Fitness to Practice Panel Consensual Panel Determination. 4 August Nursing and Midwifery Council: 2 Stratford Place, London E20 1EJ

Transcription

1 Fitness to Practice Panel Consensual Panel Determination 4 August 2017 Nursing and Midwifery Council 2 Stratford Place, London E20 1EJ Name of Registrant Nurse: NMC PIN: Mrs Julia Forrest 05H1375E Part(s) of the register: Registered Nurse Sub Part 1 Adult 23 March 2006 Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: West Sussex Misconduct and Lack of Competence Mr Nigel Hallam (Chair & Lay member) Ms Frances Clarke (Registrant member) Ms Elspeth Metcalfe (Lay member) Mr Peter Jennings Mr Ian Dennehey Representation: Nursing and Midwifery Council: Registrant: Represented by Ms Katherine Higgins, Counsel, instructed by NMC Regulatory Legal Team. Mrs Forrest was neither present nor represented at the hearing. Facts no evidence offered: 4, 6b, 6c, 6d, 7b, 8, 23, 25, 42, 44. Facts proved by admission: 1, 2, 3, 5, 6a, 6e, 7a, 7c, 7d, 7e, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 and 43. Fitness to practise: Outcome: Currently impaired by reason of Misconduct and Lack of Competence CPD accepted: Conditions of Practice Order for 12 months with a review hearing and Interim Condition of Practice Order for 18 months.

2 Detail of Charges That you, between December 2013 and July 2015 failed to demonstrate the standards of knowledge, skill, and judgement required to practise without supervision as a Band 5 Registered Nurse in that you: 1. On an unknown date between December 2013 and January 2014, gave an unknown patient incorrect medication, namely codeine tablets 2. On an unknown date, failed to escalate an unknown patient with a heart rate of 140bpm 3. On 4 February 2014: a. Failed to ensure the prompt administration of Morphine Sulphate to Patient A b. Incorrectly administered a second dose of Warfarin to Patient B within a 24 hour period 4. Between 19 January 2014 and 17 February 2014, failed to ensure that an unknown patient had a fracture clinic outpatient appointment No evidence offered 5. On 24 February 2014, in respect of an unknown patient who had a systolic blood pressure reading of 70 you moved the patient to Computed Topography: 5.1 Without IV fluids 5.2 Without monitoring equipment 5.3 Without discussing with a doctor whether the patient needed to be accompanied. 6. On 25 March 2014: a. Did not complete a baseline assessment of an unknown patient for four hours b. Did not perform observations for Patient C No evidence offered

3 c. Did not perform observations for Patient D No evidence offered d. Did not adequately complete observations for Patient E No evidence offered e. Did not adequately monitor Patient E s blood sugar levels f. Did not ensure that Patient F promptly received analgesia 7. On 29 March 2014: a. Failed to adequately monitor and / or record an unknown patient s observations b. Failed to escalate an unknown patient with an National Early Warning Score (NEWS) of seven No Evidence Offered c. Failed to escalate to the nurse in charge that after two unsuccessful attempts to take blood from Patient G, you were unable to do so d. Failed to record three unsuccessful attempts to take blood from Patient G e. Failed to document any observations for Patient G for two and a half hours 8. On or around 7 April 2014, failed to change Patient G s dressing No evidence offered 9. On 7 May 2014: a. Failed to promptly assess Patient J b. Did not complete observations for Patient J c. Did not assess and / or complete observations for Patient K d. Did not perform any baseline observations for Patient L

4 e. Did not perform an electrocardiogram (ECG) on Patient L 10. On 9 May 2014: a. Failed to escalate that Patient M had a heart rate of 146bpm b. Incorrectly recorded that Patient M had a normal heart rate c. Failed to recognise that an ECG was required for Patient M 11. On 15 June 2014: a. Did not complete repeat observations and / or a HOTPIN for Patient N b. Did not promptly assess Patient O c. Did not assess and / or monitor Patient P d. Did not assess Patient Q e. Did not perform a repeat set of observations for Patient Q f. Did not promptly assess Patient R 12. On 2 July 2014, administered oxycodone to a patient from another patient s stock 13. On 7 July 2014 left an unknown patient on a commode for hours 14. On 12 July 2014, did not adequately complete and / or monitor observations for one or more patients 15. On 13 July 2014: a. Did not complete and / or record observations for Patient S as frequently as required

5 b. Did not complete and / or record observations for Patient T as frequently as required c. Did not document the time you assessed Patient T 16. During a night shift commencing 12 August 2014 did not transfer one or more unknown patients in a timely manner 17. On 20 August 2014, did not administer intravenous (IV) antibiotics to an unknown patient 18. On 20 August 2014: a. Did not complete and / or record neurological observations for Patient U b. Did not administer intravenous (IV) antibiotics to Patient V 19. On 28 August 2014: a. Did not promptly transfer an unknown patient to another ward b. Prepared medication for an unknown patient when they were not ready to receive it 20. On 30 August 2014, did not record that you had administered Fragmin to an unknown patient 21. On 20 October 2014, took an hour to assess Patient W 22. On 8 December 2014: a. Recorded observations taken for one patient on another patient s records b. Removed an IV line from a pump when you were not competent in that area

