Part(s) of the register: Registered Nurse Sub Part 1 Adult Nursing April 1980

Transcription

1 Fitness to Practise Committee Substantive order review hearing 15 February 2018 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of registrant: NMC PIN: Susan Anne Beevers 77A0283E Part(s) of the register: Registered Nurse Sub Part 1 Adult Nursing April 1980 Area of registered address: Registered Midwife August 1981 Yorkshire Type of case: Panel Members: Legal Assessor: Panel Secretary: Ms Beevers: Nursing and Midwifery Council: Order to be reviewed: Misconduct Jane Davis (Chair Registrant member) Linda Tapson (Registrant member) Trevor Spires (Lay member) Paul Hester Anita Abell Present and represented by Andrew Bousfield, Counsel instructed by Thompsons Solicitors Represented by Daniel Walker, Case Presenter Suspension order for 12 months Outcome: Conditions of practice order for 18 months to take effect from end of 29 March 2018 under Article 31 of the Nursing and Midwifery Order

2 Decision and Reasons: The panel determined that your fitness to practise remains impaired. The panel decided to impose a conditions of practice order for a period of 18 months to take effect from end of 29 March This hearing was the first review of a twelve month suspension order imposed on your registration by a panel of the Conduct and Competence Committee on 24 February The order expires on 29 March Substantive hearing February 2017 At the substantive hearing held between February 2017 the following charges were admitted and found proved: Charges That you, a registered midwife and whilst employed as a Band 6 Midwife on the Delivery Suite at St James' University Hospital: 1. On 7 April 2015 and in relation to Patient A: 1.1. At or around and after categorising the cardiotocography ("CTG") trace as 'suspicious' failed to request a review from an obstetrician 1.2. At or around incorrectly categorised the CTG trace as 'normal' when the CTG trace was 'suspicious' 1.3. Incorrectly increased the dose of syntocinon at or around one or more of the following times:

3 1.4. Between and failed to record a categorisation of the CTG 1.5. Between and failed to identify that the CTG trace was pathological 1.6. At or after failed to record your reasons for performing an episiotomy 1.7. At or around recorded that you had given fluids at one or more of the following times, when you had not been responsible for Patient A's care: On 19 April 2015 and in relation to Patient B: 2.1. Failed to record your reason for not undertaking a vaginal examination within one hour prior to commencing syntocinon at 00: Failed to take, and/or failed to record that you had taken, blood pressure readings every five minutes for one or more of the following 15 minute periods: At or around failed to record your reason for catheterising the patient 2.4. At or around 06.48: failed to escalate a foetal bradycardia that had lasted for more than three minutes and/or failed to discontinue syntocinon 2.5. Failed to record why you amended your categorisation of the CTG at from 'suspicious' to 'pathological' That you, a registered midwife: 3

4 3. On 27 February 2016 stole a number of products from Boots the Chemist; 4. On 19 March 2016 stole a number of products from Boots the Chemist. In light of the above your fitness to practise is impaired by reason of your misconduct. Extract from Panel Reasons February 2017: Agreed Facts The panel was provided with the following statement of facts which was agreed by both parties: It is agreed between the parties that the facts are as follows: 1. On 18 August 2015, the NMC received a complaint about Mrs Beevers with regards to her practice in April Mrs Beevers was employed as a midwife at the Leeds Teaching Hospital NHS Trust ( the Trust ) since December Mrs Beevers initially worked in the delivery suite ( the Ward ) at St James University Hospital ( the Hospital ) but in April 2015 was transferred to the post-natal ward following concerns raised in relation to two incidents which occurred on 7 and 18/19 April Mrs Beevers was subsequently suspended whilst an investigation was commenced into the incidents, 4

5 3. The Trust s investigation was conducted by Ms 1, Delivery Suite Manager. Additionally, a Local Supervisory Authority ( LSA ) supervisory investigation was also conducted by Ms 2, Supervisor of Midwives. March In or around March 2015, Mrs Beevers was responsible for the care of a diabetic patient whose baby was born with low blood glucose levels. Mrs Beevers conducted a blood sugar test with a result of 0.0mmol/l. Mrs Beevers did not request a review from the doctor and instead decided to cup feed the baby. The baby subsequently became unwell so Mrs Beevers took the baby out of the room and out to the corridor. Another midwife, Ms 3, took the baby from Mrs Beevers and went back into the room where the baby was resuscitated. Ms 3 also called the doctor to review the baby and the baby was subsequently transferred to the critical care unit for observation. There was no harm to the baby and no action was taken in relation to this incident. 7 April On 7 April 2015, Patient A, a low risk primigravida was admitted to the Ward on 7 April 2015 in spontaneous labour. At 06:45, Patient A was prescribed syntocinon to augment her labour. Syntocinon is a synthetic oxytocin that helps to increase the rate of a woman s contractions. The dose needed to be increased every 30 minutes in line with the Trust s guidelines Oxytocin for the Induction and/or Augmentation of Labour in Pregnant Women. The syntocinon regime was correctly commenced at 07:00 with an initial dose of 1.00ml/hr. 6. Mrs Beevers took over Patient A s care at 07:24. At 07:32 she increased the dose of syntocinon to 2.00ml/hr. At 07:47, Mrs Beevers categorised the 5

