Nursing and Midwifery Council:

Transcription

1 Nursing and Midwifery Council Fitness to Practise Committee Substantive Hearing 13 to 17 November 2017 Nursing and Midwifery Council, 2 Stratford Place, Montfichet Road, London, E20 1EJ Name of registrant: Diana Silvanos NMC PIN: 04F0019O Part(s) of the register: Registered Nurse Sub Part 1 Adult Nursing 1 June 2004 Area of Registered Address: England Type of Case: Misconduct Panel Members: Jane Kivlin (Chair, Registrant member) Catherine Cooper (Registrant member) Jill Wells (Lay member) Legal Assessor: Gelaga King Panel Secretary: Deepan Jaddoo 13 November 2017 Lesley Rudd November 2017 Rebekah Isaacs 17 November 2017 Registrant: Not present and not represented. Participated by telephone. Nursing and Midwifery Council: Represented by Michael Collis, Counsel, instructed by NMC Regulatory Legal Team. Page 1 of 25

2 Facts proved by admission: 1, 3, 4 Facts not proved: 2, 5 Fitness to practise: Impairment Sanction: Conditions of Practice Order 12 months Interim Order: Conditions of Practice Order 18 months Details of charge: That you, a registered nurse employed by Nottingham University Hospitals NHS Trust at Ward C52 of the Queen s Medical Centre Campus on 3 September 2015; 1. Left the cohort nursing bay unattended, during which time Patient A fell to the floor; 2. Failed to inform a doctor of Patient A s fall in accordance with the Trust s Falls Management policy 3. Failed to complete relevant documentation including updating the falls care plan, Patient A s progress notes and a Datix form in accordance with the trust s falls management policy in a timely fashion and/or at all; 4. Failed to report the circumstances of patient A s fall at the shift handover. 5. Your actions at charges 2-4 were dishonest in that your intention was to conceal the circumstances of Patient A s fall. And, in light of your actions, your fitness to practise is impaired by reason of your misconduct. Page 2 of 25

3 Decision on Service of Notice of Hearing The panel was informed at the start of this hearing that Ms Silvanos was not in attendance and that written notice of this hearing had been sent to Ms Silvanos registered address by recorded delivery and by first class post on 29 September The panel took into account that the notice letter provided details of the allegations, the time, dates and venue of the hearing and, amongst other things, information about Ms Silvanos right to attend, be represented and call evidence, as well as the panel s power to proceed in her absence. Mr Collis submitted the NMC had complied with the requirements of Rules 11 and 34 of the Nursing and Midwifery Council (Fitness to Practise) Rules 2004, as amended ( the Rules ). The panel accepted the advice of the legal assessor. In the light of all of the information available, the panel was satisfied that Ms Silvanos has been served with notice of this hearing in accordance with the requirements of Rules 11 and 34. It noted that the rules do not require delivery and that it is the responsibility of any registrant to maintain an effective and up-to-date registered address. Decision on proceeding in the absence of the Registrant The panel next considered whether it should proceed in the absence of Ms Silvanos. The panel had regard to Rule 21 (2), which states: (2) Where the registrant fails to attend and is not represented at the hearing, the Committee Page 3 of 25

4 (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 Collis invited the panel to continue in the absence of Ms Silvanos on the basis that she had voluntarily absented herself. Mr Collis submitted that Ms Silvanos was aware of today s hearing and that she had indicated that she was unable to attend due to child care difficulties. He submitted that she had provided a written response to the allegations so there was no risk of the panel reaching the wrong conclusion. He further submitted that there was no reason to believe that an adjournment would secure her attendance on some future occasion. The panel accepted the advice of the legal assessor. The panel noted that its discretionary power to proceed in the absence of a registrant under the provisions of Rule 21 is not absolute and is one that should be exercised with the utmost care and caution as referred to in the case of R. v Jones (Anthony William), (No.2) [2002] UKHL 5. The panel further noted the case of R (on the application of Raheem) v Nursing and Midwifery Council [2010] EWHC 2549 (Admin) and the ruling of Mr Justice Holman that:...reference by committees or tribunals such as this, or indeed judges, to exercising the discretion to proceed in the person's absence "with the utmost caution" is much more than mere lip service to a phrase used by Lord Bingham of Cornhill. If it is the law that in this sort of situation a committee or tribunal should exercise its discretion "with the utmost care and caution", it is extremely important that the committee or tribunal in question demonstrates by its language (even though, of course, it need not use those precise words) that it appreciates Page 4 of 25

