrs James did not hand over this information to Mr 1. Ms 5 went on to tell the panel that Patient 5 was a very poorly patient, who required 1:1 care. She explained to the panel that the handover left by Mrs James was inadequate in that it did not note the EWS for Patient 5 and it did not inform the day shift nurses that 18

19 Patient 5 had been receiving 1:1 care throughout the night. As a result, Mr 1 was not in a position to plan properly the patient s care for the day. Ms 5 told the panel that the handover provided by Mrs James falls short of the expectations of a senior registered nurse. The panel had no doubt that the importance of a handover at the change of any shift is to ensure that the nurses due to commence their shift have a total overview of their patients care needs. Nurses handing over their patients have a duty to relay what has happened to them during the course of the night, so that the nurses assuming responsibility can plan and deliver patient care needs for the day. In the panel s view, Mrs James did not adequately handover her patients to Mr 1 and Ms 4 and subsequently, their ability to provide patients with the continuity of care required during the day shift was compromised. The panel therefore found charge 2 proved. Charge 3.1: 3. In respect of Patient 1: 3.1 Did not document the start time, duration, and / or rate of a Percutaneous Endoscopic Gastrostomy (PEG) feed; Charge 3.1 is found proved. The panel had regard to Ms 5 s evidence in which she told the panel that despite Mrs James recording on the PEG feeding care plan the batch number of the PEG feed, she did not record the start time, duration, end time and/or rate of the PEG feed for Patient 1. She told the panel that on a Gastroenterology ward, PEG feeds are quite common and it is imperative that nurses know how much feed a patient has had and when it was started. 19

20 The panel concluded that Mrs James had not documented the start time, duration or end time of Patient 1 s PEG feed. She also had not documented the rate of the feed. The panel therefore found charge 3.1 proved. Charge 3.2: 3. In respect of Patient 1: Between 18:00 and 06:00 did not complete the fluid balance chart; Charge 3.2 is found proved. In reaching this decision, the panel took into account the documentary evidence, this being Patient 1 s fluid balance chart. This chart had not been completed for the entirety Mrs James shift. The panel was of the view that there was a need for the chart to be completed as the patient was on a PEG feed. Ms 5 told the panel during her evidence that it is a requirement that PEG feed intake be documented on a fluid balance chart. It is clear from the chart that prior to and after Mrs James shift, entries had been made by other nurses to record Patient 1 s aspirate, PEG feed and urinary output. On the balance of probabilities, the panel determined that if Patient 1 had urinary output, aspirate and PEG feed intake information recorded on the fluid balance chart both prior to and after Mrs James night shift on 30 June 2013, it was highly likely that PEG feed continued along with urinary and aspirate output throughout her night shift as well, which could have been recorded on the fluid balance chart. Mrs James did not do this. The panel therefore found charge 3.2 proved. Charge 3.3: 20

21 3. In respect of Patient 1: Did not monitor and / or record blood glucose levels. Charge 3.3 is found NOT proved. Patient 1 had diabetes and required blood glucose levels to be monitored. The panel had regard to the handover notes prepared by Mrs James for Mr 1 which suggest that Patient 1 had a blood sugar level of 6.3 at some point during the course of Mrs James night shift. The panel also had regard to the capillary blood glucose record chart before it. However, the panel cannot be satisfied that this was the blood glucose chart for Patient 1. Ms 5 confirmed that she also could not be certain that this was Patient 1 s blood glucose chart. On the evidence before it, the panel could not determine if Mrs James did or did not monitor or record Patient 1 s blood glucose levels. The panel therefore found charge 3.3 not proved. Charge 4.1: 4. In respect of Patient 2: 4.1 Did not complete a stool chart; Charge 4.1 is found NOT proved. 21

22 The panel had regard to Ms 5 s evidence in which she told the panel that a stool chart is required for all patients on the ward, because it is a gastroenterology ward. The panel noted that in her written statement Ms 5 states: it is important to complete this information on Ward L2 because we need to know if a patient is constipated or if their stools are loose, whether they are infectious. The panel also took into account Ms 5 s evidence that Mrs James had not started a stool chart and that she should have known to have implemented one. There was no suggestion by Ms 5 that there was an existing stool chart for Patient 2 which Mrs James could have completed. Ms 5 went on to say that, with reference to Mrs James nursing evaluation note, Susan has recorded using toilet, no concerns expressed although this doesn t explicitly say that this patient had a bowel movement, from what Susan documented, this indicates that this patient had a bowel movement. Notwithstanding Ms 5 s interpretation, the panel could not be satisfied that this entry showed there to have been a bowel movement, as opposed to the passing of urine. In any event, the charge alleges that Mrs James did not complete a stool chart. As a matter of proper interpretation, Mrs James could have only completed a stool chart if there was already one in existence to complete. It concluded that the evidence before it does not indicate that there was a stool chart in use for Mrs James to complete. The panel therefore found charge 4.1 not proved. Charge 4.2: 4. In respect on Patient 2: Between 19:00 and 06:00 did not complete the fluid balance chart. 22