6 cardiotocography ( CTG ) scan for Patient A as suspicious due to the presence on non-reassuring feature, being that the fetal heart rate had dropped to 100 bpm for a period of 90 seconds. Due to the fact that Patient A was receiving syntoconin the Delivery Suite Coordinator should have been informed that the CTG was suspicious and the Obstetrician should have been asked to review Patient A. This is because the use of syntocinon can cause a decrease in the fetal heart rate. Mrs Beevers did not request a review and instead made a plan to observe Patient A for a further 30 minutes then reassess the CTG. Mrs Beevers did not change the syntocinon regime. 7. At 08:04, Mrs Beevers increased the dose of syntocinon to 4.0ml/hr. At 08:15, Mrs Beevers categorised that CTG scan as normal. At 08:17, Ms 3 reviewed the CTG scan and disagreed with Mrs Beevers categorisation: she categorised the CTG as suspicious due to the presence of decelerations, a non-reassuring feature. 8. Mrs Beevers increased the dose of syntocinon to 6.00 ml/hr at 08:41, to 8.00 ml/hr at 09:24 and then to ml/hr at 10:02. This was not in line with the Trust s guidelines, which provide that the dose should have been increased to 8.00 ml/hr, then to ml/hr and finally to ml/hr. 9. AT 10:07, Mrs Beevers documented her review of the CTG, stating that the CTG was NORMAL FOR 2ND STAGE. This is not a recognised way of categorising a CTG. Mrs Beevers did not ensure that this assessment was checked by a buddy, When in line with the Trust s Guidelines in relation to fetal monitoring which advises that the CTG should be buddied by another midwife hourly or at least every two hours as a minimum. The CTG had been buddied at 08:17 and 09: At or around 10:40, Mrs Beevers buzzed for a second midwife to attend. Ms 4, a midwife, answered the call and entered Patient A s room. Ms 4 remained in the 6

7 room with Patient A from 10:41 until 10:57. When Ms 4 entered the room Mrs Beevers was poised to deliver Patient A s baby. The vertex was on the perineum and delivery appeared to be imminent. After a few minutes the baby had not been delivered and Mrs Beevers asked Ms 4 to remain the room while she went for a bathroom break. The baby was not born during Mrs Beevers absence and when she returned. Ms 4 left Patient A s room to go back to her own patient. At this time, the vertex remained on the perineum but was not advancing and Ms 4 advised Mrs Beevers to call for assistance again when required. 11. Mrs Beevers recorded in Patient A s notes that she called for a second midwife at 11:21. Ms 4 states that she returned to Patient A s room of her own accord, without being called, at approximately 10:24. The CTG trace showed that there was atypical deep decelerations of the fetal heart with more than half of Patient A s contractions and the baseline had become tachycardic. 12. When Ms 4 entered the room she saw that Mrs Beevers was performing an episiotomy. The episiotomy was recorded as being performed at 11:26. Mrs Beevers s record in respect of the episiotomy was not made until 17:58 and provided no explanation as to why the episiotomy was required. 13. Ms 4 asked Mrs Beevers whether she had reviewed the CTG since she had last been in the room and Mrs Beevers said that she had not. Ms 4 waited for Patient A's next contraction and the vertex did not deliver. Ms 4 therefore opened the door and notified Ms 3 that assistance was required by way of immediate medical review. At 11:27, Mrs Beevers recorded in the notes PUSHING ENCOURAGED VX POSSIBLY OP POSITION ASSISTANCE FROM DR REQUESTED BUSY IN THEATRE AT PRESENT WILL COME. Ms 4 states that shortly after she had informed Ms 3 of the need for medical review, she then requested a review from Dr 2, Registrar. Ms 3 states that she requested the review from Dr 1. 7

