Conduct and Competence Committee Substantive hearing

Transcription

1 Conduct and Competence Committee Substantive hearing April June 2012 Nursing and Midwifery Council, First Floor, 61 Aldwych, London, WC2B 4AE Name of registrant: NMC Pin: Regina Koennecke 05J0010C Part(s) of the register: Registered Nurse- sub part 1 Adult (October 2005) Area of registered address: Type of case: Panel members: Legal Assessor: Panel Secretary: Nursing and Midwifery Council: Representation: England Misconduct James Spencer (Chair, lay member) Fiona Barrie (registered midwife) Jacki Pearce (lay member) Douglas Hogg (23-26 April) Ben Stephenson (15 June) Lucia Owen Represented by Elena Elia, Case Presenter, NMC Regulatory Legal Team (23-26 April) Hannah Fellows (15 June) Not present and not represented. Facts proved: 1(a), 1(b), 1(c), 1(d), 1(e), 2 Fitness to practise: Sanction: Interim order: Impaired Striking Off Order Interim Suspension Order- 18 months Page 1 of 15

2 Decision on proceeding in the absence of the registrant The panel has decided to proceed in the absence of Ms Koennecke. The panel received evidence in respect of both the Case Management form and proof of posting documentation, and noted that the notice of hearing was sent to Ms Koennecke and her representative on 17 February The panel is satisfied that the relevant rules have been complied with, and that all reasonable efforts have been made in accordance with the rules to serve the notice of hearing. The panel then heard submissions from the case presenter, who submitted that it would be appropriate to proceed with the hearing in the absence of Ms Koennecke. The panel received advice from the legal assessor, which it accepted. The panel has had well in mind that it must exercise its discretion as to whether or not to proceed in the absence of Ms Koennecke with the utmost care and caution. The panel has had regard to all the circumstances, and has concluded, in the light of Ms Koennecke s representative s dated 20 April 2012, that the panel has not read but the legal assessor has confirmed all the information within, that Ms Koennecke has voluntarily absented herself from the proceedings. Additionally, Ms Elia has confirmed that written submissions have been submitted by the representative and that a voic has been left on her personal voic confirming both Ms Koennecke and her representative s absence at this hearing. The panel has further determined that no useful purpose would be served in adjourning these proceedings, no adjournment having been requested by Ms Koennecke, and that the public interest requires the hearing to proceed today. The panel therefore concludes that it would be fair and proportionate to proceed in the absence of Ms Koennecke. Decision on application to amend the charge The panel has considered the application by Ms Elia who cited the provision of Rule 28 of the Nursing and Midwifery Council (Fitness to Practise) Rules 2004 and noted that the wording would properly reflect the evidence and the amendment at this stage would cause no unfairness or prejudice to the registrant. The panel has determined that there is no unfairness or injustice by changing the words of the opening sentence of charge one from competent to adequate and the amendment has thus been incorporated to the charge. Details of charge (as read out): That you, whilst employed as a Registered nurse; 1. Between on 23 April 2010 and on 24 April 2010 failed to provide adequate care for Patient A in that you: Page 2 of 15

3 a. Failed to ensure that Patient A s tracheostomy and ventilator remained connected at all times; b. Failed to ensure that Patient A s suction machine was emptied and in working order; c. Failed to ensure that Patient A s oxygen tubing was connected to the ventilator at all times; d. Failed to ensure that Patient A s oxygen tubing remained accessible at all times; e. Incorrectly attempted to plug Patient A s ambu-bag into the rear of the ventilator; 2. Between and on 24 April 2010, when faced with Patient A s emergency situation you panicked and/or shouted. AND, in light of the above, your fitness to practise is impaired by reason of your misconduct Decision on application to read witness statement The panel heard the application by Ms Elia, who has requested to read the witness statement of Ms Sally Page dated 8 April The reason for the application was that Ms Page s father had recently died and as his funeral was fixed for Friday, Ms Page felt that she was not in the right state of mind to give evidence. Ms Elia noted that the statement of witness Sally Page is not an eye-witness account and submitted that it would cause no prejudice or unfairness to the registrant were this statement to be read out. While the witness can provide the details of the training the registrant undertook, she does not provide a first person account of the events of the night of 23/24 April The panel has also heard and accepted the advice of the legal assessor. The panel has kept in mind that because the registrant is neither present nor represented no questions could be put by or on her behalf to Ms Page. Whilst it is true that Ms Page could be questioned by the panel members, the panel concluded that their inability to do so- due to her absence- was unlikely to cause unfairness to the registrant. The panel notes that relevance and weight are matters for the panel and will keep this in mind when considering the evidence of Ms Page. The panel has considered the application very carefully and determined that there is no unfairness or injustice in allowing the witness statement of Ms Sally Page to be read and as a consequence the application to admit the statement of Sally Page is allowed. Decision on the findings on the facts and reasons Page 3 of 15

