Nursing and Midwifery Council: Fitness to Practise Committee

Transcription

1 Nursing and Midwifery Council Fitness to Practise Committee Substantive Hearing 5 7 December 2017 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of registrant: NMC PIN: Part(s) of the register: Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Registrant: Nursing and Midwifery Council: Lucia Claudia Small 11H1444E Registered Nurse Adult Nursing England Misconduct Paul Powici (Chair, lay member) Jane Fraser (Registrant member) Colin Sturgeon (Lay member) Michael Levy Virginia Sardeli Not present and not represented Represented by Ruth Alabaster, case presenter, NMC Regulatory Legal Team. Facts proved: Charge 1 Facts proved by admission: Charges 2, 3 Facts not proved: Charge 4 Fitness to practise: Sanction: Interim Order: Impaired Suspension order 6 months Interim suspension order 18 months 1

2 Details of charges That you, a registered nurse, whilst working for Walsall Healthcare NHS Trust: 1. On 13 June 2014, upon recording Patient A s blood glucose level to be 2.9 mmols at 7:50am, failed to escalate his condition to the nurse-in-charge and/or the doctor. 2. On 12 July 2014 failed to administer and/or failed to record the administration of Nystatin to Patient B at: : : :00 3. On 15 and/or 16 July 2014 failed to administer and/or failed to record the administration of Enoxaparin to Patient B at 18:00 hours. 4. On or about 6 August 2014 adhered dressing to Patient E s wound using micropore tape which was clinically unsuitable. AND, in light of the above, your fitness to practise is impaired by reason of your misconduct. Decision on Service of Notice of Hearing The panel was informed at the start of this hearing that Ms Small was not in attendance and that written notice of this hearing had been sent to her registered address by recorded delivery and by first class post on 1 November While the Rules do not require delivery, the post office had confirmed that notice of this hearing was delivered on 2 November 2017 and signed for in the name of Small. 2

3 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 Ms Small s right to attend, be represented and call evidence, as well as the panel s power to proceed in her absence. Ms Alabaster submitted the NMC had complied with the requirements of Rules 11 and 34 of the Nursing and Midwifery Council (Fitness to Practise) Rules 2004, as amended ( the Rules ). The panel accepted the advice of the legal assessor. In the light of all of the information available, the panel was satisfied that Ms Small had been served with notice of this hearing in accordance with the requirements of Rules 11 and 34. Decision on proceeding in the absence of the Registrant The panel next considered whether it should proceed in the absence of Ms Small. Rule 21 (2) states: (2) Where the registrant fails to attend and is not represented at the hearing, the Committee (a) (b) shall require the presenter to adduce evidence that all reasonable efforts have been made, in accordance with these Rules, to serve the notice of hearing on the registrant; may, where the Committee is satisfied that the notice of hearing has been duly served, direct that the allegation should be heard and determined notwithstanding the absence of the registrant; or 3

4 (c) may adjourn the hearing and issue directions. Ms Alabaster invited the panel to continue in the absence of Ms Small on the basis that she had voluntarily absented herself. She handed up to the panel a bundle of documents detailing a number of the NMC s communications with Ms Small since 6 July Ms Alabaster submitted that 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 not absolute and is one that should be exercised with the utmost care and caution, as referred in the case of R. v Jones (Anthony William), (No.2) [2002] UKHL 5 (Jones). Ms Small had also indicated her intention not to attend the hearing and her reasons in a number of her written responses to the NMC. The NMC telephone records showed that Ms Small had also repeatedly confirmed that she would not be attending the hearing, including during her latest telephone communication of 4 December The panel decided to proceed in the absence of Ms Small. In reaching this decision, the panel considered the submissions of the case presenter, and the advice of the legal assessor. It had particular regard to the factors set out in the decision in Jones. It had regard to the overall interests of justice and fairness to all parties. It noted that: no application for an adjournment has been made by Ms Small; there is no reason to suppose that adjourning would secure her attendance at some future date; 4