8 14. Ms 4 began preparing Patient A for an instrumental delivery. Dr 1 entered Patient A's room within 60 to 90 seconds of being called. Shortly after she entered the room, at 11:36, Patient A gave birth by kiwi ventouse delivery. Following the birth the baby ("Baby A") required inflation breaths. Ms 4 assisted with the resuscitation and Baby A's respiratory effort and heart rate improved. Within two minutes of birth the heart rate was regular and Baby A was crying. Baby A remained under observation on the resuscitaire and was returned to Patient A at 11 minutes of age. Between 10:17 and the birth at 11:36 Mrs Beevers had not recorded any review of the CTG. 15. The Ward operates a computer records system 'K2'. Midwives are expected to record their actions on the computer as they go, rather than handwriting notes. Mrs Beevers made multiple retrospective entries on the patient notes for Patient A. Amongst the retrospective entries made by Mrs Beevers were records indicating that fluids were given to Patient A at 02:19, 04:20 and 07:00 on 7 April Mrs Beevers did not take over Patient A's care until 07:24 and could therefore not have administered fluids at the times stated. Next to each of the records on the K2 notes a time stamp indicating the time of the entry appears. Each of the previously mentioned records was made by Mrs Beevers between 16:20 and 16:21 on 7 April Mrs Beevers made further retrospective entries for the actions that she took immediately prior to Patient A giving birth, including: a Fetal Heart Rate 160bpm (Recorded by Mrs Beevers at 13:11) b. 11:00 Fetal Heart Rate - 160bpm (Recorded by Mrs Beevers at 13:11) c. 11:11 Maternal Temperature o C (Recorded by Mrs Beevers at 13:17) 8

9 d. 11:11 Maternal Pulse - 89bpm (Recorded by Mrs Beevers at 13:17) e. 11:11 Blood Pressure 139mmHg/86 mmhg, calculated Mean Arterial Pressure (MAP) 103 mmhg (Recorded by Mrs Beevers at 13:17) f. 11:11 Maternal SpO2-98% (Recorded by Mrs Beevers at 13:17) g. 11:11 Respiratory Rate - 16 breaths/min (Recorded by Mrs Beevers at 13:17) h. 11:11 Neuro Response - Alert (Recorded by Mrs Beevers at 13:17) i. 11:11 2nd Stage Maternal Status - Effective Pushing Yes; Head Descent Yes; Maternal Position Checked Yes; Bladder Care Checked No; Emotional Needs Considered - Yes (Recorded by Mrs Beevers at 13:18) j. 11:15 Fetal Heart Rate - 100bpm (Recorded by Mrs Beevers at 13:15) k. 11:20 Note: Infiltration Lidocaine 1% 5mls with consent for Episiotomy (Recorded by Mrs Beevers at 17:56) l. 11:20 Fetal Heart Rate 165bpm (Recorded by Mrs Beevers at 13:15) m. 11:21 Note: 2nd Midwife called for (Recorded by Mrs Beevers at 13:22) n. 11:25 Fetal Heart Rate 165bpm (Recorded by Mrs Beevers at 13:16) 9

10 o. 11:26 Note: Episiotomy performed with consent (Recorded by Mrs Beevers at 17:58) p. 11:27 Note: Pushing encouraged vx [vertex] advancing possibly op [occipital posterior] position assistance from Dr requested busy in theatre at present will come (Recorded by Mrs Beevers at 13:23 q. 11:30 Fetal Heart Rate 143bpm (Recorded by Mrs Beevers at 13:16) 18/19 April On the night shift of 18/19 April 2015, Mrs Beevers was responsible for the care of Patient B, who was admitted to the Ward for induction of labour. Mrs Beevers took over Patient B's care at The Coordinator for the shift was Ms The Trust's guidelines on Oxytocin for the Induction and/or Augmentation of Labour in Pregnant Women state that an abdominal palpation and vaginal examination should have taken place within the last hour prior to commencement of oxytocin. Patient B was commenced on a syntocinon regime at 00:44 on 19 April Mrs Beevers had performed a vaginal examination of Patient B at 23:14 on 18 April 2015, which was not within the hour prior to commencement of syntocinon. No reason for the failure to perform the vaginal examination was recorded in the notes. During interview with Ms 2, Mrs Beevers stated that she had not performed another vaginal examination prior to commencing syntocinon because Patient B's membranes had ruptured and performing another examination within a short amount of time could pose an infection risk. Ms 2 felt that Mrs Beevers s decision not to perform the examination was appropriate in 10

11 the circumstances, but the reason for this should have been recorded in Patient B's notes. 19. At 02:10, Mrs Beevers recorded TOP UP DOSE GIVEN AS FEELING CONTRACTIONS and Epidural Catheter Top-Up Dose at 02:11. The Trust's guidelines on Regional Anaesthesia for Pain Relief in Labour provide two different procedures following the administration of a top up epidural. The first is that after each top up the mother's blood pressure should be measured every five minutes for 20 minutes. The second is that the blood pressure should be recorded every five minutes for 15 minutes. Mrs Beevers recorded taking Patient B's blood pressure at 02:12, 02:19, 02:31 and 02:38. This is not in line with either guideline. 20. Mrs Beevers gave a further epidural top-up to Patient B at 03:06. Mrs Beevers then recorded taking Patient B's blood pressure at 03:08 and 03:12. There are no further records of Patient B's blood before a further epidural top up was given to Patient B at 03: At 04:43 Mrs Beevers recorded that she had inserted a catheter for Patient B with consent. Mrs Beevers did not document the reason for inserting the catheter. 22. At approximately 07:00 Ms 5 looked at the central monitor, which is located at the central area of the Ward, and reviewed the CTG for each of the patients on the Ward at that time. When Ms 5 looked at the CTG for Patient B she noticed that the CTG showed a fetal bradycardia, which is a prolonged deceleration of the fetal heartbeat. Ms 2, Ms 1 and Ms 5 all provide evidence in relation to the CTG trace for this period. Ms 2 states that the fetal decelerations were apparent between 06:46 and approximately 06:52. Ms 1 states that there was a significant drop in the fetal heartrate from 06:45 until 06:53. Ms 5 states that the bradycardia had been ongoing from around 06:50 and was recovering when she entered Patient B's room at around 07:00. The baseline for the fetal heartrate was 11

