Nursing and Midwifery Council:

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1 Nursing and Midwifery Council Fitness to Practise Committee Substantive Hearing 5 8 March 2018 Nursing and Midwifery Council, George Street, Edinburgh, EH2 4LH Name of registrant: NMC PIN: Helen Barfield 11F1800E Part(s) of the register: Registered Nurse (Sub Part 1) Adult Nursing September 2011 Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Miss Barfield: Nursing and Midwifery Council: Facts proved: England Misconduct Malcolm Davidson (Chair, Lay member) John McGrath (Registrant member) Bill Matthews (Lay member) Angela Hughes Caroline Pringle Not present and not represented Represented by Michael Bellis, Case Presenter 2(a), 2(b) and 2(c) Facts proved by admission: 1, 3, 4, 5, 6, 7 and 8 Facts not proved: Fitness to practise: Sanction: Interim Order: 2(d) Impaired Striking-off order Interim suspension order (18 months) 1

2 Details of charge That you, a registered nurse: 1. On 14 October 2015, left a box of tramadol, a controlled drug, on top of a medication trolley which was unattended. [found proved by way of admission] 2. On 6 November 2015, practised inadequate medication administration in that you; a) Pre-potted medication for a number of residents. [found proved] b) Did not carry out an appropriate identification check for Resident B. [found proved] c) Left medication with Resident B without ensuring that it was administered. [found proved] d) Signed for medication when you were not sure that it had been administered. [found NOT proved] 3. On 17, 18, 19, 20 and/or 21 November 2015, did not administer Resident A s prescribed tinzaparin. [found proved by way of admission] 4. On 17, 18, 19, 20 and/or 21 November 2015, incorrectly recorded in Resident A s MAR chart that you had administered the prescribed tinzaparin. [found proved by way of admission] 5. Your conduct in Charge 4, above, was dishonest in that you knowingly recorded incorrect information in Resident A s MAR chart. 2

3 [found proved by way of admission] 6. On 11 May 2016, left an unlocked medication trolley unattended. [found proved by way of admission] 7. On 29 August 2016, did not cross reference blister pack medication against the patient medication administration record charts. [found proved by way of admission] 8. On 14 September 2016 handled hyoscine medication without gloves. [found proved by way of admission] AND in light of the above, your fitness to practise is impaired by reason of your misconduct. 3

4 Decision on service of notice of hearing The panel was informed at the start of this hearing that Miss Barfield was not in attendance and that written notice of this hearing had been sent to Miss Barfield s registered address by recorded delivery and by first class post on 2 February Royal Mail Track and Trace documentation confirmed that notice of this hearing was delivered and signed for at Miss Barfield s registered address on 3 February 2018 in the printed name of BARFIELD. Further, the panel noted that notice of this hearing was also sent to Miss Barfield s representative at the Royal College of Nursing (RCN) on 6 February The panel took into account that the notice letter provided details of the allegation, the time, dates and venue of the hearing and, amongst other things, information about Miss Barfield s right to attend, be represented and call evidence, as well as the panel s power to proceed in her absence. Mr Bellis submitted that 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 Miss Barfield 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 Miss Barfield. The panel had regard to Rule 21 (2) which states: 4

5 (2) Where the registrant fails to attend and is not represented at the hearing, the Committee (a) (b) (c) shall require the presenter to adduce evidence that all reasonable efforts have been made, in accordance with these Rules, to serve the notice of hearing on the registrant; may, where the Committee is satisfied that the notice of hearing has been duly served, direct that the allegation should be heard and determined notwithstanding the absence of the registrant; or may adjourn the hearing and issue directions. Mr Bellis invited the panel to continue in the absence of Miss Barfield on the basis that she had voluntarily absented herself. Mr Bellis referred the panel to an received from Miss Barfield s RCN representative, dated 22 February 2018, which stated that Miss Barfield would not be present or represented at this hearing and was content for it to proceed in her absence. In these circumstances, Mr Bellis submitted that an adjournment would be unlikely to secure Miss Barfield s attendance and invited the panel to proceed in her absence. The panel accepted the advice of the legal assessor which included reference to the case of GMC v Adeogba [2016] EWCA Civ 162. 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. The panel noted the correspondence from the RCN, dated 22 February 2018, which stated: 5