6 23. On 11 December 2014, took two hours to complete an assessment on an unknown patient No evidence offered 24. On 15 December 2014: a. Did not sign for the administration of Fragmin to an unknown patient b. Did not administer Warfarin and / or insulin to an unknown patient 25. On 18 December 2014, administered incorrect medication to an unknown patient No evidence offered 26. On 11 January 2015 a. Did not sign for the administration of medication to two unknown patients b. Attempted to administer medication to an unknown patient when it was not necessary to do so 27. On 12 January 2015, did not administer Heparin to an unknown patient 28. On 18 January 2015, did not prompt Colleague A to administer IV antibiotics to an unknown patient 29. On 21 January 2015, did not sign for the administration of Tranexamic acid for an unknown patient 30. On or around 25 January 2015, did not record the reason for omitting to administer medications to two unknown patients 31. During a night shift commencing 29 January 2015: a. Drew forty units of insulin instead of the four units prescribed to an unknown patient b. Did not administer Fluconazole to an unknown patient

7 32. During week commencing 23 February 2015, did not administer Fragmin to an unknown patient or in the alternative, did not sign for the administration of Fragmin to an unknown patient 33. During week commencing 23 February 2015, did not administer Insulin to an unknown patient or in the alternative, did not sign for the administration of Insulin to an unknown patient 34. During week commencing 10 March 2015, signed for but did not administer medications to an unknown patient 35. On 21 March 2015, did not administer Rasburicase to an unknown patient 36. During week commencing 18 March 2015, took an hour and a half to complete a drug round 37. On 27 May 2015, did not sign for the administration of medication to one or more unknown patients 38. On 19 June 2015: a. Administered Flucloxacillin to an unknown patient orally instead of intravenously as it was prescribed b. Did not administer an unknown patient their morning dose of Fragmin c. Did not sign for the omission of an unknown patient s aspiration tablet d. Did not administer pain relief to an unknown patient 39. On 25 June 2015, did not identify that an unknown patient s butterfly needle needing changing 40. On 30 June 2015, did not sign for the administration of medication to an unknown self-medicating patient

8 41. On 14 July 2015, did not sign for the administration of paracetamol to an unknown patient AND, in light of charges 1 to 41 above, your fitness to practise is impaired by reason of your lack of competence and / or in light of charges 4, 8, 13, and 22b your fitness to practise is impaired by reason of your misconduct. Found Proved AND, That you, a registered nurse, whilst employed at Western Sussex Hospitals NHS Foundation Trust: 42. On or around 7 July 2014 you administered medication to an unknown patient contrary to previous instructions not to be involved in the administration of medication No evidence offered 43. On 15 October 2014, offered to second check medications contrary to previous instructions not to be involved in the administration of medication 44. On 4 April 2015, left two insulin pens on a table No evidence offered And in light of the above charges 42 and/ or 43 and/or 44 your fitness to practise is impaired by reason of your misconduct Found Proved

9 Determination on Service of Notice: The panel was told that written notice of this hearing had been sent to Mrs Forrest s address, as recorded in the NMC s electronic Register, by Royal Mail Signed For service and by first class post on 30 June The notice letter provided details of the allegation, the time, dates and venue of the hearing and, amongst other things, information about Mrs Forrest s right to attend, be represented and call evidence, as well as the panel s power to proceed in her absence. A copy of the notice letter was sent to Mrs Forrest s legal representatives, the Royal College of Nursing (RCN), on 30 June The panel accepted the advice of the Legal Assessor. The panel had regard to the fact that the allegations as particularised in the notice letter itself are not fully and accurately numbered. However, accompanying the notice letter was a schedule which did include the correctly numbered allegations. The panel decided that what was clearly a clerical or typographical error in the notice letter did not invalidate the notice since the detail of the allegations would be clear to any average reader and because there was nothing before the panel to suggest that Mrs Forrest, who has the benefit of legal representation, had been confused or misled in any way as to the exact nature of the allegation. In the light of all of the information available, the panel was satisfied that Mrs Forrest has been served with notice of this hearing in accordance with the requirements of Rules 11 and 34 of the Nursing and Midwifery Council (Fitness to Practise) Rules 2004, as amended ( the Rules ). Determination on Proceeding in the Absence of Mrs Forrest: The panel had regard to Rule 21 (2) (b) which states: Where the registrant fails to attend and is not represented at the hearing, the Committee...may, where the Committee is satisfied that the notice of hearing has been duly served, direct that the allegation should be heard and determined notwithstanding the absence of the registrant...