12 approximately 130bpm, but dropped to around 80bpm. There was no harm to the baby as a result of the bradycardia. 23. A bradycardia lasting for three minutes or longer should be escalated to a doctor. Mrs Beevers did not take any action to escalate the bradycardia despite the fact that it lasted for a period of at least eight minutes. At around 07:00, Dr 2 entered Patient B's room, together with Ms 5. By this time the fetal heartrate had recovered. Mrs Beevers made a recorded in Patient B's notes at 06:53 Dr called but no record of the doctor's review was made until 07: Mrs Beevers summarised her review of the CTG for Patient B at 06:57, in which she categorised the CTG as suspicious. Mrs Beevers also recorded the following, BRADYCARDIA FOLLOWING VE FSE APPLIED TURNED LEFT LAT RECOVERED TO BASELINE. At approximately 07:13, Mrs Beevers deleted these records and made an update entry stating that the CTG was pathological. Mrs Beevers recorded FSE APPLIED PT ON BACK BRADY DOWN TO 80PM TURNED TO L LAT FLUIDS INCREASED. During Mrs Beevers s interview with Ms 2 she stated that she had initially thought the CTG was suspicious, but updated this after the doctor had reviewed Patient B and found that the CTG had been pathological. Outcome of the LSA & Trust Investigations 25. Ms 2 completed her investigation for the LSA on 30 June 2015 and drafted two separate investigation reports for the incidents of 7 April and 18/19 April Ms 2 found that Mrs Beevers had not demonstrated competence in relation to the following areas of practice: 7 April 2015: 12

13 a. Following clinical guidelines in relation to fetal monitoring b. Recognising fetal compromise and escalating appropriately c. Following protocol in relation to the syntocinon regime as per Trust guideline d. Accurately documenting reasons for altering an entry in the medical records e. Documenting an indication for undertaking an episiotomy 18/19 April 2015: a. Following clinical guidelines in relation to fetal monitoring b. Recognising fetal compromise and escalating appropriately c. Following guidelines relating to post epidural anaesthesia observations d. Accurately documenting care in relation to intravenous fluids and bladder care e. Failing to accurately document reasons for altered entry in the medical records 13

14 26. Ms 1 completed her investigation for the Trust and produced an investigation report. During the course of the investigation Mrs Beevers raised mitigating factors, including that she was feeling ill during the incident on 7 April 2015 and felt that she was having a hypoglycaemic episode. Ms 1 found that the following allegations were substantiated. a. Negligence in duty that compromised the safety of patients; b. Breach of the NMC code of Conduct; and c. Failure to follow Trust Guidelines and Protocols in relation to fetal monitoring. 27. Ms 1 recommended that the matter be taken to a disciplinary hearing. The disciplinary hearing took place on 18 November 2015 and Ms 1 presented the management case. The outcome of the hearing was that a final written warning was placed on the Mrs Beevers s file. Mrs Beevers is no longer employed by the Trust and plans to take early retirement. She does however plan to undertake work through an Agency. Misconduct and impairment The panel was of the view that your actions amounted to the following breaches of the The Code: Professional standards of practice and behaviour for nurses and midwives 2015 (the Code): 1 Treat people as individuals and uphold their dignity To achieve this, you must: 1.2 make sure you deliver the fundamentals of care effectively 6 Always practise in line with the best available evidence To achieve this, you must: 14

15 6.2 maintain the knowledge and skills you need for safe and effective practice. 8 Work cooperatively To achieve this, you must: 8.3 keep colleagues informed when you are sharing the care of individuals with other healthcare professionals and staff 8.4 work with colleagues to evaluate the quality of your work and that of the team 8.5 work with colleagues to preserve the safety of those receiving care 8.6 share information to identify and reduce risk, 10 Keep clear and accurate records relevant to your practice To achieve this, you must: 10.1 complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event 10.2 identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need 10.3 complete all records accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements 13 Recognise and work within the limits of your competence To achieve this, you must: 13.1 accurately assess signs of normal or worsening physical and mental health in the person receiving care 15