6 Our member will not be attending the hearing nor will she be represented. No disrespect is intended by her non-attendance. Our member has received the notice of hearing and is happy for the hearing to proceed in her absence. She is keen to engage with the proceedings. The panel decided to proceed in the absence of Miss Barfield. In reaching this decision, the panel considered the submissions of the case presenter, the advice of the legal assessor and the correspondence from the RCN. It had regard to the overall interests of justice and fairness to all parties and noted that: Miss Barfield has clearly communicated, via her RCN representative, that she will not be attending today and is content for the hearing to proceed in her absence; no application for an adjournment has been made by Miss Barfield or her RCN representative and there is no reason to suppose that adjourning would secure her attendance at some future date; one witness has attended today to give live evidence; not proceeding may inconvenience the witness, her employer and the clients who need her professional services; the charges relate to events that occurred in 2015 and 2016; further delay may have an adverse effect on the ability of the witness accurately to recall events; there is a strong public interest in the expeditious disposal of the case. There is some disadvantage to Miss Barfield in proceeding in her absence but, in the panel s judgement, this is minimal. Miss Barfield has been sent the evidence on which the NMC seeks to rely and the RCN has, on her behalf, provided detailed written submissions which set out Miss Barfield s position in relation to each charge. The panel can, of its own volition, put Miss Barfield s positon to the witness and can consider her submissions alongside the NMC s evidence. Furthermore, Miss Barfield has provided these written submissions because she intended not to attend or be represented, and in the expectation that the panel would proceed in her absence today. 6

7 In these circumstances, the panel decided that it was fair, appropriate and proportionate to proceed in the absence of Miss Barfield. The panel will draw no adverse inference from Miss Barfield s absence in its findings. Background The NMC received a referral on 15 December 2015 from Hillfield Nursing Home ( Hillfield ) where Miss Barfield had been employed as a staff nurse from August to November The referral raised a number of concerns regarding Miss Barfields s nursing practice, specifically medicines management and administration, and forms the basis of charges 1 5. In relation to charge 1, it is alleged that Miss Barfield left a box of tramadol (a controlled drug) on top of the medication trolley unattended while undertaking a medication round. The medication trolley and box of tramadol were discovered in the corridor by the manager at Hillfield, Mr 2, whilst Miss Barfield was in a resident s room. In relation to charge 2, it is alleged that on 6 November 2015 Miss Barfield administered medication to Resident B but failed to do so in accordance with the medicines administration policy. Specifically, that she pre-potted medication for a number of residents, did not carry out an appropriate identification check for Resident B, and signed to confirm that Resident B had taken this medication, without waiting to ensure that he had. This alleged incident was witnessed by Ms 1, a healthcare assistant at Hillfield. In relation to charges 3, 4 and 5, it is alleged that on a number of occasions in November 2015 Miss Barfield failed to administer tinzaparin to Resident A. It is further alleged that she incorrectly recorded that she had administered this medication in Resident A s Medicines Administration Record ( MAR ) chart and that this was dishonest in that she knew she had not administered the medication. 7