23 Charge 4.2 is found proved. The panel had regard to Patient 2 s nursing evaluation chart as completed by Mrs James during her night shift. She recorded that Patient 2 was taking fluids as tolerated however she did not record on the fluid balance chart that Patient 2 had received any oral fluids. She also indicated on the nursing evaluation chart that Patient 2 had been using the toilet however urinary output was not recorded on the fluid balance chart during the entirety of Mrs James shift. Ms 5 told the panel that this information should have been recorded on the fluid balance chart. The panel was satisfied that Patient 2 took in fluid and passed urine during Mrs James shift. These could have been recorded by Mrs James, but were not. The panel therefore found charge 4.2 proved. Charge 5.1: 5. In respect of Patient 3: 5.1 Did not document the number of days the cannula had been inserted; Charge 5.1 is found proved. In reaching this decision, the panel took into account the care of peripheral cannula documentation before it. This was completed by Mrs James during the course of her night shift on 30 June This documentation clearly states the following: No. of indwell days of cannula: Other please specify (number) had the reason for cannula to remain insitu been documented?. There is no evidence to indicate the number of days this cannula had been in place, from which the panel concluded that Mrs James did not record this. 23

24 The panel therefore found charge 5.1 proved. Charge 5.2: 5. In respect of Patient 3: Between 18:00 and 06:00 did not adequately complete the fluid balance chart; Charge 5.2 is found NOT proved. The panel had regard to Ms 5 s evidence, in which she told the panel, after reexamining the fluid balance chart for Patient 3, that Mrs James had in fact entered a record on to the chart at 03:00. This indicated that Patient 3 had an oral intake of 150mls, an IV intake of 100mls and urine output at 03:00 and 04:00. Ms 5 accepted during her evidence that she was not in a position to express a view whether or not further oral or IV intake and urinary output occurred thereafter which Mrs James could have recorded. As Mrs James had recorded oral intake, IV intake and urinary output during the course of her shift, and in the absence of any reason to infer further unrecorded fluid intakes or outputs, the panel was not able to conclude that she had not completed Patient 3 s fluid balance chart adequately. The panel therefore found charge 5.2 not proved. Charge 5.3: 5. In respect of Patient 3:

25 Signed to say that you had administered Zomorph 30mg without a second signatory; Charge 5.3 is found proved. The panel had evidence of the hospital s controlled drugs policy, which states the following: The nurse administering the CD [controlled drug] must have the administration of the CD witnessed by the second person and must record the administration in the CD register and sign that the drug has been administered, this must be counter-signed by the witness. The panel had regard to the controlled drugs register that 30mg of Zomorph was prepared by Mrs James for Patient 3 at 06:15 on 1 July This is signed by Mrs James alone; there is no second witness signature as is required by hospital policy. The panel therefore found charge 5.3 proved. Charge 5.4: 5. In respect of Patient 3: Delegated the administration of Zomorph to Colleague A; Charge 5.4 is found proved. 25

26 The panel heard evidence from Ms 3, who told the panel that she was asked by Mrs James to administer medication to Patient 3, which Ms 3 had seen Mrs James leave in a pot by Patient 3 s bedside just before she left the ward. Ms 3 went on to confirm that she did in fact administer this medication to Patient 3. It is not entirely clear from Ms 3 s evidence if Mrs James told her that the medication was Zomorph or whether Ms 3 had herself identified it as Zomorph as she was familiar with its appearance. The panel had regard to the controlled drugs register, which recorded that Mrs James took the Zomorph for Patient 3 out of the controlled drugs cupboard and signed for it at 06:15. This correlates with the time Mrs James left her shift. The panel concluded on the balance of probabilities that Mrs James did delegate the task of administering Zomorph to Ms 3. The panel therefore found charge 5.4 proved. Charge 5.5: 5. In respect of Patient 3: Did not administer and / or ensure the administration of Zomorph 30mg. Charge 5.5 is found proved. Ms 5 gave evidence that Zomorph, being a controlled drug, must be administered by a registered nurse. Ms 3, a clinical support worker, gave evidence which the panel accepted that Mrs James had delegated the task of administering Patient 3 s Zomorph to her and that she had done this. 26