16 13.2 make a timely and appropriate referral to another practitioner when it is in the best interests of the individual needing any action, care or treatment 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 that there is a risk to patient safety or public protection To achieve this, you must: 16.1 raise and, if necessary, escalate any concerns you may have about patient or public safety, or the level of care people are receiving in your workplace or any other healthcare setting and use the channels available to you in line with our guidance and your local working practices 20 Uphold the reputation of your profession at all times To achieve this, you must: 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, treating people fairly and without discrimination, bullying or harassment 20.4 keep to the laws of the country in which you are practising The panel accepted that breaches of the Code do not automatically result in a finding of misconduct. However, the panel was of the view that your actions fell far below the standards expected of a registered midwife. The panel found that your conduct was a serious departure from the Code in relation to the standards of integrity fundamental to the requirements of being a registered midwife and to upholding the reputation of the profession. 16

17 The panel considered that your behaviour was sufficiently serious to amount to misconduct. Decision on impairment In addressing impairment, the panel bore in mind that its concern was with the current position, looking forwards, not backwards. However, past events could assist it in making judgments about what is likely to happen in the future. It took account of the test set out in the Fifth Shipman Report and quoted with approval by Mrs Justice Cox in the case of Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin). Do our findings of fact in respect of [the registrant s] misconduct show that her fitness to practise is impaired in the sense that she: 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 profession into disrepute; and/or c. has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the profession; d. has in the past acted dishonestly and/or is liable to act dishonestly in the future. 17

18 The panel was satisfied that you have in the past acted so as to put patients at unwarranted risk of harm. Although there was no evidence of actual patient harm, your record keeping errors and in particular failure to escalate a number of concerns including a foetal bradycardia involved potential harm to patients. Your failure to provide good care put mothers and their babies at risk of suffering harm. The panel considered that the facts found proved are serious in nature, multiple, and wideranging, and cover specific concerns relating to basic clinical practise. The panel also found that your actions had in the past brought the professions into disrepute. The panel also found that your actions had in the past breached the fundamental tenets of the nursing profession both in your clinical practice and your dishonest conduct. The panel next considered whether you would be liable in the future to act in such a way as to exhibit current impairment as set out in the Fifth Shipman Report. It took into account any evidence of your insight and remediation. The panel acknowledged that you have made early admissions to the charges and made efforts to demonstrate insight. The panel found that in oral evidence, you have been open and honest with the panel. You also provided evidence that you have taken steps to remedy your failings. Further you have reflected on the incidents in question as evidenced in your reflective pieces. You have some understanding into the events and circumstances surrounding your misconduct. You told the panel about the difficult personal and family circumstances and the significant stress you were under. You have also shown remorse for your actions and made apologies. You assured the panel that you have developed coping mechanisms and have the relevant support if faced with a similar situation to enable you to act differently. 18

19 However, the panel found your oral evidence at times to be confusing, unclear and somewhat contradictory particularly in relation to the issues of impairment and remediation. The panel did not find that you had a clear understanding of what you meant by accepting that your fitness to practise was impaired and during the course of questioning on occasions you recognised you were impaired whilst on other occasions you considered yourself safe to practise with no risk of repetition. In relation to remediation, the panel acknowledged your efforts: you have provided several examples of completed relevant training courses and provided evidence of study and references. Nevertheless, the panel found that you have not been able to remediate the clinical deficiencies in your practice which relate to a number of basic nursing and midwifery skills including record keeping and escalation. In addition the panel considered that the issue of dishonesty is particularly difficult to remediate. The panel therefore concluded it cannot discount the risk of repetition of similar behaviour and it therefore finds that you are liable in the future to act so as to put a patient or patients at unwarranted risk of harm and thereby breach fundamental tenets of the nursing and midwifery profession and bring the professions into disrepute. The panel therefore concluded that your fitness to practise is currently impaired. The panel bore in mind that its primary function is to protect patients and the wider public interest, which includes maintaining confidence in the nursing and midwifery profession and upholding proper standards and behaviour. The panel considered that the facts found proved are serious and involve dishonest behaviour leading to a conviction for theft. The panel has also determined that, the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment was not made in the circumstances of this case. 19

20 For the reasons set out above, the panel finds that your fitness to practise is currently impaired by reason of your misconduct. Determination on sanction The panel accepted the advice of the legal assessor. The panel has borne in mind that any sanction imposed must be reasonable, appropriate and proportionate. Under Article 29 of the Nursing and Midwifery Council Order 2001, the panel can take the following actions in ascending order: no action; make a caution order for one to five years; make a conditions of practice order for no more than three years; make a suspension order for a maximum of one year; or make a striking-off order. The sanction should be the least restrictive that protects patients and the wider public interest. The panel was mindful that the purpose of sanctions is not to be punitive but to protect patients and the wider public interest, although a sanction may have a punitive effect. The panel had careful regard to the Indicative Sanctions Guidance ( ISG ) published by the NMC. It recognised that the decision on sanction is a matter for the panel exercising its own independent judgment. In considering the aggravating factors of this case, the panel took into account the following: There were two incidents of dishonesty and two shifts during which serious and wide ranging clinical failings occurred that had the potential to cause significant 20