8 A second referral was received on 22 October 2016 and concerned Miss Barfield s practice as a registered nurse at Kibblesworth Specialist Support Centre ( Kibblesworth ). The allegations contained within this referral were similar to those raised by Hillfield, and form the basis of charges 6 8. In relation to charge 6, it is alleged that on 11 May 2016 Miss Barfield left an unlocked medication trolley unattended in a corridor, whilst she was engaged in conversation with another member of staff in the kitchen. In relation to charge 7, it is alleged that on 29 August 2016 Miss Barfield administered medication to residents without cross-referencing their prescription charts. This was witnessed by Acting Manager, Ms 4, who had recently come into post and was observing practice at Kibblesworth. Finally, on 14 September 2016 Miss Barfield sustained an injury to her right eye. Following attendance at A&E it was diagnosed that she had transferred the medication hyoscine into her eye as she had not been wearing gloves during its administration to a resident. This forms the basis of charge 8. Admissions to the charges At the outset of this hearing, Mr Bellis informed the panel that Miss Barfield admitted charges 1, 3, 4, 5, 6, 7 and 8. She denied charge 2 in its entirety. Mr Bellis referred the panel to the RCN s written submissions which confirmed these admissions. The panel accepted these admissions and therefore announced these charges as proved. Accordingly, charges 1, 3, 4, 5, 6, 7 and 8 are found proved. 8

9 Decision on the findings on facts and reasons In reaching its decisions on the facts, the panel took into account all the oral and documentary evidence in this case together with the submissions made by Mr Bellis, on behalf of the NMC, and the written submissions provided by the RCN on behalf of Miss Barfield. The panel 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 will be proved if the panel was satisfied that it was more likely than not that the incidents occurred as alleged. The panel drew no adverse inference from the non-attendance of Miss Barfield. The panel heard oral evidence from one witness called on behalf of the NMC: Ms 1, Healthcare Assistant at Hillfield Nursing Home. She was present during the alleged incident in charge 2. The panel found her to be a helpful and credible witness who gave clear answers. She had a good recollection of events, but was willing to admit when she could not recall details. The panel had no reason to doubt the veracity of her evidence. The panel was also provided with the written statements of six other witnesses (in light of Miss Barfield s admissions, these witnesses were not called to give oral evidence): Mr 2, Home Manager at Hillfield; Mr 3, Nursing Support Staff at Kibblesworth; Ms 4, Acting Manager at Kibblesworth; Ms 5, Clinical Director at Kibblesworth; Ms 6, Registered Nurse at Hillfield; Ms 7, Staff Nurse at Bradford Royal Infirmary. 9

10 The panel had already found charges 1, 3, 4, 5, 6, 7 and 8 proved by way of Miss Barfield s admissions. It therefore went on to consider charge 2 and made the following findings: Charge 2 2. On 6 November 2015, practised inadequate medication administration in that you; a) Pre-potted medication for a number of residents. This charge is found proved. In reaching this decision, the panel took into account the evidence of Ms 1, Miss Barfield s written submissions and Hillfield s medication policy. Hillfield s medication policy states that medication should only be administered to one resident at a time, and that staff should prepare, administer and sign for a resident s medication before moving on to the next. In her oral evidence Ms 1 told the panel that on the morning of 6 November 2015 she was standing in the dining area near Resident B. She saw Miss Barfield approach Resident B holding four small medication pots. She described Miss Barfield as holding all four cups in one hand, which she was doing by placing her fingers inside the cups and pinching them together. According to Ms 1, Miss Barfield approached Resident B, placed one of the pots in front of him, and then walked away. Although Ms 1 did not witness Miss Barfield place the medication into the pots, when questioned Ms 1 was certain that all four pots had contained medication. The panel also had regard to Miss Barfield s written submissions. It is her position that each resident at Hillfield had a tray with pre-potted medication and identification label. According to Miss Barfield, the medication was ordered and delivered by Biodose in that form. Each pot was individually sealed and labelled with the patient s details and the 10