10 Ms Higgins invited the panel to proceed in the absence of Mrs Forrest. She submitted that Mrs Forrest had made clear that she did not intend to attend the hearing and was content for it to proceed in her absence and in the absence of her representatives. The NMC had been informed that Mrs Forrest had indicated that she would seek to be available by telephone if any clarification of the provisional Consensual Panel Determination agreement was required. The panel accepted the advice of the Legal Assessor. The panel exercised its discretionary power to proceed in the absence of Mrs Forrest with the utmost care and caution. In all the circumstances, the panel decided that it was fair, appropriate and proportionate to proceed in the absence of Mrs Forrest. Mrs Forrest is engaged with the NMC regulatory process but she has informed the NMC, through the RCN, that she does not intend to attend today s hearing and she has not sought an adjournment. Although adjourning to some later date might lead to Mrs Forrest attending, in the panel s judgment, she appears to have made a conscious decision not be here today. The panel bore in mind that the provisional agreement to a consensual determination is one to which Mrs Forest has agreed: in the event that the panel do not accept that agreement, the matter will then be heard on a different date, when Mrs Forrest may attend if she thinks fit. In these circumstances, there is no injustice to Mrs Forrest in the panel proceeding today in her absence. She has agreed to be contacted by telephone if that is required. There is a public interest in the expeditious disposal of the case and it is also in Mrs Forrest s own interest that the draft CPD document, which she has agreed, is considered without undue delay. In reaching its decision, the panel had regard to the overall interests of justice and fairness to all parties. Determination on Consensual Panel Determination: Ms Higgins told the panel that agreement had been reached between the NMC and Mrs Forrest on a Consensual Panel Determination (CPD) with regard to this case. The agreement, which was put before the panel, sets out Mrs Forrest s full admissions to the facts of all of the charges still being pursued by the NMC, and her acceptance

11 that her fitness to practise is currently impaired by reason of misconduct and a lack of competence. It is agreed between the parties that the appropriate sanction in this case is a substantive conditions of practice order, for a period of 12 months, and that an interim conditions of practice order, in the same terms as the substantive order, should be imposed for a period of 18 months to cover Mrs Forrest s statutory appeal period and the time that may be needed for any appeal to be determined by the courts. The proposed CPD agreement reads as follows: Consensual panel determination: provisional agreement The Nursing and Midwifery Council and Mrs Julie Forrest, PIN 05H1375E ( the parties ) agree as follows: 1. The NMC proposes to offer no evidence on the following charges. Charge 4, 6(b), 6(c), 6 (d), 7(b), 8, 23, 25, 42 and 44. R.24(7) of the Nursing and Midwifery Council (Fitness to Practise) Rules 2004 SI 2004/1761 states, 24 (7) Except where all the facts have been admitted and found proved under paragraph (5), at the close of the Council s case, and - (i) either upon the application of the registrant, or (ii) of its own volition, the Committee may hear submissions from the parties as to whether sufficient evidence has been presented to find the facts proved and shall make a determination as to whether the registrant has a case to answer. 2. The Registrant admits all remaining charges. In view of the extent of the Registrants admissions and following a review of the evidence in relation to the disputed charges the NMC propose to adopt a proportionate approach and take the view that it would be inappropriate to pursue those matters in the particular circumstances of this case. Explanation and rationale for offering no evidence on these matters is set out as below.

12 3. Mrs Forrest admits the following charges, save for those set out at paragraph 1 above: That you, between December 2013 and July 2015 failed to demonstrate the standards of knowledge, skill, and judgement required to practise without supervision as a Band 5 Registered Nurse in that you: 1. On an unknown date between December 2013 and January 2014, gave an unknown patient incorrect medication, namely codeine tablets 2. On an unknown date, failed to escalate an unknown patient with a heart rate of 140bpm 3. On 4 February 2014: a. Failed to ensure the prompt administration of Morphine Sulphate to Patient A b. Incorrectly administered a second dose of Warfarin to Patient B within a 24 hour period 4. Between 19 January 2014 and 17 February 2014, failed to ensure that an unknown patient had a fracture clinic outpatient appointment 5. On 24 February 2014, in respect of an unknown patient who had a systolic blood pressure reading of 70 you moved the patient to Computed Topography: 5.1 Without IV fluids 5.2 Without monitoring equipment 5.3 Without discussing with a doctor whether the patient needed to be Accompanied 6. On 25 March 2014: a. Did not complete a baseline assessment of an unknown patient for four hours b. Did not perform observations for Patient C c. Did not perform observations for Patient D Did not adequately complete observations for Patient E d. Did not adequately monitor Patient E s blood sugar levels e. Did not ensure that Patient F promptly received analgesia

13 7. On 29 March 2014: a. Failed to adequately monitor and / or record an unknown patient s observations b. Failed to escalate an unknown patient with an National Early Warning Score (NEWS) of seven c. Failed to escalate to the nurse in charge that after two unsuccessful attempts to take blood from Patient G, you were unable to do so d. Failed to record three unsuccessful attempts to take blood from Patient G e. Failed to document any observations for Patient G for two and a half hours 8. On or around 7 April 2014, failed to change Patient G s dressing 9. On 7 May 2014: a. Failed to promptly assess Patient J b. Did not complete observations for Patient J c. Did not assess and / or complete observations for Patient K d. Did not perform any baseline observations for Patient L e. Did not perform an electrocardiogram (ECG) on Patient L 10. On 9 May 2014: a. Failed to escalate that Patient M had a heart rate of 146bpm b. Incorrectly recorded that Patient M had a normal heart rate c. Failed to recognise that an ECG was required for Patient M 11. On 15 June 2014 a. Did not complete repeat observations and / or a HOTPIN for Patient N b. Did not promptly assess Patient O c. Did not assess and / or monitor Patient P d. Did not assess Patient Q e. Did not perform a repeat set of observations for Patient Q f. Did not promptly assess Patient R 12. On 2 July 2014, administered oxycodone to a patient from another patient s stock