21 harm to a to a mother and her baby. Further, the panel found that there is a risk of repetition both in respect of your clinical failings and dishonest conduct. The mitigating factors include your efforts to remediate your failings, your personal circumstances, your positive testimonials, your early admissions and your full engagement. Further you have shown remorse and some insight. In determining which sanction, if any, to impose the panel has first considered whether it would be appropriate to take no action. It has concluded that the seriousness of the facts found proved was such that it could not justify such a decision. It determined that the public interest requires the imposition of a sanction and that taking no action would not address the public interest. Next, in considering whether a caution order would be appropriate in the circumstances, the panel took into account the ISG, which states that a caution order may be appropriate where the case is at the lower end of the spectrum. The panel considered that your misconduct was not at the lower end of the spectrum and that a caution order would not be appropriate in view of the seriousness of the case. Some of the charges against you relate to dishonesty and the panel decided that it would be neither proportionate nor appropriately guard the public interest. Further, the panel bore in mind that such an order would not restrict your practice rights, and would therefore be insufficient to protect the public. The panel next considered a conditions of practice order. The panel was mindful that any conditions imposed must be proportionate, measurable and workable. It noted the factors set out in paragraphs 62 to 64 of the ISG which indicate when such an order may be appropriate. The panel concluded that it could not formulate appropriate, workable and measurable conditions which would address the issue of dishonesty, protect the public and maintain the public s trust and confidence in the 21

22 profession and in the NMC as a regulator. Furthermore, the panel took the view that the public interest would not be satisfied by the imposition of a conditions of practice order, particularly given the dishonesty found proved in this case. The panel then went on to consider whether a suspension order would be an appropriate sanction. Paragraph 67 of the ISG indicates that a suspension order may be appropriate where the misconduct is not fundamentally incompatible with continuing to be a registered nurse or midwife in that the public interest can be satisfied by a less severe outcome than permanent removal from the register. This is more likely to be the case when some or all of the following factors are apparent: 67.1 A single instance of misconduct but where a lesser sanction is not sufficient No evidence of harmful deep-seated personality or attitudinal problems No evidence of repetition of behaviour since the incident. The panel was of the view that whilst the personal circumstances in which your acts of dishonesty took place may provide mitigation, they cannot excuse or fully explain your actions. The panel was not satisfied that your dishonest behaviour was directly attributable to a health condition. The panel had no evidence before it that you had repeated your dishonest behaviour. While your dishonest behaviour was not a single incident, it did not take place over an extended period of time and could therefore not be considered persistent, nor was it covered up. The panel noted that you have made admissions and you have expressed remorse. The panel considered that there is a risk of repetition in this case and, while you presently do not have full insight, this is developing. There is no evidence of deepseated attitudinal issues and your health issues appear to have been partly addressed. Taking all this into account the panel considered that your misconduct was not fundamentally incompatible with remaining on the Register and the panel 22

23 determined that a suspension order was the appropriate order in this case. Such an order will address both public protection issues and the wider public interest. The panel also considered whether a striking-off order was necessary in your case. Taking account of all the information before it, including the mitigation, the panel concluded that it was not necessary and would be disproportionate at this time and in the specific circumstances of this case. Balancing all of these factors the panel has concluded that a suspension order would be the appropriate and proportionate sanction. The panel noted the hardship such an order may cause you. However, this is outweighed by the public interest in this case. The panel considered that this order is necessary to protect the public, mark the importance of maintaining public confidence in the profession and to send to the public and the profession a clear message about the standard of behaviour required of a registered nurse/midwife. The panel determined that a suspension order for the maximum period of 12 months would be necessary to mark the seriousness of the misconduct in this case and would give you sufficient opportunity to further reflect and develop your insight. Before the end of the period of suspension, another panel will review the order. At the review hearing the panel may extend, vary, revoke or replace the order with any order the panel could have made today. A future reviewing panel may be assisted by the following: Any evidence of how you have further developed your insight Up to date references from employers and colleagues, either in the health profession or otherwise Your ongoing engagement with the NMC and attendance at a future hearing 23

24 Substantive order review hearing 15 February 2018 Application under Rule 19 for part of the hearing to be held in private Mr Bousfield stated that he would need to refer to health matters and applied for those parts of the hearing which relate to health matters to be held in private. Mr Walker did not object to this application. The panel heard and accepted the advice of the legal assessor. The panel agreed to hear those parts of the hearing that refer to health in private, but that all other parts of the hearing will be held in public. Reasons Mr Walker, on behalf of the NMC, summarised the situation. He submitted that the main concern of the substantive panel had been the issue of remediation of your clinical failings and of your dishonesty. He reminded the panel of the suggestions made by the substantive panel as to the material that might assist the reviewing panel today in reaching its decisions. He submitted that whether your fitness to practise remains impaired was a matter for the panel s judgment Mr Bousfield, on your behalf, agreed that impairment was a matter for the panel. He reminded the panel that you had attempted to remediate the issues of concern. He submitted that, in these circumstances if your fitness to practise was found to be currently impaired it would be possible to impose restrictions on your practice that would safeguard the public and the uphold the public interest. He submitted that a suspension order was not necessary. You gave evidence to the panel. You told the panel that you had a long career as a nurse and midwife and that you were keen to return to practise. You have officially retired from the NHS and you envisaged working a few shifts a week, possibly as a 24