5 a witness had attended the NMC to give live evidence and had travelled some distance to attend the hearing; not proceeding may inconvenience the witness, her employer and the clients who need her professional services; the charges relate to events that occurred in 2014; further delay may have an adverse effect on the ability of witness to accurately recall events; there is a strong public interest in the expeditious disposal of the case. The panel recognised that there would be some disadvantage to Ms Small in proceeding in her absence. She will not be able to challenge the evidence relied upon by the NMC and will not be able to give evidence on her own behalf. However, in the panel s judgment, this can be mitigated. The panel can make allowance for the fact that the NMC s evidence will not be tested by cross examination and, of its own volition, can explore any inconsistencies in the evidence which it identifies. Furthermore, the limited disadvantage is the consequence of Ms Small s decision to absent herself from the hearing, waive her right to attend and/or be represented and to not provide evidence or make submissions during the hearing on her own behalf. In these circumstances, the panel decided that it would be fair, appropriate and proportionate to proceed in the absence of Ms Small. It would draw no adverse inference from her absence in its findings of fact. Admissions to the charges At the outset of the hearing, the panel noted that Ms Small had made admissions to some of the charges. Ms Alabaster brought to the panel s attention that Ms Small appeared to have formally admitted to charges 1, 2 and 3 in the NMC response to the notice of hearing form. Ms Small s admission to charge 1 was unclear, however, due to her having provided additional information regarding her actions. Ms Small had also 5

6 appeared to comment on charge 3. However, when read in context these appeared more likely to be related to charge 4, which was denied. Ms Alabaster noted that Ms Small had made admissions to all the allegations in a handwritten note dated 17 November It was unclear, however, what the allegations were at the time. Ms Alabaster concluded by submitting that the acceptance of Ms Small s admissions was ultimately a matter for the panel s judgment. The panel heard and accepted the advice of the legal assessor. His advice included guidance to the panel acting in fairness to Ms Small by not accepting an admission to a charge if it was in any doubt as to the nature of the admission. The panel took into account all the documentary evidence provided by Ms Small along with the record of her communications with the NMC. Charge 1 The panel noted Ms Small s handwritten notes in the response to the notice of hearing form, where she had stated the following: I escalated it as soon as I found the junior doctor, but it was not escalated further..i should of [sic] checked faster and more efficiently that it was escalated correctly. The panel found Ms Small s actual position to be equivocal on the basis of the above comments. Charge 2 Ms Small had consistently admitted to charge 2 and had stated the following in the response to notice of hearing form: 6

7 Drug chart not available. It was at the hospital pharmacy I should of persued [ sic] more to get drug chart back from pharmacy The panel noted that Ms Small s comments provided an explanation regarding the allegations at charge 2. It had no evidence before it to indicate that Ms Small had ever denied this charge. It therefore accepted her admission of charge 2 and found this proved. Charge 3 (in its entirety) Ms Small had consistently admitted to charge 3 and the panel had no evidence before it indicating otherwise. It accepted Ms Alabaster s submission that Ms Small appeared to have mis-numbered her comments in the response to the notice of hearing form. It interpreted those comments numbered 3 by Ms Small in the form as corresponding to charge 4, as their content clearly related to the dressing of Patient E s wound. In light of the above, the panel accepted this charge as proved in its entirety on the basis of Ms Small s admission. Background The charges arose whilst Ms Small was employed as a registered nurse at Manor Hospital, Walsall Healthcare NHS Trust ( the Trust ), where she had worked since In 2014, she was moved to Ward 4 where she was responsible for the care of patients aged over 65 with acute medical conditions. It is alleged that, on 13 June 2014 Ms Small failed to escalate Patient A s blood sugar levels, which were below target, to nursing staff or medical staff in accordance with hospital practice. Ms Small had recorded Patient A s blood glucose level at 7.50 am as 2.9 mmols, which was dangerously below the patient s target level of between 5 and 8 mmols. As a result, the patient s blood sugar continued to drop until Dr 3 s ward round 7

8 began at 11:00 am. Ms Small s account is that she had escalated Patient A s condition by reporting it to the junior doctor, but that it was not then followed up. It is further alleged that Ms Small failed to administer and / or failed to record the administration of medication to Patient B on 12, 15 and 16 July When these incidents were investigated by the Trust, Ms Small was unclear regarding the reasons for her actions / omissions. The final allegation concerns Ms Small dressing of Patient E s leg wound using micropore tape, contrary to hospital policy. The incident was reported by Ms 3, the nurse who changed Patient E s dressing three days after Ms Small was recorded as having changed it. Ms Small denies this allegation. Ms 3 reported that the micropore tape had become stuck to Patient E s wound and that further damage was caused to the wound during its removal. 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 Ms Alabaster on behalf of the NMC. Ms Alabaster, amongst other things, invited the panel to make findings in respect of the and/or aspect of charges 2 and 3, which had been found proved. She informed the panel that the NMC s position was that, in respect of both charges, Ms Small had failed to administer the medication to Patient B and made submissions in this regard. 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 found proved if the panel was satisfied that it was more likely than not that the incidents occurred as alleged. 8