4 The panel considered all the evidence adduced, together with the submissions of Ms Elia on behalf of the NMC and Ms Koennecke s written response to the charges which was annexed to a letter from the Royal College of Nurses dated 9 th March 2012 and addressed to the NMC together with the answers that she gave in the police interview; a transcript of which is referred to below. The panel accepted the advice of the legal assessor. The panel had in mind that the burden of proof rests on the NMC and that the facts must be proved on the balance of probabilities. The panel considered each subhead of charge separately. Background Ms Regina Koennecke, was employed as a Registered General Nurse with Ambition 24 Nursing Agency ( Ambition 24 ). She stated in her application form for employment with Ambition 24 that she had undertaken paediatric work for a period of up to six months and, during her employment interview she said that she had experience of working with children. Ms Koennecke had undergone a one day training in tracheostomy care and ventilation awareness in May 2008, and it was said that this mandatory training should take place on a yearly basis. Ambition 24 has a contract with the South West Surrey Joint Domiciliary Service for Children with Disabilities ( the Domiciliary Service ) to provide nurses for children receiving continuing care in the home. Patient A was born in June 2007 and is now nearly five years of age. At the time to which these charges relate she was nearly three. Despite developing normally during the first few months of her life, she was subsequently diagnosed with a mitochondrial disorder. After she became ill at around three months of age, Patient A spent a considerable amount of time in hospitals in Surrey and London as well as the CHASE children s hospice. She was eventually discharged and is now cared for by her parents at home, with support from the Domiciliary Service and CHASE. Prior to her discharge home, an assessment of Patient A s health care needs was undertaken by one of the Senior Staff Nurses from the Domiciliary Service. Patient A s care needs are complex: she has a tracheostomy and relies on a ventilator at all times to help her breathe; she requires supplementary oxygen from a cylinder stored in her room and nebulisers to loosen secretions in her airway which need to be removed by regular suctioning. She also requires feeding via a gastrostomy tube; she has a complex drug regime and learning disabilities. Details of the care Patient A requires are set out in her Personal Details Book and various care plans, for example, relating to the management of her airway and ventilator. Copies of these documents were kept in Patient A s room. Patient A s domiciliary care package includes a nurse to care for her overnight, six nights per week, from 22:00 to 07:00. Patient A s night routine is documented in detail in a care plan, a copy of which was also available in her room. It was her father and mother s practice, when a nurse was first allocated to care for her overnight, to ask the Page 4 of 15