11 date, day and time of administration. Miss Barfield claims that she only removed the seals from the pots as she was about to administer the medication. Miss Barfield states that Hillfield only used Biodose pots and did not use disposable paper medication pots. Ms 1 was asked in her evidence about Biodose pots but denied any knowledge of this system. Having found Ms 1 to be a reliable witness, the panel accepted Ms 1 s evidence that Miss Barfield had approached Resident B carrying four medication pots, each containing tablets. It also accepted that Miss Barfield only placed one of these in front of Resident B. The panel therefore drew the reasonable inference that the other three pots contained medication for other residents. This was supported by the witness statement of Mr 2, who stated that he spoke about this incident informally with Miss Barfield and she admitted to holding on to multiple medication pots. However, the panel was mindful that the charge Miss Barfield faced was not of carrying medication for a number of residents, but of pre-potting it. It noted Miss Barfield s submission that Hillfield used Biodose pots and therefore the medication arrived at Hillfield pre-potted. However, Ms 1 denied any knowledge of the Biodose system and was certain that nursing staff had to prepare the medication pots themselves. The panel also noted that Miss Barfield s assertion that she would only take the seal off Biodose pots as she was about to administer medication did not accord with Ms 1 s evidence that Miss Barfield was holding four pots between her fingers, as this would not have been possible if the seals were still on the pots. The panel preferred the evidence of Ms 1. It was satisfied that, in order to carry four medication pots for different residents between her fingers, Miss Barfield must have either pre-potted the medication or, alternatively, removed the seals from the pots for several residents at once. 11

12 It was therefore satisfied that, on the balance of probabilities, on 6 November 2015 Miss Barfield practised inadequate medication administration in that she pre-potted medication for a number of residents. Accordingly, charge 2(a) is found proved. 2. On 6 November 2015, practised inadequate medication administration in that you; a) b) Did not carry out an appropriate identification check for Resident B. This charge is found proved. In reaching this decision, the panel took into account the evidence of Ms 1, Miss Barfield s written submissions and Hillfield s medications policy. Hillfield s medication policy states that the identity of the individual must be checked using either a photograph or other suitable means of identification. Miss Barfield states in her written submissions that she undertook the proper checks to ensure that it was the correct medication, the correct time, the correct dose and the correct resident, using the prescription and Resident B s MAR chart. She also states that she spoke with Resident B to confirm his identity. However, in her oral evidence to the panel, Ms 1 stated that she did not see Miss Barfield with any paperwork or documentation. She also denied seeing any conversation between Miss Barfield and Resident B. Having found Ms 1 to be a reliable and credible witness, the panel decided to prefer her evidence. The panel was satisfied that, without any paperwork and in the absence of 12

13 any conversation between Miss Barfield and Resident B, Miss Barfield could not have carried out an appropriate identification check for Resident B. Accordingly, charge 2(b) is found proved. 2. On 6 November 2015, practised inadequate medication administration in that you; a) b) c) Left medication with Resident B without ensuring that it was administered. This charge is found proved. In reaching this decision, the panel took into account the evidence of Ms 1, Miss Barfield s written submissions and Hillfield s medications policy. Hillfield s medications policy states that medication should then be administered directly to the individual. Medication should never be left with an individual or other person to be administered at a later time. In her written submissions, Miss Barfield states that she waited to see Resident B take the medication before recording the administration in his MAR chart. However Ms 1, who was present in the room with Miss Barfield and Resident B, told the panel in her oral evidence that Miss Barfield placed the medication pot in front of Resident B and then immediately walked away. According to Ms 1, Miss Barfield did not wait to ensure Resident B took the medication. 13

14 Having found Ms 1 to be a reliable and credible witness, the panel decided to prefer her evidence. It was satisfied that, on the balance of probabilities, Miss Barfield left medication with Resident B without ensuring that it was administered. Accordingly, charge 2(c) is found proved. 2. On 6 November 2015, practised inadequate medication administration in that you; a) b) c) d) Signed for medication when you were not sure that it had been administered. This charge is found NOT proved. The panel noted that it had heard very little evidence regarding the completion of Resident B s MAR chart. It acknowledged the NMC s submission that there was insufficient evidence to support this charge. In her written submissions Miss Barfield stated that she completed the chart after witnessing Resident B take the medication. Ms 1 was unable to confirm or deny if Miss Barfield had completed Resident B s MAR chart and the panel did not have the relevant MAR chart before it at this hearing. The panel was therefore not satisfied that the NMC had provided sufficient evidence to prove on the balance of probabilities that Miss Barfield signed for medication when she was not sure that it had been administered. Accordingly, charge 2(d) is found not proved. 14