9 The panel drew no adverse inference from the non-attendance of Ms Small. The panel heard oral evidence from one witness on behalf of the NMC, Ms 1 who was the senior sister in charge of Ward 4 at the Trust during the time of the alleged incidents and had conducted the relevant investigations. The panel first considered the overall credibility and reliability of Ms 1. It found her to be a credible witness who gave clear and concise evidence that was consistent with what was contained within the documents, including her written statements. She readily admitted not knowing the answer to certain questions. Overall, the panel found Ms 1 s evidence to be convincing and reliable The panel considered each charge and made the following findings: That you, a registered nurse, whilst working for Walsall Healthcare NHS Trust: 1. On 13 June 2014, upon recording Patient A s blood glucose level to be 2.9 mmols at 7:50am, failed to escalate his condition to the nurse-in-charge and/or the doctor. In reaching its decision in respect of this charge, the panel took into account the fact that it had no evidence before it showing a record of Ms Small escalating Patient A s condition to a junior doctor or anyone else. Furthermore, Patient A s records contained no details of Ms Small s concerns regarding the patient s condition; no reference to this being escalated, the name of the junior doctor to whom she alleges she escalated the condition or any notes by the junior doctor. The panel considered it likely that, if the matter had been escalated as Ms Small alleged, there would have been a record, either by Ms Small or by the junior doctor. According to Ms 1 s evidence, the escalation of Patient A s condition should have taken place immediately after Ms Small had discovered the patient s low blood glucose. Given 9

10 the absence of any notes to that effect, the panel did not find Ms Small s account persuasive or plausible. This charge is therefore found proved. 2. On 12 July 2014 failed to administer and/or failed to record the administration of Nystatin to Patient B at: : : :00 This charge is found proved in its entirety by way of Ms Small s admission. The panel accepted Ms Alabaster s submissions that Ms Small, on the balance of probabilities, had failed to administer Nystatin to Patient B. In reaching its decision, the panel had regard to Patient B s records. These show that the patient was administered benzylpenicillin at 12:00 and 18:00 on the same day, with what appear to be Ms Small s initials at the relevant entries. This would not have been possible if the patient s drug chart was at the pharmacy as she alleges. Furthermore, the panel had regard to Ms 1 s investigation records. While Ms Small made reference to the Nystatin not being available at the time, the panel heard evidence from Ms 1 confirming that this was a stock drug and would have been available. Ms Small had provided no explanation as to why the drug had not been administered or recorded as administered during any of her drug rounds, and said she could not recall the reasons for her actions or omissions. 10

11 3. On 15 and/or 16 July 2014 failed to administer and/or failed to record the administration of Enoxaparin to Patient B at 18:00 hours. This charge is found proved by way of Ms Small s admission. The panel accepted Ms Alabaster s submissions that Ms Small, on the balance of probabilities, had failed to administer Enoxaparin to Patient B and had therefore failed to record it. In reaching its decision, the panel had regard to the contemporaneous record of the incident in Ms 2 s report dated 17 July 2016, a date very close to the events in question. Ms 1 also gave oral evidence that, from her memory, the relevant dates of administration on the patient s record were blank. 4. On or about 6 August 2014 adhered dressing to Patient E s wound using micropore tape which was clinically unsuitable. The panel noted Ms Small s consistent denial in respect of this charge and her detailed documented description of the correct procedure that she followed in dressing Patient E s wound on 5 August The panel considered that it had no evidence confirming whether or not Patient E s wound dressing had been changed by anyone in the three days between 5 and 8 August It took into account Patient E s records and considered Ms 1 s oral evidence that the changing of patients wound dressings was often not documented. Ms 1 also told the panel that she had not made any enquiries in the course of her investigations regarding whether someone else may have changed Patient E s wound dressing between 5 and 8 August In light of the above, the panel found this charge not proved. Submissions on misconduct and impairment Having announced its finding on all the facts, the panel then moved on to consider, whether the facts found proved amount to misconduct and, if so, whether Ms Small s 11