5 nurse to arrive one hour early so that they could explain her night routine and care plans and ensure that the nurse was confident in the use of the equipment that Patient A requires. Prior to the incident which occurred during the night shift of 23 rd / 24 th April 2010, Ms Koennecke had cared for Patient A on a number of occasions. According to Patient A s parents, she arrived for the night shift of 23 rd / 24 th April 2010 half an hour late, stating that she had been resting. Mother A provided a handover to the Registrant, informing her that Patient A had not been feeling 100%. In the early hours of the morning of 24 th April 2010, the Registrant woke the mother, by shouting and banging on her bedroom door Patient A is turning blue. Mother A went to Patient A s room and found that her oxygen saturation level was extremely low. They were reading 35%. Father A then came to assist. Both parents changed Patient A s tracheostomy tube, suctioned her airway and bagged her using an ambu-bag and emergency oxygen therapy. Patient A s oxygen saturation level rose and remained stable. The registrant did not assist the parents with these emergency measures, and they subsequently sent her home. Both parents cared for Patient A for the remainder of the night. The parents called the Domiciliary Service On Call Team to report the incident and subsequently provided a written statement of events. The Domiciliary Service in turn informed Paul Sharma, the Local Authority Designated Officer, the Nursing and Midwifery Council and the Police. Three Senior Strategy Meetings were held in relation to the care provided by the Registrant to Patient A on 23 rd / 24 th April The meetings were held on 6 th May, 17 th June and 15 th July The meetings involved representatives of Ambition 24, Surrey County Council and Surrey Police. There were a number of outcomes from the Senior Strategy Meetings, including the decision that the NMC was the appropriate body to consider the Registrant s fitness to practise. An investigation was undertaken by Surrey Police, however, no criminal charges were brought against the Registrant. Following the incident involving Patient A, Ambition 24 restricted the Registrant from working in home care settings. The Registrant s accounts of events of 23 rd / 24 th April 2010 can be seen in the entry which she made for this shift in Patient A s communication book and which forms part of the documentary evidence available to the panel. Also available to the panel was a transcript of an interview between the registrant and police constable Paul Carpenter conducted on 15 th June Page 5 of 15

6 Witnesses The Panel considered all the documentary evidence before it including extracts from the relevant agency worker handbook declaration, transcript of police interview, the Child and Young Person Minimal Handling Assessment notes, the patient notes, the management care plan and the detailed night routine, all of which the Panel examined in detail in determining the charges. The Panel heard oral evidence from both Mother A and Father A, and from Karen Sahlsberg, [then] Manager of the South West Surrey Joint Dom Care Services for Children with Disabilities, Anne Bridgman, [then] Team Leader within the Complex Health Needs Team at Surrey Community Health Services, and Jane Smith, Children s Community Nursing Services Manager. The panel found the witnesses to be credible, balanced and reliable. They considered all of the oral evidence from the witnesses mentioned above to be consistent with and supported by the documentary evidence which they produced and which the panel has seen. In considering each charge, the panel has kept in mind that the burden of proof rests with the NMC and that the standard of proof is the civil one namely on the balance of probability. Charges That you, whilst employed as a Registered nurse; 1. Between on 23 April 2010 and on 24 April 2010 failed to provide adequate care for Patient A in that you: a. Failed to ensure that Patient A s tracheostomy and ventilator remained connected at all times; The panel has considered both the written statement and the oral evidence of Mother A in which she stated that as soon as she came into the Patient A s room, she noticed that the ventilator tubing was disconnected from the tracheostomy. The panel is satisfied by the evidence of Mother A on this point which was supported by the evidence of the low oxygen saturation levels. Both Mother A and Father A recalled more than one alarm sounding and the panel notes that there are only two alarms capable of sounding [a ventilator alarm and an oxygen saturation monitor]. This supports the evidence of Mother A that the ventilator tubing was disconnected from the tracheostomy because in such circumstances the alarm would have sounded unless it had been previously muted. The panel therefore finds the charge proved. b. Failed to ensure that Patient A s suction machine was emptied and in working order; Page 6 of 15