5 that the discretion which it is exercising is one that requires to be exercised with that degree of care and caution. The panel has decided to proceed in the absence of Ms Silvanos. In reaching this decision, the panel has considered the submissions of the case presenter, and the advice of the legal assessor. It has had particular regard to the factors set out in the decision of Jones. It has had regard to the overall interests of justice and fairness to all parties. It noted that: no application for an adjournment has been made by Ms Silvanos; there is no reason to suppose that adjourning would secure her attendance at some future date; two witnesses have attended today to give live evidence, others are due to attend; not proceeding may inconvenience the witnesses, their employer(s) and, for those involved in clinical practice, the clients who need their professional services; the charges relate to events that occurred in 2015; further delay may have an adverse effect on the ability of witnesses accurately to recall events; there is a strong public interest in the expeditious disposal of the case. Before announcing its decision, the panel invited Mr Collis on behalf of the NMC to contact Ms Silvanos to clarify her position. Mr Collis confirmed that Ms Silvanos does not wish to request this matter be adjourned and that she will be available on the telephone to answer any questions. In these circumstances, the panel has decided that it is fair, appropriate and proportionate to proceed in the absence of Ms Silvanos. The panel will draw no adverse inference from her absence in its findings of fact. Page 5 of 25

6 After taking legal advice the panel decided that Ms Silvanos should be telephoned when the charges were read out and asked whether she admits any of them and whether she accepts that her fitness to practice is impaired. Ms Silvanos stated that she admits all of the charges, she accepted that her fitness to practice was impaired at the time of these events but would leave the issue of current impairment to the panel s judgement. When questioned by the panel on her admissions, Ms Silvanos, on reflection, stated that she did not admit Charge 2 or Charge 5. She agreed to participate in the hearing via telephone. Hereafter, this determination will read in view of Ms Silvanos attendance and will address her in the first person. Background Ms Silvanos, The charges arose whilst you were employed as a Registered Nurse by Nottingham University Hospitals NHS Trust (the Trust) at Queens Medical Centre Campus (the Hospital) as a Staff Nurse. This incident occurred on Ward C52 at the Queens Medical Centre Campus at around 0400 hours on 3 September You were the nurse-in-charge and were responsible for the cohort bay (Green Bay), which consisted of very vulnerable patients with a high falls risk. Patient A was at high risk of falls and required 1 to 1 nursing care. She fell whilst unattended in the cohort nursing bay. Following the fall, the patient was returned to bed, observations were carried out and she was seen by a doctor. Page 6 of 25

7 You allegedly failed to inform the doctor of Patient A s fall and did not complete the relevant documentation identified in the Trust Falls Management Policy. Furthermore, it is alleged that you failed to report the fall at shift handover or at all for five days. You allegedly admitted during the Trust s investigation that you had left the cohort bay unattended. You also told the Trust that you had requested that another staff member attend at the cohort bay to ensure that the patients were not left unattended, but had left the bay before the staff member had come into the bay. You also admitted that you did not handover the fall to the next nursing shift. Witnesses The panel heard oral evidence from four witnesses tendered on behalf of the NMC. In addition, the panel heard oral evidence from you. Witnesses called on behalf of the NMC were: Ms A Investigating Ward Sister; Ms B Auxiliary Nurse; Ms C Deputy Sister; Ms D Deputy Sister During the questioning of Ms C, you asked questions which revealed sensitive personal information, both about you and about the witness. The legal assessor explained to the witness and to you that such matters would ordinarily be dealt with in private session and advised the panel accordingly. Mr Collis, on behalf of the NMC, agreed with the legal assessor. The panel accepted the legal assessor s advice, and determined that all evidence or submissions which touched upon health or sensitive matters would be heard in private. The panel first considered the overall credibility and reliability of all of the witnesses it had heard from, including you. Page 7 of 25