14 13. On 7 July 2014 left an unknown patient on a commode for hours 14. On 12 July 2014, did not adequately complete and / or monitor observations for one or more patients 15. On 13 July 2014: a. Did not complete and / or record observations for Patient S as frequently as required b. Did not complete and / or record observations for Patient T as frequently as required c. Did not document the time you assessed Patient T 16. During a night shift commencing 12 August 2014 did not transfer one or more unknown patients in a timely manner 17. On 20 August 2014, did not administer intravenous (IV) antibiotics to an unknown patient 18. On 20 August 2014: a. Did not complete and / or record neurological observations for Patient U b. Did not administer intravenous (IV) antibiotics to Patient V 19. On 28 August 2014: a. Did not promptly transfer an unknown patient to another ward b. Prepared medication for an unknown patient when they were not ready to receive it 20. On 30 August 2014, did not record that you had administered Fragmin to an unknown patient 21. On 20 October 2014, took an hour to assess Patient W 22. On 8 December 2014: a. Recorded observations taken for one patient on another patient s records b. Removed an IV line from a pump when you were not competent in that area

15 23. On 11 December 2014, took two hours to complete an assessment on an unknown patient 24. On 15 December 2014: a. Did not sign for the administration of Fragmin to an unknown patient b. Did not administer Warfarin and / or insulin to an unknown patient 25. On 18 December 2014, administered incorrect medication to an unknown patient 26. On 11 January 2015 a. Did not sign for the administration of medication to two unknown patients b. Attempted to administer medication to an unknown patient when it was not necessary to do so 27. On 12 January 2015, did not administer Heparin to an unknown patient 28. On 18 January 2015, did not prompt Colleague A to administer IV antibiotics to an unknown patient 29. On 21 January 2015, did not sign for the administration of Tranexamic acid for an unknown patient 30. On or around 25 January 2015, did not record the reason for omitting to administer medications to two unknown patients 31. During a night shift commencing 29 January 2015: a. Drew forty units of insulin instead of the four units prescribed to an unknown patient b. Did not administer Fluconazole to an unknown patient 32. During week commencing 23 February 2015, did not administer Fragmin to an unknown patient or in the alternative, did not sign for the administration of Fragmin to an unknown patient

16 33. During week commencing 23 February 2015, did not administer Insulin to an unknown patient or in the alternative, did not sign for the administration of Insulin to an unknown patient 34. During week commencing 10 March 2015, signed for but did not administer medications to an unknown patient 35. On 21 March 2015, did not administer Rasburicase to an unknown patient 36. During week commencing 18 March 2015, took an hour and a half to complete a drug round 37. On 27 May 2015, did not sign for the administration of medication to one or more unknown patients 38. On 19 June 2015: a. Administered Flucloxacillin to an unknown patient orally instead of intravenously as it was prescribed b. Did not administer an unknown patient their morning dose of Fragmin c. Did not sign for the omission of an unknown patient s aspiration tablet d. Did not administer pain relief to an unknown patient 39. On 25 June 2015, did not identify that an unknown patient s butterfly needle needing changing 40. On 30 June 2015, did not sign for the administration of medication to an unknown self-medicating patient 41. On 14 July 2015, did not sign for the administration of paracetamol to an unknown patient AND, in light of charges 1 to 41 above, your fitness to practise is impaired by reason of your lack of competence and / or in light of charges 4, 8, 13, and 22b your fitness to practise is impaired by reason of your misconduct. AND,

17 That you, a registered nurse, whilst employed at Western Sussex Hospitals NHS Foundation Trust: 42. On or around 7 July 2014 you administered medication to an unknown patient contrary to previous instructions not to be involved in the administration of medication 43. On 15 October 2014, offered to second check medications contrary to previous instructions not to be involved in the administration of medication 44. On 4 April 2015, left two insulin pens on a table And in light of the above charges 42 and/ or 43 and/or 44 your fitness to practise is impaired by reason of your misconduct FACTS 4. The facts are as follows: 5. Julie Forrest was a Registered Nurse ( the Registrant ) working for Western Sussex Hospitals NHS Foundation Trust ( the Trust ) from 11 November 2013 and at the relevant times. The concerns related to Mrs Forrest making multiple errors between December 2013 and July 2015, including drug errors, inadequate observations and inaccurate medication recordings. 6. A referral was received from the Trust on 30 November 2015 in relation to the Registrant working in her capacity as Staff Nurse at the Worthing Hospital within the Accident and Emergency Department (A&E) and on Burlington Ward. The Registrant was initially employed with the Trust from 11 November 2013 in the Accident and Emergency Department for one year then on Burlington Ward until her demotion to a Health Care Assistant as a result of informal and formal periods of performance management. 7. The allegations in this case relate to a lack of competence and involve multiple drug errors, failure to undertake observations, poor clinical decision making, poor time management and prioritisation skills. These span a period of eighteen months whilst