7 Admitted by the registrant. In accordance with Rule 24(5) the panel has found this fact proved. c. Failed to ensure that Patient A s oxygen tubing was connected to the ventilator at all times; Mother A in her written statement asserted that [Patient A] needed oxygen and although Ms Koennecke had previously turned the oxygen up to 15 liters per minute, she had failed to connect the tube to the ventilator which was connected to the concentrator ; because the tube to the ventilator was not connected when she entered her daughter's room and the oxygen needed to keep Patient A alive was not available to her. This was also stated in the written statement of Father A. Both Father and Mother A repeated these assertions in their oral evidence to the panel. The registrant in her written response says that the tubing became disconnected during the commotion around patient A s bed. In her interview with the police she quotes I think I kind of disconnected the oxygen tube [ ]. The panel did not regard the registrant s account as satisfactory or compatible with the clear evidence of Father and Mother A. It accepts the evidence of Mother and Father A and on that basis finds this charge proven. d. Failed to ensure that Patient A s oxygen tubing remained accessible at all times; In her written statement Mother A states that the oxygen tubing had at some point during that evening fallen down the back of patient A s cot and that they were unable to retrieve it. This assertion was supported by the written statement of Father A. Both Father and Mother A repeated these assertions in their oral evidence to the panel. The registrant suggests in her written response that the tubing must have fallen down during the commotion around patient A s bed and became entangled with electric wiring and other tubing. The panel had received evidence from both Father and Mother A that the tubing in question should have been tied to the cot and in any event the electric wiring was well away from the tubing and at another level. Patient A s care plans list all the checks the nurse or carer on duty should carry out and ensuring immediate access to the oxygen tube is an essential part of her life-sustaining care. The panel did not accept the explanation advanced by the registrant in her written response. It preferred and accepted the written and oral evidence of Father and Mother A and on that basis found that charge proven. e. Incorrectly attempted to plug Patient A s ambu-bag into the rear of the ventilator; Page 7 of 15

8 During this emergency Patient A s oxygen saturation dropped to 7%. At this point Father A made the decision to ambu-bag Patient A and made the request for the ambu-bag from Ms Koennecke. Both Father and Mother A in their respective written statements state that the registrant attempted to plug the ambu-bag into the rear of the ventilator instead of directly into the oxygen cylinder. These written statements were supported by the oral evidence of both Father and Mother A. Plugging the ambu-bag into the rear of the ventilator was a wholly inappropriate response to the situation because the ventilator could not produce the required percentage of oxygen required in this emergency. The registrant herself in her written response, identified above, denied ever handling the ambu-bag. There was a clear conflict between the consistent evidence of Father and Mother A on the one hand, and the assertion made by the registrant in her written response on the other. The panel accepts the evidence of Father and Mother A and finds this charge proved. 2. Between and on 24 April 2010, when faced with Patient A s emergency situation you panicked and/or shouted. There is clear evidence from both Mother and Father A that the registrant panicked. Indeed the registrant admitted in her interview with Police Constable Carpenter that she panicked. Both Father and Mother A told the panel that the registrant played no constructive role in assisting patient A. Indeed the registrant spent much of the time in the kitchen. There was clear evidence from both Mother and Father A that the registrant screamed and shouted and repeatedly called for an ambulance to be summoned and failed to manage the situation appropriately. Father A in his oral evidence told the panel that the registrant was flustered, scared, appeared to freeze and was also shouting Patient A s name over and over again. In Father A s statement he said Ms Koennecke was shouting Patient A speak!. The panel heard that this was an impossibility for Patient A. He described her as being like a rabbit in the headlights. None of this behaviour was of the kind to be expected from a professional nurse and indeed the nursing witnesses describe to the panel that a nurse should not act in this way. The panel concludes that it was the quick thinking actions of both Mother and Father A that saved Patient A s life. The panel accepts the evidence of Father and Mother A as to the conduct of the registrant and finds this charge proven. Decision on misconduct and impairment The Panel has considered, on the basis of the matters found proved, whether Ms Koennecke s fitness to practise is now impaired by reason of her misconduct. It has had regard to all the evidence adduced, has considered the submissions of Ms Elia for the NMC and the registrant s own comments as contained in her written response and in the police interview both of which are identified previously. Page 8 of 15