25 bank or agency midwife or nurse. You told the panel of some difficult family circumstances which put you under stress and which, you claimed, affected your practice and judgment. You told the panel of how you have addressed these issues with your GP and through other means of help, including hypnotherapy, mindfulness and yoga. You told the panel that you considered that the change of workplace and the use of computer-based as opposed to paper records had contributed to the incidents at St James University Hospital. You stated that you now realised the importance of escalation. You informed the panel that you have completed some on-line training and read a number of articles. Your financial circumstances have prevented you from doing any face to face training. You expressed remorse for the shoplifting. The panel heard and accepted the advice of the legal assessor. When reaching its decision on impairment the panel took into account all of the evidence before it, and the submissions made by Mr Walker and Mr Bousfield. The evidence includes your oral evidence today, the NMC bundle which contains the determination of the substantive panel, a lengthy on-table document submitted by you which contained an updated reflection, details of relevant on-line training and reading you have undertaken since the substantive panel hearing, and updated references. The panel noted that your failings encompassed two discrete areas of your practice as a registered professional. Your failings covered clinical shortcomings and dishonesty which occurred outside of your workplace. The panel firstly considered your clinical failings. Whilst these failings occurred on two shifts, they were serious and wide-ranging. The panel carefully considered all of the evidence and, in particular, gave regard to your sworn evidence. The panel 25

26 reminded itself that it must consider evidence of your remediation and whether there is a real risk of you repeating your clinical shortcomings. The panel carefully considered the evidence of your remediation. It noted that you have undertaken a significant amount of learning. The panel scrutinised the relevance of this learning in respect of your clinical failings. Whilst some of the learning was relevant and addressed your clinical deficiencies, the panel found that the majority of the learning was not directly relevant. Given the serious and wideranging extent of your clinical deficiencies the panel was concerned that your learning was neither sufficient nor pertinent so as to address your shortcomings in your practice. The panel noted that you have not worked in a clinical setting since you retired and have not had a full opportunity to practically remedy your deficiencies. Accordingly, the panel is concerned about a lack of relevant of theoretical and practical remediation. The panel had careful regard to your oral evidence and your written reflective pieces. Whilst you expressed genuine remorse the panel was concerned as to whether your insight into your clinical failings is sufficient in terms of its development. In particular, the panel was concerned that you did not fully recognise the significance of your shortcomings and the work that is required to achieve full remediation. In your oral evidence you stated that you could safely practise whilst being mentored rather than by direct supervision. Given the nature and extent of the clinical findings against you the panel determined that this was a significant shortfall in insight. The panel reminded itself that the NMC has defined impairment as the suitability to remain on the register without restriction. Given that your insight is not fully developed and that you have not practically remediated your failings the panel decided that there is a real risk of you repeating your clinical shortcomings. The panel concluded that the lack of remediation is such as to engage the first three limbs of the Shipman test approved in Grant. Namely, you are liable in the future to act so as to put patients at unwarranted risk of harm and; bring the nursing 26

27 profession inio disrepute; and; breach one of the fundamental tenets of the professions. The panel next considered the shoplifting and the resulting dishonesty. The panel took into account your genuine remorse. The panel carefully considered the mitigating circumstances in relation to your shoplifting. In this regard the panel considered and accepted the significant personal background to you acting in a way which was out of character. The panel noted that you have significantly addressed some of those personal circumstances with the help of relevant professionals. Other personal circumstances have been remedied over time. Accordingly, the panel concluded that the risk of you repeating your dishonesty is low. In respect of your dishonesty the panel noted that you have almost completed your twelve month suspension order and in all the circumstance the panel concluded that this is sufficient to satisfy the public interest in upholding standards of behaviour in the professions and maintaining confidence in the professions and the NMC as regulator. The panel concluded that limb (d) (dishonesty) of the Shipman test in Grant is not engaged and that you are no longer impaired on the grounds of the wider public interest in respect of your dishonesty. Sanction Having found your fitness to practise currently impaired, the panel then considered what, if any, sanction it should impose on your registration. The panel noted that its powers are set out in Article 29 of the Order. The panel has also taken into account the NMC s Sanctions Guidance (SG) and has borne in mind that the purpose of a sanction is not to be punitive, though any sanction imposed may have a punitive effect. 27