18 the Registrant was employed in the Accident and Emergency Department and Burlington Ward. 8. Following a drug error which occurred in the Accident and Emergency Department in February 2014, the Registrant was commenced on an informal capability programme. In April 2014, this was changed to a formal capability programme due to further errors in her practice. At a meeting on 23 October 2014, it was agreed that she should be re-deployed within the Trust to establish whether she could achieve the required nursing standards of care in an alternative ward environment. The Registrant started working as a registered nurse on the Burlington ward in December There were a number of further concerns largely regarding medication administration. 9. The Registrant attended a final stage capability hearing in July At that hearing, she raised her underlying health issues. As a result of this hearing, her employment was terminated on the grounds of capability. From 14 September 2015, the Registrant was employed within the Trust as a Health Care Assistant in the Endoscopy Unit. 10. [Mrs 1] Matron provided an overview of her informal and formal periods of performance management within the Accident and Emergency Department. [Mrs 1 s] involvement in the performance management process was indirect in that a lot of the concerns / errors were reported to her by numerous members of her team. 11. [Mrs 2], Band 7 Senior Sister was responsible for the Registrant s performance management whilst she worked within the Accident and Emergency Department from November 2013 until December [Mrs 2] was her direct line manager. [Mrs 2] states that concerns were raised regarding the Registrant s practice from an early stage. [Mrs 2] states that many of the concerns regarding her practice were due to her working in an area that was too acute which then resulted in Mrs Forrest being redeployed to Burlington Ward. 12. [Mrs 3], Band 7 Ward Manager explains that the Registrant began working on Burlington Ward in December 2014 following her redeployment from the Accident and Emergency Department. [Mrs 3] states that she was initially asked to assess her

19 capability in the area of medicines management during which time she would be working under direct supervision of mentors for a period of three months. [Mrs 3] states that she was not initially asked to put an action plan in place but that she ensured that she worked alongside her mentors on a daily basis which was then recorded. [Mrs 3] states that at a later date, more formal daily reviews were commenced in line with specific objectives set out as a personal improvement plan. [Mrs 3] states that despite the Registrant working on Burlington Ward for a period of eight months, she did not feel she was able to work without supervision. 13. [Mrs 4] Band 5 Senior Staff Nurse was allocated to be the Registrant s preceptor on Burlington Ward and to supervise her in line with the capability process. [Mrs 4] states that whilst her redeployment to Burlington Ward was only initially for a one month period, this was extended to three months and then eight months due to the continued concerns with the Registrant s practice. 14. [Mrs 5], Staff Nurse dated 22 December [Mrs 5] worked directly with the Registrant during her employment on Burlington Ward and made records of her performance during those shifts. [Mrs 5] states that she felt that she needed to supervise the Registrant as she was consistently making mistakes, largely relating to medicines management and prioritisation of her workload. 1. On an unknown date between December 2013 and January 2014, gave an unknown patient incorrect medication, namely codeine tablets 15. On the 5 February 2014 it was brought to the attention of [Mrs 1] that the Registrant had given an unknown patient incorrect medication. This was reported some six weeks after the event and the identity of the Patient was not known. A Health Care Assistant has noticed that codeine tablets had been giving to the wrong patient. The Health Care Assistant corrected this to ensure the Patient received the correct medication. 2. On an unknown date, failed to escalate an unknown patient with a heart rate of 140bpm 16. [Mrs 1] recalled an occasion when she was covering a senior nurse over lunch which she often does. A patient had presented with chest pain. The patient had been

20 allocated to the Registrant s care and she was required to take an electrocardiogram (ECG) to measure the patient s heart rate. Whenever a patient presents with chest pain it is necessary to take an ECG within 15 minutes of their arrival as this could indicate a heart attack. Once the ECG has been taken it is necessary to get it signed off by a Doctor. [Mrs 1] checked the patient s notes and could see that he had been in the ward for an hour and ten minutes. She could also see that the Registrant had taken an ECG which showed the patient s heart rate at 140bpm. The normal heart rate would be 70bpm. The patient s heart rate was therefore double the normal rate. Despite this the ECG had not been signed off by a doctor. [Mrs 1] would have expected the Registrant to have identified that such a high reading was a red flag and to have immediately taken it to a Doctor. This would have enabled the patient to have been transferred to the resuscitation area. Despite this the Registrant did not escalate the matter as she should have done. 3. On 4 February 2014: a. Failed to ensure the prompt administration of Morphine Sulphate to Patient A b. Incorrectly administered a second dose of Warfarin to Patient B within a 24 hour period 17. On the 5 February 2014 [Mrs 2] was made aware of concerns relating to a shift on the Clinical Decision Unit (CDU) of the Accident and Emergency Ward on the 4 February It was explained to [Mrs 2] that the Registrant was taking a long time to administer lunch time medication during which time Patient A went without his Morphine Sulphate (MST). Patient A was said to have been in a lot of pain and had not been prescribed his normal medication MST 60mg. At it was noticed the MST had still not been given so Registrant was asked to stop what she was doing and administer it with a colleague as her signature was needed to be countersigned. 18. [Mrs 2] was made aware of another incident on 4 February 2014 in which the Registrant gave a second dose of warfarin 1mg to a Patient B. On 7 February 2014 [Mrs 2] spoke to the Registrant about the error and she recognised and owned up to her mistake. It was explained that the error had been caused by a lack of awareness on the part of the Registrant in that she had not checked the drug chart correctly to see that the medication had already been given