9 Ms Elia submitted that on the basis of the facts found proved there had been misconduct which was serious and she drew the panel s attention to various paragraphs within The Code: Standards of conduct, performance and ethics for nurses and midwives [The Code]. She went on to submit that Ms Koennecke s fitness to practice is thereby impaired. The Panel has heard and accepted the advice of the Legal Assessor. It was referred to the 5 th Shipman Report, and the cases of Roylance v GMC, Cohen v GMC and CHRE v NMC & Grant. The Panel has exercised its own judgment in determining the issues before it, and in this context, it has had well in mind the need for weight to be given to the protection of the public, the maintenance of public confidence in the profession, and the upholding of proper standards of conduct and behaviour. Misconduct The panel had regard to the NMC publication The Code. The Preamble to The Code states: The people in your care must be able to trust you with their health and wellbeing To justify that trust, you must: make the care of people your first concern, treating them as individuals and respecting their dignity work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community 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.... Failure to comply with this code may bring your fitness to practise into question and endanger your registration. The panel also had regard to the following numbered standards. 8. You must listen to the poeple in your care and respond to their concerns and preferences. 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. 38. You must have the knowledge and skills for safe and effective practice when working without direct supervision. 39. You must recognize and work within the limits of your competence. 40. You must keep your knowledge and skills up to date throughout your working life. 61. You must uphold the reputation of your profession at all times. The Panel concluded that, by reason of its findings of fact, the registrant had breached these standards. Page 9 of 15

10 On the basis of the findings of fact already made, the panel concluded that the registrant s failures put Patient A at risk of harm, and that her conduct that night fell far short of the clinical standards to be expected of a registered nurse of her stated experience responding to the emergency that she then faced. In all the circumstances the panel determined that Ms Koennecke s failings in her clinical practise were serious and amounted to misconduct. Accordingly, the Panel went on to consider whether by reason of Ms Koennecke s misconduct, her fitness to practice is impaired. Impairment For this purpose the panel had careful regard to the questions posed by Lady Justice Smith in her 5th Shipman Report. The panel first considered whether the registrant: (a) had acted so as to put a patient or patients at unwarranted risk of harm; (b) had brought the profession into disrepute; (c) had breached one of the fundamental tenets of the profession The Panel concluded that by Ms Koennecke s actions she had put Patient A at risk of harm, and by her various failings as identified above. She brought the profession into disrepute and was thereby in breach of fundamental tenet of the profession as identified in the NMC Code of Professional Conduct The panel next considered whether in the future the registrant is liable to: - act so as to put a patient or patients at unwarranted risk of harm - bring the profession into disrepute - breach one of the fundamental tenets of the profession. In that regard, the panel considered whether the registrant s misconduct is easily remediable; whether it has been remedied and whether it is likely to be repeated. The Panel had regard to all the circumstances of the case and also to the issue of the registrant s insight into her misconduct. The panel noted that Ms Koennecke s misconduct had occurred in the context of an emergency situation during a night shift. The panel has not heard about the registrant s current employment. It had not received any references that could attest to her good practice or qualities as a nurse or received any certificates regarding further training on her part. In terms of Ms Koennecke s clinical failings, the panel were particularly concerned that she had not applied her knowledge and skills consistently. It noted that although the registrant had only taken a day training in tracheostomy care and ventilation awareness in May 2008, she should have warned the parents of the critical level of Patient A before her condition deteriorated in the way that it did. Further, although the registrant was not in charge of Patient A prior to her arrival, part of the handover included ensuring that all the equipment was in working order and this she had clearly failed to do. There was no Page 10 of 15

11 evidence that the registrant had reflected on or had any insight into her wholly inadequate performance that night. She abdicated her responsibilities and retreated into the kitchen whilst the parents of Patient A were left to perform the necessary lifesaving resuscitation. The Panel had careful regard to all the circumstances of this case. The Panel concluded that on the night in question the registrant s fitness to practise was clearly and conspicuously impaired. In excersing its own independent judgment the panel concluded that they had no reason to think Ms Koennecke s failings were not liable to be repeated. As a consequence, the Panel concluded that she is liable in the future to act so as to put patients at unwarranted risk of harm, to bring the profession into disrepute and to breach fundamental tenets of the profession. During the course of its deliberations the Panel had well in mind the observation of Silber J in the case of Cohen v GMC [2008] EWHC 581 (Admin): There must always be situations in which a Panel can properly conclude that the act of misconduct was an isolated error on the part of a medical practitioner and that the chance of it being repeated in the future is so remote that his or her fitness to practice is not impaired. The panel considered that although the matters found proved in this case relate to a single shift it is not one of those situations envisaged by Silber J above, by reason of the registrant s liability to repeat the failings found proved. In all the circumstances of the case, the Panel concluded that the need to uphold proper professional standards and public confidence in the profession would be undermined if it did not make a finding of impairment. For all the reasons outlined above, the Panel determined that Ms Koennecke s fitness to practice is now impaired by reason of her misconduct. Decision on proceeding in the absence of the registrant The panel has decided to proceed in the absence of Ms Koennecke. The panel received evidence in proof of posting documentation, and noted that the notice of hearing was sent to Ms Koennecke and her representative on 3 May Additionally, although the registrant was not present during the commencement of this case in April, the transcript as of the 26 th April 2012 noted that the hearing would continue on the 15 th June The panel is satisfied that the relevant rules have been complied with, and that all reasonable efforts have been made in accordance with the rules to serve the notice of hearing. The panel then heard submissions from the case presenter, who submitted that it would be appropriate to proceed with the hearing in the absence of Ms Koennecke. The panel received advice from the legal assessor, which it accepted. The panel has had well in Page 11 of 15