12 fitness to practise is currently impaired. There is no statutory definition of fitness to practise. However, the NMC has defined it as a registrant s suitability to remain on the register unrestricted. In her submissions, Ms Alabaster invited the panel to take the view that Ms Small s actions amount to breaches of The Code: Standards of conduct, performance and ethics for nurses and midwives 2008 ( the Code (2008) ). She then directed the panel to specific paragraphs and identified where, in the NMC s view, Ms Small s actions amounted to misconduct. She drew the panel s attention to the evidence of Ms 1 who had said in respect of charge 1 in particular, that it would have never been acceptable to leave a patient who was so unwell without taking any action. Ms Alabaster referred the panel to the case of Roylance v GMC (No. 2) [2000] 1 AC 311 which defines misconduct as a word of general effect, involving some act or omission which falls short of what would be proper in the circumstances. She then moved on to the issue of impairment, and addressed the panel on the need to have regard to protecting the public and the wider public interest. This includes the need to declare and maintain proper standards and maintain public confidence in the profession and in the NMC as a regulatory body. Ms Alabaster referred the panel to the cases of GMC v Meadow [2007] QB 462 (Admin) and Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin) (Grant). She outlined the approach cited in Grant as to what might lead to a finding of impairment. She submitted that the first three limbs of this approach were engaged and gave reasons for this. Ms Alabaster referred the panel to the guidance on remediation as set out in Cohen v GMC [2008] EWHC 581 (Admin). The panel must consider whether the conduct which led to the charges is easily remediable; whether it has been remedied and whether it is likely to be repeated. 12

13 Ms Alabaster submitted that Ms Small s failings were clinical in nature, and therefore capable of remediation by an appropriately motivated individual. She referred the panel to the NMC guidance in respect of remediation and insight, which sets out the various considerations that should be taken into account. She drew the panel s attention to Ms Small s apparent lack of appreciation of the seriousness of the incidents at the time, and referred to the possibility of Ms Small having attitudinal issues that may affect her ability to remediate. Although Ms Small appears to have left the nursing profession and has expressed an intention to not return, Ms Alabaster invited the panel to make its decision on the basis that she may wish to return to nursing in the future. In her submissions in respect of insight, Ms Alabaster drew the panel s attention to the lack of a reflective piece from Ms Small or of any evidence demonstrating her insight. She referred the panel to Ms Small s explanations in respect of some of the charges. She invited the panel to give some weight to the degree of remorse that Ms Small has expressed. Ms Alabaster concluded by submitting that, given the lack of evidence in terms of remediation or insight, the panel would have difficulty in finding that Ms Small poses no risk to the public and there was therefore a risk of repetition. She invited the panel to make a finding of impairment on the grounds of public protection and the wider public interest. The panel accepted the advice of the legal assessor which included reference to a number of relevant judgments: Roylance v General Medical Council (No 2) [2000] 1 A.C. 311, Cohen v GMC [2008] EWHC 581 (Admin) and Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin). The panel adopted a two-stage process in its consideration. First, it must determine whether the facts found proved amount to misconduct. Secondly, only if the facts found 13

14 proved amount to misconduct, it must decide whether, in all the circumstances, Ms Small s fitness to practise is currently impaired as a result of that misconduct. Decision on misconduct When determining whether the facts found proved amount to misconduct the panel had regard to the terms of the Code (2008). In reaching its decision, the panel had regard to the public interest. It accepted that there was no burden or standard of proof at this stage and exercised its own professional judgement. The panel found that Ms Small s actions in respect of the charges found proved fell seriously short of the conduct and standards expected of a registered nurse and amounted to breaches of the Code (2008). Specifically: The people in your care must be able to trust you with their health and wellbeing. To justify that trust, you must: work with others to protect those in your care provide a high standard of practice and care at all times As a professional, you are personally accountable for actions and omissions in your practice, and must always be able to justify your decisions. 14

15 21 You must keep your colleagues informed when you are sharing the care of others. 26 You must consult and take advice from colleagues when appropriate. 28 You must make a referral to another practitioner when it is in the best interests of someone in your care. 32 You must act without delay if you believe that you, a colleague or anyone else may be putting someone at risk. 35 You must deliver care based on the best available evidence or best practice. 42 You must keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give, and how effective these have been. 61 You must uphold the reputation of your profession at all times. The panel appreciated that breaches of the Code do not automatically result in a finding of misconduct. It considered the significance of Ms Small s breaches in respect of each charge and whether they amounted to misconduct. The ward on which Ms Small worked cared for patients with complex medical needs and conditions. The panel considered that, as a result of her failings, action was not taken to escalate the issue or stabilise Patient A s blood glucose level which continued to decrease until the ward round several hours later. Whilst the panel has no evidence of actual harm being caused to Patient A, there was a potential for serious harm. 15