8 Ms A was the Investigator on behalf of the Trust. The panel took the view that she answered questions openly and honestly, and did her best to assist the panel. In relation to Ms B, the panel took the view that her account of events was broadly consistent with her earlier statements. Ms B was an Auxiliary Nurse on duty that night. She gave evidence that she found Patient A on the floor and assisted her back to bed. The panel was of the opinion that Ms B s admission that her recall of events was not good added to her credibility and could explain some of the inconsistencies in her evidence. It was noted that there were inconsistencies between the more contemporaneous records and the later statements and oral evidence given. Further, Ms B, in the panel s view, had clearly reflected on the events in question and stated that she felt that she should have done more at the time by reporting the fall herself. In relation to Ms C, the panel noted that there were major inconsistencies in her evidence, both with the contemporaneous records and with her own statements of the relevant facts. Ms D gave frank and open evidence from her recall of events. The panel was concerned that Ms D was firm in her evidence that she specifically asked you about patient falls during handover, but it came to light when challenged by the panel and on checking the off-duty rota and during panel questioning that in fact she was not working on the shift in question. The panel was also concerned about Ms D s evidence that she made several attempts to contact you by telephone but did not leave a message as she said that you were busy. Nor did she speak to you about her reason for attempting to telephone you the next time she saw you. The panel found your evidence to be clear and credible, although it noted some inconsistencies with your written statements at the time of the events. The panel noted that while this evidence was given by phone, rather than in person, this did not undermine your credibility or the strength of your evidence. Page 8 of 25

9 Decision on the findings on facts and reasons At the start of this hearing you admitted charges 1, 3 and 4. These were therefore announced as proved. The panel then went on to consider the remaining charges and made the following findings. Charge 1: 1. Left the cohort nursing bay unattended, during which time Patient A fell to the floor; This charge was admitted and found proved. Charge 2: 2. Failed to inform a doctor of Patient A s fall in accordance with the Trust s Falls Management policy This charge is found not proved. Both you and Ms C gave evidence that you contacted Ms C by telephone on 8 September 2015 when you realised that you had not reported Patient A s fall. The panel took into account the note of the telephone call between Ms C and you, completed by Ms C. The panel was mindful of the fact that there was a stark conflict between the evidence of Ms C and yourself. There was no evidence from the doctor himself or from anyone other than you who witnessed your interaction with the doctor. Ms C alleged, in her written statement dated 28 March 2017, and in her oral evidence to the panel that during a telephone call on 8 September 2015, that you told her you had not disclosed the fall to the doctor. You have been consistent in maintaining that you did inform the doctor and had not said this to Ms C. Page 9 of 25

10 In resolving the conflict the panel noted that the first time Ms C alleged that you admitted that you had not informed the doctor about the fall was in her witness statement to the NMC dated 28 March The panel concluded that Ms C s evidence was undermined when tested against her own record of the telephone call at on 8 September 2015 written on the same day. In the record, Ms C states: [Ms B] HCA then found [Patient A] on the floor beside her bed and she let Diana know. The doctor was on the ward seeing another patient and was informed, observations were done and her EWS was 4. I have looked on Eobs and obs were done at score 4 on temperature and BP, and at scoring 3 on BP, and at scoring 3 on BP. The record goes on to say: The doctor has not made an entry in the notes and the correct procedure post fall was not followed and none of the appropriate paperwork completed. Diana also did not report the fall at handover. Ms C, when questioned, said that her record was ambiguous. This record was significantly different to her witness statement dated 28 March 2017 which states that...she admitted that the fall was not disclosed to the doctor The panel took the view that the contemporaneous record made at the time of the telephone call was more likely to be accurate, and the panel determined that on a proper construction of the relevant passages, the obvious and safe inference is that the registrant had informed the doctor. The record of Ms C s internal investigation interview on 24 November 2015 does not contain her reference to the doctor not being informed of the fall. Page 10 of 25

11 Ms C s evidence was further undermined by your Datix Record of the incident, also made by you on 8 September 2015, in which it is recorded that the night doctor was informed of the fall. As a result of the question marks raised over the reliability of Ms C s evidence on this issue, the panel concluded that it could not exclude the possibility that your account is the correct one. This charge is therefore found not proved. Charge 3: 3. Failed to complete relevant documentation including updating the falls care plan, Patient A s progress notes and a Datix form in accordance with the trust s falls management policy in a timely fashion and/or at all; This charge was admitted and found proved. Charge 4: 4. Failed to report the circumstances of patient A s fall at the shift handover. This charge was admitted and found proved. Charge 5: 5. Your actions at charges 2-4 were dishonest in that your intention was to conceal the circumstances of Patient A s fall. This charge is found not proved. In reaching this decision, the panel took into account all of the evidence before it. It noted your admissions and its own findings about Charge 2. Page 11 of 25