27 The panel concluded that it was more likely than not that Mrs James did not administer the Zomorph to Patient 3 and was not present to witness the administration of the controlled drug, having left that task to Ms 3, who was not authorised to administer such medication. The panel therefore found charge 5.5 proved. Charge 6.1: 6. In respect of Patient 4: 6.1 Did not complete a stool chart; This charge is found NOT proved. The panel took into account the nursing evaluation chart for Patient 4 as completed by Mrs James during her night shift. She recorded the following: BNO [bowels not open], no concerns expressed using toilet independently. For the same reasons set out in relation to charge 4.1, the panel concluded that Mrs James could have only completed the stool chart if there was in fact one in existence to complete. There is no evidence that there was a stool chart already in use for Mrs James to complete. The panel therefore found charge 6.1 not proved. Charge 6.2: 6. In respect of Patient 4: Between 18:00 and 06:00 did not complete the fluid balance chart; 27

28 This charge is found proved. The panel had regard to the nursing evaluation chart for Patient 4 in which Mrs James recorded that Patient 4 was tolerating oral fluids well and feed continues as per regime. It took into account Ms 5 s evidence which indicated that any oral or feed intake should be documented on the fluid balance chart. When assessing the fluid balance chart for Patient 4, the panel determined that, despite information pertaining to oral and feed intake having been entered by Mrs James in the patient s nursing evaluation record, she did not make any entries on the fluid balance chart during her shift. The panel also took into account that staff on the shifts both prior to and after Mrs James night shift had made entries on the chart, from which it inferred that it was more likely than not that during the course of the night shift there was oral intake and urinary output which Mrs James could have recorded. The panel therefore found charge 6.2 proved. Charge 6.3: 6. In respect of Patient 4: Did not document the start time, duration, and / or rate of a Nasogastric feed. This charge is found proved. The panel had regard to the Nasogastric Feeding Care Plan. While the batch number of the feed and the expiry date were recorded, there was no documentation in relation to 28

29 the start, duration or rate of the nasogastric feed for Patient 4. It took into account Ms 5 s evidence that this information should have been recorded as staff need to know when the nasogastric feed started, how long it had been running for and at what rate. The panel concluded that Mrs James had not documented the start time, the duration or the rate of the feed for Patient 4. The panel therefore found charge 6.3 proved. Charge 7.1: 7. In respect of Patient 5: 7.1 Did not complete a cannula pathway; This charge is found NOT proved. In reaching this decision, the panel had regard to the body map documentation of Patient 5. This clearly indicates that Patient 5 had a cannula inserted. While the panel had previously had sight of documentary evidence of a cannula pathway record for another patient, namely Patient 3, this was not the case for Patient 5. It noted the nursing evaluation record made by Mrs James for this patient on 1 July 2013 which makes no reference to a cannula. The panel could not be satisfied from the evidence before it that Patient 5 s cannula was inserted during Mrs James shift. Therefore it determined that Mrs James could not complete documentation in the form of a cannula pathway record if there was not one in existence to complete. There is no evidence before it to indicate that there was a cannula pathway record in use for Mrs James to complete and therefore she had no obligation to complete one. The panel therefore found charge 7.1 not proved. 29

30 Charge 7.2: 7. In respect of Patient 5: Did not complete a stool chart; This charge is found not proved. For the same reasons as set out in relation to charge 4.1, the panel concluded that Mrs James could have only completed a stool chart for Patient 5 is there was in fact one in existence for her to complete. There is no evidence before the panel to indicate that there was a stool chart in use for Mrs James to complete. The panel therefore found charge 7.2 not proved. Charge 7.3: 7. In respect of Patient 5: Did not handover the EWS score; This charge is found proved. The panel had regard to the Adult Observation Chart for Patient 5, which indicates that Patient 5 had an EWS of 2 during the night shift in question. Patient 5 was very ill and required 1:1 care. Ms 5 told the panel that this score should have been in the handwritten notes handed over to Mr 1 at the commencement of his day shift on 1 July

31 Mr 1 gave evidence that observations and EWS were normally received at handover. He states: We are also told about observations and EWS (Early Warning Score). Susan did not give a handover because she had left by the time I had arrived. She had written some notes on a scrap piece of paper but this contained only very minimal information. The panel had regard to the handover notes left by Mrs James for Mr 1, which did not record the EWS for Patient 5. It also took into account that, as she had left her shift early, Mrs James was not present to give Mr 1 a verbal handover where this information could have been exchanged. Despite Patient 5 s EWS being recorded in the Adult Observation Chart, the panel concluded that Mrs James did not handover Patient 5 s EWS to Mr 1. The panel therefore found charge 7.3 proved. Charge 7.4: 7. In respect of Patient 5: Between 22:00 and 06:00 did not complete the fluid balance chart. This charge is found NOT proved. The panel had regard to Patient 5 s health at the time of the incident. Patient 5 was very ill and needed considerable care. In her nursing evaluation note for Patient 5, Mrs James made the following entry: 31