21 4. Between 19 January 2014 and 17 February 2014, failed to ensure that an unknown patient had a fracture clinic outpatient appointment 19. [Mrs 2] was made aware that a patient had been discharged from the CDU without a fracture clinic outpatient's appointment, which meant they went home without a back slab in place from 19 January to 17 February [Mrs 2] could not recall the specifics of this issue or what it was that the Registrant should have done. It is something that she would have gone over with the Registrant during the next review meeting. It is possible to make an outpatients appointment via the reception staff and it is something that is regular practice for nurses in A & E. The patient would have been sent to the CDU, which is still part of A & E but is a bit more of a ward environment. The Registrant was allocated to the CDU on 19 January 2014 and was involved with the patient's care. It was established that there was also another nurse involved in the patient's care so it would have been both the Registrant and the other nurse who were responsible for arranging the appointment with outpatients. Whilst the Registrant admits this charge it is accepted that it does not amount to misconduct and therefore the NMC propose to offer no evidence on this matter. 5. On 24 February 2014, in respect of an unknown patient who had a systolic blood pressure reading of 70 you moved the patient to Computed Topography: 5.1 Without IV fluids 5.2 Without monitoring equipment 5.3 Without discussing with a doctor whether the patient needed to be Accompanied 20. On 27 February 2014 [Mrs 2] was made aware of an incident relation to a shift occurring on the 24 February [Mrs 2] was working on this shift with the Registrant. The first incident was in relation to a patient who was transferred for a computed tomography ("CT") scan with a systolic blood pressure ("BP") of 70. A normal BP reading would be 120/70, the first figure being the systolic one. This patient had a systolic reading of 70 which was very low and meant there was a significant risk of the patient collapsing or having an event as she was being moved. There was also a risk that the patient would deteriorate rapidly so she needed to be properly monitored and possibly accompanied by a doctor. The Registrant informed [Mrs 2], as the nurse in charge, that the patient's BP was low. However, when [Mrs

22 2] checked on the patient she found that she had been moved to the CT scanner without any monitoring equipment and without the Registrant having checked with a doctor to see whether the patient needed to be accompanied. The Registrant should have notified a doctor that the patient was being moved with such a low BP so that the doctor could have made the decision as to whether or not they needed to accompany the patient. At the very least the Registrant should have ensured that the patient was placed on monitoring for heart rate, BP, pulse and oxygen. The monitoring equipment should have gone with the patient to the CT scanner so that she could be continuously monitored for any deterioration. It was about managing clinical risk to prevent any avoidable harm to the patient. 6. On 25 March 2014: a. Did not complete a baseline assessment of an unknown patient for four hours b. Did not perform observations for Patient C c. Did not perform observations for patient D d. Did not adequately complete observations for Patient E e. Did not adequately monitor Patient E s blood sugar levels f. Did not ensure that Patient F promptly received analgesia 21. [Mrs 2] was made aware of another incident during the night shift on 25 March A patient had been to move to the Acute Medical Unit ("AMU") but no assessment had been carried out despite the patient having been in A & E for four hours. The Registrant was allocated as the named nurse on the side of the department that the patient was based. For each patient that comes in it is necessary to take the details of their condition. A patient who has come in of their own accord will be assessed by the triage nurse. The Registrant never worked in triage as this requires the nurse to have a lot of experience working in A & E. Patients arriving by ambulance, however, will be assessed by the nurse that they are allocated to. Each staff nurse is allocated to five patients and must take details of their condition from the paramedics then complete a baseline assessment for that patient. This includes taking their oxygen readings, heart rate, BP and temperature for example. The readings will give an indication of how unwell that patient is and whether they are at risk. It also allows the nurse to assess how successful and interim treatments will be, before they are seen by a doctor or transferred to another

23 part of the Hospital. After the assessment has been completed the patient will wait to see a doctor and will be prioritised on the basis of how unwell they have been assessed to be. It is therefore important that the patient is assessed quickly, and normally the assessment should be completed within minutes of the patient arriving. The Registrant should not have left a patient for four hours without completing a baseline assessment and posed a risk that if the patient was very unwell this may not have been picked up on. 22. Copies of Patient C s notes were obtained and at the time of making her witness statement it was suggested by [Mrs 2] that Mrs Forrest had not taken any observations from Patient C. Having examined the observation chart it is has been clarified that she did in fact do so. In light of this there is no evidence in support of this charge and the NMC will be offering no evidence on it. 23. Patient D attended at Accident and Emergency ward with a bleed at From examination of the patient s records it has been established that an initial set of observations were done by the Registrant and in light of this the NMC propose to offer no evidence on this charge. 24. Patient E attended at Accident and Emergency Ward at There is a set of observations conducted by the registrant as she conducted the initial assessment. The NMC propose to offer no evidence in relation to that charge dealing with the observations as there is no evidence to support this. 25. It was recorded that Patient E had a blood sugar level of 18. Despite this high reading the registrant had not placed any continuing monitoring in place. 26. Patient F attended Accident and Emergency ward with hip pain having fallen, which is recorded in the patient s initial assessment. The Patient arrived at It was recorded that he had not received analgesia until The registrant should have ensured that the patient received analgesia at an earlier stage following his arrival. 7. On 29 March 2014: a. Failed to adequately monitor and / or record an unknown patient s observations b. Failed to escalate an unknown patient with a National Early Warning Score (NEWS) of seven