16 In respect of charges 2 and 3, the panel considered that Patient B did not receive two different types of prescribed medication on more than one occasion, which could have affected the patient s course of treatment. The panel was also conscious that patients on the ward would have been reliant on Ms Small to ensure they received the correct medication. Incomplete recording of medication has the potential to mislead other staff and could lead to potential harm. The panel found that Ms Small s actions in respect of all the charges found proved constituted serious departures from the Code (2008) and amounted to misconduct. Decision on impairment The panel next went on to decide if, as a result of this misconduct, Ms Small s fitness to practise is currently impaired. Nurses occupy a position of privilege and trust in society and are expected at all times to be professional and to maintain professional boundaries. Patients and their families must be able to trust nurses with their lives and the lives of their loved ones. They must make sure that their conduct at all times justifies both their patients and the public s trust in the profession. In this regard, the panel considered paragraph 74 of the judgment of Mrs Justice Cox in the case of Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin): In determining whether a practitioner s fitness to practise is impaired by reason of misconduct, the relevant panel should generally consider not only whether the practitioner continues to present a risk to members of the public in his or her current role, but also whether the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular circumstances. 16

17 Mrs Justice Cox went on to say in Paragraph 76: I would also add the following observations in this case having heard submissions, principally from Ms McDonald, as to the helpful and comprehensive approach to determining this issue formulated by Dame Janet Smith in her Fifth Report from Shipman, referred to above. At paragraph she identified the following as an appropriate test for panels considering impairment of a doctor s fitness to practise, but in my view the test would be equally applicable to other practitioners governed by different regulatory schemes. Do our findings of fact in respect of the doctor s misconduct, deficient professional performance, adverse health, conviction, caution or determination show that his/her fitness to practise is impaired in the sense that s/he: a. has in the past acted and/or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and/or b. has in the past brought and/or is liable in the future to bring the medical profession into disrepute; and/or c. has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the medical profession; and/or d. The panel had regard to the seriousness of Ms Small s failings and decided that limbs a, b and c of the Grant guidance, are engaged in this matter. It considered that, given the nature of the misconduct, it is remediable. However, it had no evidence before it of any remediation having taken place. 17

18 Ms Small has shown some limited insight, as she has accepted that she failed to take certain actions. She has not, however, provided a reflective piece demonstrating her insight, nor evidence of any training or working within a clinical environment since leaving the Trust. The panel noted that Ms Small has shown remorse, as she has apologised for her actions on several occasions. The panel had some concerns regarding Ms Small not demonstrating a full understanding or appreciation of the seriousness of her misconduct. However, it did not consider the evidence before it strong enough to enable it to conclude that Ms Small has an attitudinal problem. The panel considered that, by her actions, Ms Small put patients, who were entirely reliant on her for their treatment and care, at risk of harm, thus failing in a fundamental part of a registered nurse s role. It also took the view that in the absence of any evidence of remediation, there remains a risk of the misconduct being repeated. It therefore decided that a finding of impairment is necessary on the grounds of public protection. The panel bore in mind that the overarching objectives of the NMC are to protect, promote and maintain the health safety and well-being of the public and patients, and to uphold/protect the wider public interest. This includes promoting and maintaining public confidence in the nursing and midwifery professions and upholding the proper professional standards for members of those professions. The panel decided that, in this case, a finding of impairment on public interest grounds was also required due to the seriousness of the charges found proved and their implications for the standing of the profession and the NMC as its regulator. Having regard to all of the above, the panel was satisfied that Ms Small s fitness to practise is currently impaired. 18

19 Determination on sanction The panel heard submissions from Ms Alabaster in relation to the appropriate sanction in this matter. She drew the panel s attention to the aggravating and mitigating factors in this case and to the NMC Sanctions Guidance (28 July 2017) ( the Guidance ). She submitted that the appropriate sanction in this case was nothing less than a conditions of practice order and made submissions in respect of the difficulties in the workability of this sanction. She invited the panel to apply the principle of proportionality in reaching its decision. The panel considered this case very carefully and has decided to make a suspension order. The effect of this order is that the NMC register will show that Ms Small s registration has been suspended. In reaching this decision, the panel has had regard to all the evidence that has been adduced in this case. It has accepted the advice of the legal assessor. The panel has borne in mind that any sanction imposed must be appropriate and proportionate and, although not intended to be punitive in its effect, may have such consequences. The panel had careful regard to the Guidance. It recognised that the decision on sanction is a matter for the panel, exercising its own independent judgement. The panel had regard to the aggravating and mitigating factors in this case, which it found to be as follows: Aggravating: - Ms Small s actions had the potential to cause serious harm to patients. - Ms Small breached basic fundamental aspects of nursing care. - There were repeated errors in Ms Small s clinical practice. - Ms Small s insight does not appear to be fully developed and she has not provided any evidence of having remediated her clinical practice. 19