28 The panel first considered whether to take no action but concluded that this would be inappropriate as it would allow you to practise without restriction, when the panel has concluded that there is a risk of repetition of the clinical incidents.. Taking no further action would not address the issue of public protection. The panel then considered whether to replace the existing order with a caution order but concluded that this would be inappropriate for the same reasons as taking no further action The panel next considered a conditions of practice order. The panel concluded that there was no evidence of attitudinal issues and that there were identifiable areas of your practice that needed to be addressed. As the incidents occurred in a relatively short period in a long and varied career the panel concluded there was no evidence of general incompetence. Further, you have already demonstrated a willingness to undergo training. In such circumstances the panel concluded that a conditions of practice order was appropriate and proportionate. The panel has decided to impose the following conditions, which it considers to be workable, practical and will provide sufficient public protection: 1. You must tell the NMC within 14 days of any nursing or midwifery appointment (whether paid or unpaid) you accept within the UK or elsewhere, and provide the NMC with contact details of your employer. 2. You must tell the NMC about any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 14 days of you receiving notice of them. 28

29 3. a) You must within 14 days of accepting any post or employment requiring registration with the NMC, or any course of study connected with nursing or midwifery, provide the NMC with the name/contact details of the individual or organisation offering the post, employment or course of study. b) You must within 14 days of entering into any arrangements required by these conditions of practice provide the NMC with the name and contact details of the individual/organisation with whom you have entered into the arrangement. 4. a) At any time that you are employed or otherwise providing midwifery services, you must place yourself and remain under the supervision of a workplace line manager, mentor or supervisor nominated by your employer, such supervision to consist of working at all times under the direct observation of a registered midwife of band 6 or above. b) At any time that you are employed or otherwise providing nursing services, you must place yourself and remain under the supervision of a workplace line manager, mentor or supervisor nominated by your employer, such supervision to consist of: working at all times on the same shift as, but not necessarily under the direct observation of, a registered nurse of band 6 or above who is physically present in or on the same ward, unit, floor or home that you are working in or on. 5. When working either as a midwife or a nurse, you must work with your line manager, mentor or supervisor (or their nominated deputy) to create a personal development plan designed to address the concerns about the following areas of your practice: Medication administration Record-keeping including electronic records Escalating concerns and identifying deteriorating patients Recognising the limits of your competence. 29

30 6. You must meet with your line manager, mentor or supervisor (or their nominated deputy) at least every 4 weeks to discuss the standard of your performance and your progress towards achieving the aims set out in your personal development plan. 7. You must forward to the NMC a copy of your personal development plan within 28 days of the date on which these conditions become effective or the date on which you take up an appointment, whichever is sooner. 8. You must send a report from your line manager, mentor or supervisor (or their nominated deputy) setting out the standard of your performance and your progress towards achieving the aims set out in your personal development plan to the NMC at least 14 days before any NMC review hearing or meeting 9. You must allow the NMC to exchange, as necessary, information about the standard of your performance and your progress towards achieving the aims set out in your personal development plan with your line manager, mentor or supervisor (or their nominated deputy) and any other person who is or will be involved in your retraining and supervision with any employer, prospective employer and at any educational establishment. 10. You must disclose a report not more than 28 days old from your line manager, mentor or supervisor (or their nominated deputy) setting out the standard of your performance and your progress towards achieving the aims set out in your personal development plan to any current and prospective employers (at the time of application) and any other person who is or will be involved in your retraining and supervision with any employer, prospective employer and at any educational establishment. 11. When working either as a midwife or a nurse, you must not carry out unsupervised medication administration until such time as you have been assessed both theoretically and practically as competent to do so. 30

31 12. You must not care for women having continuous electronic fetal monitoring until such time as you have been assessed and signed off by a Band 6 or above midwife, both theoretically and practically, as competent to do so safely. 13. You must keep your nursing and midwifery commitments under review and immediately limit your practice or stop practising in line with advice from your general practitioner, or any other registered medical practitioner or therapist responsible for your care. 14. You must immediately tell the following parties that you are subject to a conditions of practice order under the NMC s fitness to practise procedures, and disclose the conditions listed at (1) to (13) above, to them. 1) Any organisation or person employing, contracting with, or using you to undertake nursing or midwifery work. 2) Any agency you are registered with or apply to be registered with (at the time of application) to provide nursing or midwifery services. 3) Any prospective employer (at the time of application) where you are applying for any nursing or midwifery appointment. 4) Any educational establishment at which you are undertaking a course of study connected with nursing or midwifery, or any such establishment to which you apply to take such a course (at the time of application). The panel has concluded that this order should run for a period of 18 months. This will give you sufficient time to find employment and to demonstrate that you have addressed the shortcomings in your practice. 31

32 The panel did consider whether the imposition of a further suspension order was appropriate. However, it concluded that the public interest has been satisfied by the period of suspension. The panel considered a further period of suspension would be both disproportionate and would be punitive in that it would not afford you a proper opportunity to fully remediate your clinical shortcomings. That concludes this determination. 32