24 c. Failed to escalate to the nurse in charge that after two unsuccessful attempts to take blood from Patient G, you were unable to do so d. Failed to record three unsuccessful attempts to take blood from Patient G e. Failed to document any observations for Patient G for two and a half hours 27. On 14 April 2014 a Deputy Sister ed [Mrs 2] in relation to a night shift that she worked with the Registrant on 29 March Concerns were raised about the time the Registrant was taking to complete observations as well as specific issues in relation to two patients. 28. In relation to charge 7(b) the Registrant was not the nurse who conducted the initial assessment and therefore it was not her responsibility to escalate the unknown patient with a NEWS score of Patient G needed a blood test to be taken. The Registrant attempted to take the blood test three times but did not successfully take the blood test on any of these occasions. The Registrant also failed to document any observations for Patient G for two and a half hours. Observations should be completed at a frequency depending on how unwell that patient is. For every patient, observations should be completed a minimum of hourly, or more often depending on how unwell the patient is. No patient should be left for two and a half hours without observations having been completed. Blood tests are taken after the initial assessment has been completed so A & E nurses take blood all of the time. There is a rule within the department that if a nurse fails to take two blood tests, they should not attempt to take a third and should instead get another nurse to come and try. This is because it is not fair to the patient to keep jabbing them with a needle and not successfully taking blood. The Registrant should have informed the nurse in charge that she had not been able to take the blood tests on two occasions. The nurse in charge would then have been able to allocate another nurse to that patient to take the test and would also have been aware of the delay caused in that patient receiving care because of the blood test not having been taken. Most of the patients in A & E require a blood test in order to establish what the problem is. 8. On or around 7 April 2014, failed to change Patient H s dressing

25 30. Further concerns were raised in relation to the Registrant's handling of a Patient H who needed a dressing changed on 7 April The Registrant s case is that she under a duty to do something but it is not accepted that the Registrant was under a duty to change dressing as she did not have the knowledge or expertise to change the dressing. Instead she asked for the Doctor to look at the wound and was advised to pass on to [Ms 6]. In the context of the Registrant s other admissions to the charges and having fully evaluated the evidence obtained the NMC propose to take a proportionate view in relation to this matter and offer no evidence in respect of this charge. 9. On 7 May 2014: a. Failed to promptly assess Patient J b. Did not complete observations for Patient J c. Did not assess and / or complete observations for Patient K d. Did not perform any baseline observations for Patient L e. Did not perform an electrocardiogram (ECG) on Patient L 31. The Registrant was on duty on the 7 May 2014 and was allocated to the majors unit bays 1-4. Copies of Patient J s records were examined and it was apparent that he was brought into Accident and Emergency ward at Patient J had been brought in by ambulance and had a NEWS score of 8 which is high. Patient J further complained of shortness of breath. Despite arriving at the registrant did not complete an assessment of Patient J until No observations had been conducted by the registrant. When she was asked why the registrant explained that she was asked to take an x ray for another patient. Patient J should have prioritised over other Patients given his condition. 32. Patient K arrived at Accident and Emergency ward at The Registrant did not complete an assessment for Patient K or any observations. 33. Patient L arrived at Accident and Emergency Ward at The registrant did not conduct an assessment of Patient L until Patient L presented with left arm pain which can be a symptom of a heart attack. The registrant should have identified that a cardiac event was a possibility and performed an ECG. The registrant did not carry out an ECG nor did she conduct any baseline observations.

26 10. On 9 May 2014: a. Failed to escalate that Patient M had a heart rate of 146bpm b. Incorrectly recorded that Patient M had a normal heart rate c. Failed to recognise that an ECG was required for Patient M 34. Further concerns were raised concerns in relation to the Registrant's treatment of a patient ("Patient M"). The registrant had recorded a normal heart rate. The recording of the heart rate as normal was questioned as Patient M had been tachycardic at handover from the ambulance. Tachycardic is where the patient has a heart rate over 100bpm. The Registrant was asked to do an electrocardiogram ("ECG"). The Registrant did this and the reading showed that Patient M had a heart rate of 146bpm. Whenever a patient is showing signs of a high heart rate, for instance chest pain or shortness of breath, the nurse responsible for their care should take an ECG reading, rather than simply measure their pulse. In this instance Patient M had been identified as tachycardic when transferred from the ambulance so the Registrant should have set up an ECG. The Registrant should then have got the ECG reading signed off by a doctor to show that they had seen it and could take any action they felt necessary. The Registrant in fact recorded the Patient as having a normal heart rate. Any heart rate above 100bpm is too fast, so a heart rate of 146bpm was very significant and meant the patient was at risk of going into cardiac arrest. 11. On 15 June 2014 a. Did not complete repeat observations and / or a HOTPIN for Patient N b. Did not promptly assess Patient O c. Did not assess and / or monitor Patient P d. Did not assess Patient Q e. Did not perform a repeat set of observations for Patient Q f. Did not promptly assess Patient R 35. On 15 June 2014 a Senior Sister contacted [Mrs 2] in relation to a shift that she worked with the Registrant on the same date. Several concerns were raised about the Registrant, including not completing observations for two hours, for the two patients that were allocated to her. Also not completing a HOTPIN for either patient, taking 35 minutes to assess a patient, not completing nursing tasks and trying to take blood from patients when she was not supposed to be completing extended