15 Submission on misconduct and impairment Having announced its finding on all the facts, the panel then moved on to consider whether the facts found proved amount to misconduct and, if so, whether Miss Barfield s 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 his submissions Mr Bellis invited the panel to take the view that Miss Barfield s actions amounted to a breach of The Code: Professional standards of practice and behaviour for nurses and midwives (2015). He then directed the panel to specific paragraphs and identified where, in the NMC s view, Miss Barfield s actions amounted to misconduct. Mr Bellis 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. He then moved on to the issue of impairment, and addressed the panel on the need to have regard to protecting the public and the wider public interest. This included the need to declare and maintain proper standards and maintain public confidence in the profession and in the NMC as a regulatory body. Mr Bellis referred the panel to the cases of Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin) and Cohen v General Medical Council [2008] EWHC 581 (Admin). He also referred the panel to the written reflective piece, training certificates and testimonials provided by Miss Barfield. The panel accepted the advice of the legal assessor which included reference to Roylance [2000], GMC v Meadow [2007] QB 462 (Admin), Cohen [2008], and Grant [2011]. 15

16 The panel adopted a two-stage process in its consideration, as advised. First, the panel must determine whether the facts found proved amount to misconduct. Secondly, only if the facts found proved amount to misconduct, the panel must decide whether, in all the circumstances, Miss Barfield 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: Professional standards of practice and behaviour for nurses and midwives (2015) (the Code). The panel, in reaching its decision, had regard to the public interest and accepted that there was no burden or standard of proof at this stage. It acknowledged that Miss Barfield has admitted that her actions amounted to misconduct, but exercised its own professional judgement as to this issue. The panel was of the view that Miss Barfield s actions did fall significantly short of the standards expected of a registered nurse, and that her actions amounted to a breach of the Code. Specifically: 8 Work cooperatively To achieve this, you must: 8.2 maintain effective communication with colleagues 10 Keep clear and accurate records relevant to your practice This includes but is not limited to patient records. It includes all records that are relevant to your scope of practice. To achieve this, you must: 16

17 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 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 16.3 tell someone in authority at the first reasonable opportunity if you experience problems that may prevent you working within the Code or other national standards, taking prompt action to tackle the causes of concern if you can 19 Be aware of, and reduce as far as possible, any potential for harm associated with your practice To achieve this, you must: 19.1 take measures to reduce as far as possible, the likelihood of mistakes, near misses, harm and the effect of harm if it takes place 19.3 keep to and promote recommended practice in relation to controlling and preventing infection 19.4 take all reasonable personal precautions necessary to avoid any potential health risks to colleagues, people receiving care and the public. 20 Uphold the reputation of your profession at all times To achieve this, you must: 17

18 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 The panel was also of the view that Miss Barfield s failings had breached Hillfield s local medicines policy (relevant sections referenced in its decision on facts) and the following aspects of the NMC Standards for Medicines Management: Standard 2: Checking 3.1 clearly identified the patient for whom the medication is intended Standard 5: Patients own medicines 6 As a registrant you have the following responsibilities: 6.4 that the medicines cabinet or locker is kept locked and that the master key is kept secure Standard 8: Administration 2 As a registrant, in exercising your professional accountability in the best interests of your patients: 2.1 you must be certain of the identity of the patient to whom the medicine is to be administered 2.10 you must make a clear, accurate and immediate record of all medicine administered, intentionally withheld or refused by the patient, ensuring the signature is clear and legible; it is also your responsibility to ensure that a record is made when delegating the task of administering medicine. In addition: 3 Where medication is not given, the reason for not doing so must be recorded. 18