20 Mitigating: - Ms Small made admissions to some of the charges at an early stage, and to impairment. - There have been no prior regulatory findings in respect of Ms Small s nursing practice and there is no evidence of any further issues arising since these matters have come to light. - She has shown some remorse for her actions. The panel first considered whether to take no action but concluded that this would be inappropriate in view of the seriousness of the case. The panel decided that it would be neither proportionate nor in the public interest to take no further action, nor would it protect the public. Next, in considering whether a caution order would be appropriate in the circumstances, the panel took into account the Guidance, which states that a caution order may be appropriate where the case is at the lower end of the spectrum of impaired fitness to practise and the panel wishes to mark that the behaviour was unacceptable and must not happen again. The panel considered that Ms Small s misconduct was not at the lower end of the spectrum and that a caution order would be inappropriate in view of the seriousness of the case. It decided that it would be neither proportionate nor in the public interest to impose a caution order, nor would it protect the public. The panel gave serious consideration as to whether placing conditions of practice on Ms Small s registration would be a sufficient and appropriate response. It was mindful that any conditions imposed must be proportionate, measurable and workable. Whilst the misconduct identified could be addressed through retraining under the appropriate conditions, the panel had no information from Ms Small to indicate whether she would be willing to comply with conditions or respond positively to retraining. In fact, according to the evidence before the panel, Ms Small had not worked as a nurse since 20

21 2014 and had indicated at various times that she did not wish to return to nursing. In light of this, the panel decided that there were no workable conditions that could be formulated in the circumstances. The panel then went on to consider whether a suspension order would be an appropriate sanction. It considered that it had no evidence of Ms Small having any deep seated personality or attitudinal problems, and no evidence of her having repeated the misconduct since the incidents. It took into account Ms Small s limited insight. The panel determined that a suspension order for a period of 6 months was appropriate in this case to mark the seriousness of the misconduct and to give Ms Small an opportunity to reflect on her actions and develop her insight. The panel considered that this would also give her a final opportunity to decide whether she wishes to return to nursing practice. The panel noted that even if Ms Small was to decide to return to nursing, it was likely that she would need to complete a return to practice course. The panel considered whether a striking-off order would be proportionate in Ms Small s case. Taking account of all the information before it, the panel concluded that it would be disproportionate. Although there had been a clear breach of fundamental tenets of the profession, the misconduct was not fundamentally incompatible with remaining on the register. Whilst the panel acknowledges that a suspension may have a punitive effect, it would be unduly punitive in Ms Small s case to impose a striking off order. Balancing all of these factors, the panel has concluded that a 6 month suspension order would be the appropriate and proportionate sanction. The panel noted the hardship such an order may cause Ms Small. However, the panel considered that this order is necessary to protect the public and mark the importance of maintaining public confidence in the profession. It is further necessary to send to the public and the profession a clear message about the standard of behaviour required of a registered nurse. 21

22 At the end of the period of suspension, another panel will review the order. At the review hearing the panel may revoke the order, it may confirm the order, or it may replace the order with another order. A future reviewing panel may be assisted by evidence of: - A detailed piece prepared by Ms Small focusing on the impact of her actions on patients, colleagues and the wider profession; what she has learned; what she would do differently and how she has changed her decision-making practices; what she feels she needs to do to increase her clinical competence in relation to caring for the deteriorating patient, keeping clear and accurate records and medicines management. - Evidence of Ms Small keeping up to date with developments in the nursing profession, such as a reflective diary in relation to her reading of relevant journals. - Evidence or information to satisfy the panel that she is committed to returning to the nursing profession. Determination on Interim Order The panel has considered the submissions made by Ms Alabaster that an interim order should be made on the grounds that it is necessary for the protection of the public and is otherwise in the public interest. The panel accepted the advice of the legal assessor. The panel was satisfied that an interim suspension order is necessary for the protection of the public and is otherwise in the public interest. The panel had regard to the seriousness of the facts found proved and the reasons set out in its decision for the 22

23 substantive order in reaching the decision to impose an interim order. To do otherwise would be incompatible with its earlier findings. The period of this order is for 18 months to allow for the possibility of an appeal to be made and determined. If no appeal is made, then the interim order will be replaced by the suspension order 28 days after Ms Small is sent the decision of this hearing in writing. That concludes this determination. 23