27 nursing tasks such as this. HOTPIN's are a form that is filled out in relation to the patient's personal care. The nurse needs to record information in relation to the patient's hydration, observations, toileting, pressure areas, pain, information giving and nutrition. 36. Patient N arrived in A & E at 07:13. There was no evidence in the patient records of any repeat observations or the HOTPIN being completed by the Registrant. Patient O arrived in A & E at 09:56. Patient O was not assessed until 11:35. As above an assessment should be completed within minutes of the patient arriving. No patient should be let for over an hour and a half without having been assessed. 37. Patient P arrived on A & E at and was placed in an isolation room. The Registrant did not see, assess or monitor Patient P at all. No assessment was completed until 13.00, at which point another nurse, completed the assessment. 38. Patient Q arrived on A & E at 11:58. The Registrant did not complete an assessment. The assessment was completed by another nurse. The Registrant also only completed only one set of observations for Patient Q at 12:15. As above, observations should be completed a minimum of hourly for each patient, or more often depending on how unwell the patient is. The Registrant should have been completing repeat observations for Patient Q from that point onwards. 39. Patient R arrived on A & E at The Registrant did not assess Patient R until 16: On 2 July 2014, administered oxycodone to a patient from another patient s stock 40. On the 2 July 2014 the Registrant was involved in a medication error. The Registrant had given a dose of oxytocin to one patient when this was prescribed to another patient. Both patients were prescribed the same dose and medication so there was no harm to the patient. It was that the Registrant had given the medication from the bottle belonging to the first patient, to the second patient. The registrant when spoken to appeared to have no awareness that she could not do this. Even if it is the same dose, medication that is prescribed for one patient should never be given to another as this medication belongs to that patient. 13. On 7 July 2014 left an unknown patient on a commode for hours

28 41. [Mrs 2] worked a shift with the Registrant on 7 July A patient who had difficulty mobilising and was sitting on a commode but needed to be moved. The Registrant raised this with [Mrs 2] and discussed options as to how to move the patient. [Mrs 2] suggested moving the patient to a wheelchair, with the aid of a hoist if necessary, and left this with the Registrant to manage. 42. Later that day [Mrs 2[ was confronted by the patient's daughter who was very upset that her mother had been left on the commode for hours. [Mrs 2[ was very concerned that the Registrant had not actioned what had been discussed and had instead left the patient on the commode. This was made worse by the fact that the patient had a high waterlow score. A waterlow score is an indication of how at risk that patient is of developing pressure sore. It was not acceptable to leave the patient on a commode for a long period of time as this would have put them at greater risk of pressure damage. [Mrs 2[ attended to the patient and moved her to a bed and checked her for any pressure damage. There were no breaks in the patient's skin but her sacrum was red. 14. On 12 July 2014, did not adequately complete and / or monitor observations for one or more patients 43. On the 12 July 2014 [Mrs 2[ worked a shift with the Registrant. The registrant was allocated bays 1-4 on the majors unit. The patient in bay 1 had only one set of observations whilst on the unit. The patient in bay 2 had two sets of observations. The patient in bay 3 and 4 had only one set of observations. It was likely that all patients were in the majors unit for more than an hour and as such all should have had observations conducted hourly. 15. On 13 July 2014: a. Did not complete and / or record observations for Patient S as frequently as required b. Did not complete and / or record observations for Patient T as frequently as required c. Did not document the time you assessed patient T

29 44. On 24 July 2014 [Mrs 2[ was made aware by a Senior Sister, about a shift that she worked with the Registrant on 13 July The concerns related to the Registrant not completing observations for one patient ("Patient S") for two hours and another ("Patient T") for three hours. 45. Patient S arrived in A & E at The Registrant assessed Patient S at 15:55. The Registrant only recorded one set of observations, at 16:15, before the night staff arrived at 20:00. The Registrant should have been conducting regular observations during this time. 46. Patient T arrived in A & E at 18:33. The Registrant has completed an assessment but no time appears on the assessment. It is always important to document what time the assessment is completed as otherwise there is no record of how long they have been in A & E before this has been done. 47. There are only two sets of observations recorded for Patient T whilst he was in A & E. This was particularly concerning as Patient T subsequently needed to be blue lighted to another hospital. In order to be blue lighted to another hospital this would have needed to be very serious and meant that observations should have been conducted more regularly than every hour. 16. During a night shift commencing 12 August 2014 did not transfer one or more unknown patients in a timely manner 48. On 17 August 2014 [Mrs 2[ was made aware of concerns regarding a night shift of 12/13 August The registrant was working this shift. The concerns related to the Registrant not watching another member of staff prepare a sliding scale infusion and not transferring two patients from A & E in a timely manner. The Registrant should have ensured that patients were transferred when necessary as otherwise the beds on the wards for those patients may no longer have been available by the time this was done. 17. On 20 August 2014, did not administer intravenous (IV) antibiotics to an unknown patient 49. On 21 August 2014 a Senior Sister, raised concerns relating to an incident the previous day in which the Registrant was asked by a doctor to give an intravenous ("IV") antibiotic as the patient was septic. The Registrant did not give the antibiotic