19 The panel appreciated that breaches of the Code do not automatically result in a finding of misconduct. However, the panel was of the view that the charges found proved represent multiple failings relating to basic aspects of nursing care. Miss Barfield, on several occasions, failed to practice adequate medicines management and administration such that residents either did not receive their required medication, or whereby medicines were left unattended in accessible areas where vulnerable residents could have consumed them and suffered harm. Furthermore, some of these failings were compounded by Miss Barfield s dishonest attempt to conceal the fact that she had not administered medication to Resident A on five separate occasions, by inaccurately completing records. The panel considered that these failings fell seriously short of the conduct and standards expected of a registered nurse and amounted to misconduct. Decision on impairment The panel next went on to decide if, as a result of this misconduct, Miss Barfield s fitness to practise is currently impaired. Nurses occupy a position of privilege and trust in society. Patients and their families must be able to trust nurses with their lives and the lives of their loved ones. To justify that trust, nurses must be honest and open and act with integrity. They must make sure that their conduct at all times justifies both their patients and the public s trust in the profession. In this regard the panel considered the judgement of Mrs Justice Cox in the case of Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin) in reaching its decision, in paragraph 74 she said: In determining whether a practitioner s fitness to practise is impaired by reason of misconduct, the relevant panel should generally consider not only whether the practitioner continues to present a risk to members of the public in his or her current role, but also whether the need to uphold proper professional standards and public confidence in the profession 19

20 would be undermined if a finding of impairment were not made in the particular circumstances. Mrs Justice Cox went on to say in Paragraph 76: I would also add the following observations in this case 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. has in the past acted dishonestly and/or is liable to act dishonestly in the future. 20

21 The panel found that all four limbs of the Grant test were engaged in this case. Miss Barfield had put residents at an unwarranted risk of harm by failing to administer medication (as in the case of Resident A) and by leaving controlled medication and unlocked medicine trolleys unattended, where residents could have accessed them and taken medication with potentially harmful consequences. Furthermore, Miss Barfield had dishonestly attempted to conceal some of her failings. The panel considered that, taken together, her actions had breached fundamental tenets and brought the nursing profession into disrepute. The panel then went on to consider whether Miss Barfield is liable to repeat such misconduct in the future. The panel first considered whether Miss Barfield s misconduct is capable of remediation and concluded that it is, although it acknowledged that dishonesty is inherently harder to remediate than clinical concerns. It then considered whether Miss Barfield had remediated her practice. The panel had regard to her written submissions and her assertion that she has undertaken additional training and assessments in medicines administration and record-keeping. However, the panel noted that the training certificates provided pre-dated the incidents at Kibblesworth. Charges 1-5 occurred at Hillsfield between October - November 2015 and concerned issues of medicines management, administration and record-keeping. Miss Barfield undertook a Care of Medicines training course on 11 February 2016, a medicines administration competency assessment in March 2016 and an online training course in record-keeping on 29 July 2016, all of which she passed. However, despite this additional training Miss Barfield then went on to repeat mistakes of a very similar nature at Kibblesworth between May September 2016 (charges 6-8). The panel had no further evidence from Miss Barfield of any more recent training. The panel also considered the issue of Miss Barfield s dishonesty. It noted that she had not only chosen not to administer tinzaparin to Resident A, but had also signed the MAR chart for five consecutive days to confirm that she had administered this medication 21

22 when she knew she had not. Although Miss Barfield writes in her reflective piece that she admitted her errors at the first available opportunity (at a meeting with Mr 2 on 23 November 2015) the panel was concerned that this was only when challenged bt Mr 2 some six days after she had stopped administering Resident A s tinzaparin and could not be said to amount to informing her colleagues at the earliest opportunity. The panel had regard to the positive testimonials provided on behalf of Miss Barfield but, as these all also pre-dated charges 6-8, the panel could attach limited weight to them. The panel acknowledged that Miss Barfield admitted almost all of the charges against her and has, in her written reflective piece, demonstrated some insight into her wrongdoing, the causes of it, and the impact this has had on patients, colleagues and the reputation of wider nursing profession. However, even after undergoing relevant training, she continued to make similar mistakes and errors. The panel therefore concluded that there remained a future risk of repetition and decided that a finding of impairment was necessary on the grounds of public protection. The panel also 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 and 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 determined that, in this case, a finding of impairment on public interest grounds was required to maintain standards and uphold public confidence in the profession and the NMC as regulator, particularly in light of the repeated nature of Miss Barfield s failings and her associated dishonesty. Having regard to all of the above, the panel was satisfied that Miss Barfield s fitness to practise is currently impaired. 22