12 mind that it must exercise its discretion as to whether or not to proceed in the absence of Ms Koennecke with the utmost care and caution. The panel has had regard to all the circumstances, and has concluded that Ms Koennecke has voluntarily absented herself from today s proceedings, knowing that the hearing began in April 2012 and would continue on today s date. The panel has further determined that no useful purpose would be served in adjourning these proceedings, no adjournment having been requested by Ms Koennecke, and that the public interest requires the hearing to proceed expeditiously. The panel therefore concludes that it would be fair and proportionate to proceed in the absence of Ms Koennecke. Decision on sanction and reasons Having determined that Ms Koennecke s fitness to practise is impaired, the panel has now considered in accordance with Rule 24 (13) of the NMC (Fitness to Practise) Rules 2004 what sanction, if any, should be imposed. For this purpose, the panel took into account all the evidence presented in these proceedings including Ms Fellows submission on behalf of the NMC and the NMC s Indicative Sanctions Guidance (ISG). Ms Fellows drew the panel s attention to the case of Bolton v Law Society [1991] EWCA Civ 32 as well as Giele v GMC [2005] EWHC 2143 (Admin). The panel has accepted the advice of the legal assessor and has exercised its own independent judgement with due regard to the public interest. In its approach in determining the appropriate sanction, the panel has borne in mind that it has a responsibility to protect the public interest, which includes the protection of patients, maintaining public confidence in the profession and declaring and upholding standards within the profession. The panel is aware that the purpose of a sanction is not to be punitive, although it may have a punitive effect. The panel has also borne in mind that any sanction it imposes must be proportionate and it must balance the public interest with Ms Koennecke s own interests. The panel has not received any new information from the registrant or on her behalf by a representative. The panel has considered this case very carefully and has decided to make a striking off order. In reaching its decision, the panel has considered the available sanctions in ascending order of severity. In doing so, it has had particular regard to all criteria detailed in the NMC s indicative sanctions guidance. This was a case where a particularly complex set of nursing skills and competencies was needed by a nurse caring for this totally dependent patient in her own home. Ms Koennecke had led the agency and Patient A s parents to believe she had these competencies and knowledge and could be relied upon to care for their child while they slept. When the critical emergency situation arose Ms Koennecke s response demonstrated that she completely lacked the experience and knowledge to react appropriately. Her casual approach to checking the equipment both at the start of her Page 12 of 15