32 Diet taken at start of shift, fluids need encouraging BNO [bowels not opened], using toilet with assistance x 1. Mrs James had recorded on the fluid balance chart at 22:00 that there was an oral intake of 200mls and an IV intake of 100mls. Also recorded are urinary outputs at both 20:00 and 06:00. On the balance of probabilities, the panel cannot infer that Patient 5 would have had any oral or IV intake, or urinary output between the hours of 22:00 and 06:00. The panel therefore found charge 7.4 not proved. Charge 8.1: 8 In respect of Patient 7: 8.1 Between 22:00 and 06:00 did not complete the fluid balance chart; This charge is found proved. For some reason, although that part of Patient 7 s fluid balance chart relating to 30 June 2013 was presented in evidence, the section relating 1 July 2013 was not. The panel was however prepared to accept Ms 5 s evidence that nothing was recorded on the chart until 06:00 on 1 July 2013 and has found that Mrs James made no entries on Patient 7 s fluid balance chart during her shift. The panel took into account the nursing evaluation chart of Patient 5. Mrs James recorded the following: PEG feed running as per regime, gastric port aspirated every 4 hours aspirate recorded on output chart. 32

33 The fluid balance chart for 30 June 2013 indicates that Patient 5 s PEG feed was being regularly recorded between 00:00 and 19:00, at which point the recording ceased. The panel has inferred that PEG feed intake continued throughout Mrs James night shift which she could have recorded and did not. The panel therefore found charge 8.1 proved. Charge 8.2: 8. In respect of Patient 7: Did not complete a stool chart; This charge is found NOT proved. For the same reasons as set out in relation to charge 4.1, the panel concluded that Mrs James could have only completed a stool chart for Patient 7 if there was in fact one in existence. There is no evidence before the panel to indicate that there was a stool chart in use for Mrs James to complete. The panel therefore found charge 8.2 not proved. Charge 8.3: 8. In respect of Patient 7: Did not complete a cannula pathway; This charge is found NOT proved. 33

34 There was a body map showing that Patient 7 had a Peripherally Inserted Central Catheter (PICC). Ms 5 told the panel that this should be monitored through a cannula pathway record. It is apparent from Mrs James entry on Patient 7 s nursing evaluation record that the PICC was likely to have been in place at the start of her shift. There is however no evidence as to whether a cannula pathway record was already in existence for Mrs James to complete. By a process of reasoning, similar to that already set out in relation to charges involving the non-completion of stool charts (4.1, 6.1, 7.2 and 8.2), Mrs James could only have completed a cannula pathway if there was already one in existence to complete. The panel concluded that there was no evidence to show that there was such an existing cannula pathway. The panel therefore found charge 8.3 not proved. Charge 8.4: 8. In respect of Patient 7: Incorrectly recorded the Early Warning Score (EWS) as 0. This charge is found proved. Mrs James had recorded an EWS of 0 for Patient 7 even though no blood pressure recording had been taken. Ms 5 gave evidence that it was common practice for nurses on the ward to record an EWS as 0 when for some reason the complete set of observations had not been undertaken. However, she expressed her opinion that this was an incorrect practice and that a score should not be assigned to a patient in such circumstances. She told the panel that nurses should write not possible or refused on 34

35 the Adult Observation Chart. Ms 5 accepted during her evidence that she had not followed up this incorrect recording practice with nurses on the L2 ward. The panel accepted Ms 5 s evidence that Mrs James had incorrectly recorded Patient 7 s score. The panel therefore found charge 8.4 proved. Charge 9: 9. In respect of Patient 8, between 00:00 and 06:00 did not complete the fluid balance chart. This charge is found NOT proved. The panel assessed the documentary evidence when reaching its decision on charge 9. Once again, only one sheet of the fluid balance chart (for 1 July 2013) had been presented. There was no evidence of entries prior to Mrs James shift. The only entries made after Mrs James shift were at 08:00, 10:00, 12:00 and 13:00. There was no other evidence such as the nursing evaluation record, on which Mrs James might have made reference to fluid intake and output. The panel concluded that there was insufficient evidence from which it could properly infer what, if anything, could have been recorded on Patient 8 s fluid balance chart between 00:00 and 06:00. The panel therefore found charge 9 not proved. Charge 10: 10. In respect of Patient 9, between 18:00 and 06:00 did not complete the fluid balance chart. 35