23 Application for voluntary removal Following the announcement of the panel s findings on impairment, Mr Bellis informed the panel that the NMC had received an application for voluntary removal from Miss Barfield. He provided the panel with a copy of this application and the supporting documentation. The panel accepted the advice of the legal assessor. The panel considered Miss Barfield s application and made a recommendation to the Registrar. The panel recommended that Miss Barfield not be granted voluntary removal from the register as, due to her dishonesty and repeated clinical failings, the panel was not satisfied that the public interest would be served by voluntary removal. Miss Barfield s application, the panel s recommendation, and its determination on facts and impairment were sent to the Registrar for consideration. The Registrar refused Miss Barfield s application for voluntary removal. Determination on sanction Following receipt of the Registrar s decision, the panel then moved on to consider sanction. The panel considered this case and decided to make a striking-off order. It directs the Registrar to strike Miss Barfield off the register. The effect of this order is that the NMC register will show that Miss Barfield has been struck-off the register. In reaching this decision, the panel had regard to all the evidence that has been adduced in this case, together with the submissions of Mr Bellis, on behalf of the NMC, and the written submissions of the RCN, provided on behalf of Miss Barfield. 23

24 Mr Bellis outlined the relevant aggravating and mitigating factors in this case and submitted that a lengthy suspension order was the minimum sanction in this case which would protect the public and satisfy the public interest. However, he recognised that sanction remained a matter for the panel s own independent judgement, having regard to the principles of fairness and proportionality. In the written submissions provided on behalf of Miss Barfield, the RCN submitted that a lengthy caution order would be sufficient to mark the misconduct, in light of Miss Barfield s early admissions, insight and remorse. The panel accepted the advice of the legal assessor who referred it to the NMC s Sanctions Guidance and the case of Parkinson v NMC [2010] EWHC 1898 (Admin). The panel bore in mind that any sanction imposed must be appropriate and proportionate and, although not intended to be punitive in its effect, may have such consequences. The panel had careful regard to the Sanctions Guidance published by the NMC. It recognised that the decision on sanction is a matter for the panel, exercising its own independent judgement. The panel considered that the mitigating factors in this case were: Miss Barfield has no previous fitness to practise history with the NMC; She admitted most of the charges against her; She admitted misconduct and impairment; She claims to have been under stress at the time (although the panel has no evidence of this or of any action that Miss Barfield took to manage this at the time or since). The panel considered that the aggravating factors in this case were: Miss Barfield s actions amounted to multiple instances of misconduct over a 12 month period, which persisted even after she had undergone retraining; 24

25 She failed to comply with local medicines management policies and the NMC Standards for Medicines Management; Her actions could have foreseeably resulted in serious harm to vulnerable patients; She repeatedly acted dishonestly in order to cover up clinical failings; Although she admitted at a local level to signing for medication which she had not administered, this was only when challenged by Mr 2. The panel first considered whether to take no action but concluded that this would be inappropriate in view of the seriousness of the case. It would not protect the public from the identified risk of harm, nor would it mark the severity of Miss Barfield s misconduct. The panel decided that it would be neither proportionate nor in the public interest to take no further action. Next, in considering whether a caution order would be appropriate in the circumstances, the panel took into account the Sanctions 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 had regard to the RCN s submissions but considered that Miss Barfield 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. The panel decided that it would be neither proportionate nor in the public interest to impose a caution order. The panel next considered whether placing conditions of practice on Miss Barfield s registration would be a sufficient and appropriate response. The panel was mindful that any conditions imposed must be proportionate, measurable and workable. The panel considered that Miss Barfield s clinical shortcomings as regards medicines management and administration could be addressed through retraining. However, Miss Barfield underwent retraining following the incidents detailed in charges 1-5 and yet she then went on to repeat errors of a very similar nature. The panel was therefore not satisfied 25