13 shift and as the night progressed made the emergency worse and it could have resulted in Patient A s death. No action The panel first considered whether to take no action, but concluded that given the seriousness of the facts found proved this course of action would be a wholly insufficient response in the light of the panel s finding that the registrant s practice was conspicuously and clearly impaired by her misconduct and would not sufficiently protect the public or be in the public interest. A caution order The panel was very concerned about the seriousness of the findings and it was particularly concerned about the registrant s lack of action in responding to the emergency care of Patient A. The registrant was on duty solely for the purpose of caring for Patient A but did not care for her needs in a manner that was professional. Although the incident happened over one night there were a series of failings by the registrant who was caring for a wholly dependent patient that relied on an experienced nurse to provide intensive nursing care which including caring for a patient with a tracheostomy on a ventilator. The panel determines that this case so far from being at the lower end of the spectrum of impaired fitness to practise, is at the higher end. In these circumstances, the panel has concluded that a caution order would not be sufficient to address the seriousness of the case or to protect the public interest. Conditions of Practice Order The panel next considered whether placing conditions of practice on Ms Konnecke s registration would be a sufficient and proportionate response. In order for appropriate conditions of practice to be defined a panel would need information regarding any nursing employment that the registrant may currently have, or even if she is resident in the United Kingdom, as well as willing to undertake additional retraining. The panel noted that no practicable or workable conditions could be drawn up for Ms Koennecke. Additionally, her inappropriate reaction to Patient A s needs in the emergency situation and her failure to manage it, would be difficult in the panel s opinion to remedy without her full engagement. The registrant has not engaged in this process and the panel has no reason to suppose she would engage in any conditions of practice process that might be imposed by the panel. Therefore, the panel has decided that a conditions of practice order would not be a sufficient or appropriate sanction to protect the public or be in the public interest. Suspension Order The panel then went on to consider whether a suspension order would be an appropriate sanction and decided that it was not. Although the public would be protected during a suspension order while in place, the panel found that the actions were so serious that the panel were not satisfied that this registrant does not currently pose a significant risk and would not repeat this behaviour. The sheer panic that Ms Koennecke showed could have had a catastrophic result but instead the quick thinking Page 13 of 15

14 actions of Patient A s parents were the only means of saving Patient A s life. The panel further considered that Ms Konnecke was employed specifically for this specialist task but instead of preparing and resting for her night shift, she worked a six hour shift at a hair salon and arrived late after a long car journey to Patient A s home. There is no evidence before us to indicate that the registrant has reflected on her practice and we find she has little or no insight into the wholly inadequate and unprofessional performance of her nursing duties. In these circumstances, the panel has concluded that a suspension order would not be sufficient to address the seriousness of her failings in this case, protect the public interest or to maintain confidence in the professions regulatory process. Striking Off Order The panel has determined that a striking off order is appropriate and proportionate because the registrant s behaviour is fundamentally incompatible with continuing to remain on the register. The parents of Patient A placed their trust in the registrant to care for their chronically disabled and wholly dependent child while they slept. This trust was seriously breached by the registrant. The registrant also breached a number of fundamental tenets of the nursing profession. Additionally, the panel believed that the public would not be adequately protected and that the reputation of the profession would be severely damaged if Ms Koennecke was allowed to remain on the register. In all the circumstances, and for the reasons set out above, the panel has determined that a striking off order is the sufficient and proportionate sanction to mark the misconduct, to protect patients and to maintain public confidence in the nursing profession and the regulatory process. Ms Koennecke will be notified of the panel s decision in writing. The striking off order will come into effect 28 days after the service of the notification of the panel s decision upon Ms Koennecke. If the registrant appeals the panel s decision the order will not take effect until the appeal has been concluded. Decision and reasons for an Interim Order The panel has considered in accordance with Rule 24(14) of the NMC (Fitness to Practise) Rules 2004 whether an interim order shall be imposed. Ms Fellows submitted that an interim suspension order should be made to cover the period before the substantive striking off order takes effect and to cover a period of appeal. The panel has accepted the advice of the legal assessor. The panel has determined, for the same reasons as outlined in its determinations on impairment and sanction, that an Interim Order is necessary because of the seriousness of the findings. It first considered whether a Conditions of Practice order would suffice but rejected this as impracticable and inappropriate for all the reasons previously identified. It then considered whether an Interim Suspension Order is necessary for the Page 14 of 15

15 protection of the public and to maintain public confidence and determined that this was necessary. The period of this interim order is 18 months. If at the end of the 28 day appeal period, Ms Koennecke has not lodged an appeal, the interim order will lapse and will be replaced by the final order. On the other hand, if Ms Koennecke does lodge an appeal, the Interim Order will continue to run for the period imposed or until the appeal is decided. Page 15 of 15