26 that retraining would effectively address the risks she poses. The panel also noted that Miss Barfield has indicated that she does not intend to practise as a nurse. Consequently, the panel decided that there were no practical or workable conditions that could be formulated in this case. Furthermore, the panel concluded that placing conditions on Miss Barfield s registration would not adequately address the seriousness of this case or Miss Barfield s dishonesty. The panel then went on to consider whether a suspension order would be an appropriate sanction. The Sanctions Guidance indicates that a suspension order would 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 (this list is not exhaustive): 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 Committee is satisfied that the nurse or midwife has insight and does not pose a significant risk of repeating behaviour The panel considered that this was not a case involving a single instance of misconduct. Miss Barfield had made serious and repeated medicines management errors which had continued despite retraining. Furthermore, although Miss Barfield admitted most of the charges and the panel had earlier found that she had demonstrated some insight, the 26

27 panel was not satisfied that she did not pose a significant risk of repeating similar behaviour in the future. The panel also gave particular consideration to Miss Barfield s dishonesty. It noted that, in this case, Miss Barfield had acted dishonestly in order to conceal the fact that she had not administered Resident A s tinzaparin. She did this for five days, which could potentially have had very serious consequences for Resident A. Further, although Miss Barfield claims to have admitted to this at the earliest opportunity, in fact she admitted this at a local level only when challenged by Mr 2. The panel therefore concluded that Miss Barfield s dishonesty was of a particularly serious nature and had the potential to undermine public confidence in the nursing profession. Miss Barfield s conduct, as highlighted by the facts found proved, was a significant departure from the standards expected of a registered nurse. She had put vulnerable patients at risk of serious harm, made repeated mistakes despite retraining, and had dishonestly concealed her own clinical failings. The panel considered that this was a serious breach of the fundamental tenets of the nursing profession and was fundamentally incompatible with her remaining on the register. Balancing all of these factors, the panel determined that a suspension order would be insufficient and inappropriate to satisfy and uphold the public interest in this case. The panel therefore moved on to consider a striking-off order. It took note of the following sections of the Sanctions Guidance: Key considerations are: can public confidence in the professions and the NMC be maintained if the nurse or midwife is not removed from the register? is striking-off the only sanction which will be sufficient to protect the public interest? 27

28 is the seriousness of the case incompatible with ongoing registration (see above for the factors to take into account when considering seriousness)? This sanction is likely to be appropriate when the behaviour is fundamentally incompatible with being a registered professional, which may involve any of the following factors. A serious departure from the relevant professional standards as set out in key standards, guidance and advice. Doing harm to others or behaving in such a way that could foreseeably result in harm to others, particularly patients or other people the nurse or midwife comes into contact with in a professional capacity. Harm is relevant to this question whether it was caused deliberately, recklessly, negligently or through incompetence, particularly where there is a continuing risk to patients. Harm may include physical, emotional and financial harm. The seriousness of the harm should always be considered. Dishonesty, especially where persistent or covered up The panel considered that Miss Barfield s actions, particularly in relation to Resident A, were significant departures from the standards expected of a registered nurse and are fundamentally incompatible with her remaining on the register. The panel was of the view that to allow Miss Barfield to continue practising, having dishonestly attempted to conceal clinical failings which could have caused serious harm to a vulnerable patient, would undermine public confidence in the profession and in the NMC as a regulatory body. 28

29 After taking into account all the evidence before it during this case, the panel determined that the appropriate and proportionate sanction is that of a striking-off order. Having regard to the matters it identified, in particular the effect of Miss Barfield s actions in bringing the profession into disrepute by adversely affecting the public s view of how a registered nurse should conduct herself, the panel has concluded that nothing short of this would be sufficient in this case. The panel considered that this order is necessary to 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. Determination on interim order The panel considered the submissions made by Mr Bellis 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 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 striking-off order 28 days after Miss Barfield is sent the decision of this hearing in writing. 29

30 That concludes this determination. 30