12 The panel took the view that it was more likely than not that you told the doctor about Patient A s fall. In these circumstances the panel found it highly unlikely that you would intentionally not record the circumstances of Patient A s fall, nor informed colleagues of the fall at handover if you had informed the doctor of the fall earlier on during the shift. The panel accepted your evidence that you were under immense stress at the time of these events due to personal circumstances and being at the end of a period of five consecutive night shifts. The panel took the view that on the balance of probabilities, it is more likely than not that you did not intend to conceal Patient A s fall, rather that your state of mind clouded your judgement. In these circumstances Charge 5 is not proved. Proceeding in the absence of Ms Silvanos Prior to hearing submissions on misconduct and impairment, the panel received an from Ms Silvanos dated 17 November 2017, stating that she is unwell and cannot continue to participate. Ms Silvanos also states that I would therefore like to ask the NMC to decide what they want to do. The panel noted that Ms Silvanos has previously indicated that she wishes this hearing to reach a speedy conclusion. Mr Collis invited the panel to continue in the absence of Ms Silvanos on the basis that she has indicated that she wishes for a speedy resolution to this matter. Mr Collis submitted that there was no reason to believe that an adjournment at this stage would secure her attendance on some future occasion. The panel accepted the advice of the legal assessor. The panel took the view that Ms Silvanos has participated in the hearing until now, she has provided information for the panel to consider and stated that she wishes that this matter be resolved. Page 12 of 25

13 The panel determined to continue in the absence of Ms Silvanos. It took the view that proceeding in the absence of Ms Silvanos at this stage would be in the interests of patient safety, in the public interest and in Ms Silvanos own interest. 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 Ms Silvanos fitness to practise is currently impaired. There is no statutory definition of fitness to practise. However, the NMC has defined fitness to practise as a registrant s suitability to remain on the register unrestricted. In his submissions Mr Collis invited the panel to take the view that Ms Silvanos actions amount to a breach of The Code: Professional standards of practice and behaviour for nurses and midwives (2015) (the Code). He then directed the panel to specific paragraphs and identified where, in the NMC s view, Ms Silvanos actions amounted to misconduct. Mr Collis 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 Collis referred the panel to the case of Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin). Lord Clyde, giving judgment in Roylance, went onto state: It is not any professional misconduct which would qualify. The professional conduct must be serious. Page 13 of 25

14 In her Ms Silvanos reiterated her remorse for her failings and her love of the nursing profession. She included comments that demonstrated some level of insight. The panel has accepted the advice of the legal assessor The panel adopted a two-stage process in its consideration, as advised. First, the panel had to 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, Ms Silvanos 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. 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 and exercised its own professional judgement. The panel was of the view that Ms Silvanos 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: Paragraph 8 Work cooperatively To achieve this, you must: 8.2: Maintain effective communication with colleagues; 8.3: Keep colleagues informed when you are sharing the care of individuals with other healthcare professionals and staff; 8.5: Work with colleagues to preserve the safety of those Page 14 of 25

15 receiving care; 8.6: Share information to identify and reduce risk Paragraph 10 Keep clear and accurate records relevant to your practice To achieve this, you must: 10.1: Complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event; 10.2: Identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need; Paragraph 11 Be accountable for your decisions to delegate tasks and duties to other people To achieve this, you must: 11.1: Only delegate tasks and duties that are within the other person s scope of competence, making sure that they fully understand your instructions The NMC s Record-Keeping Guidance sets the following requirements: You should record details of any assessments and reviews undertaken, and provide clear evidence of the arrangements you have made for future and ongoing care. This should also include details of information given about care and treatment; Records should identify any risks or problems that have arisen and show the action taken to deal with them; You have a duty to communicate fully and effectively with your colleagues, ensuring that they have all the information they need about the people in your care. Page 15 of 25

16 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 both individually and collectively Ms Silvanos conduct outlined in Charges 1, 3 and 4 does constitute misconduct. Ms Silvanos left a bay of vulnerable patients unattended when it was known to her that the bay in question should never be left unattended. One of those patients was especially vulnerable, prone to falls and required one to one care. She left the bay because a patient had become agitated and had demanded tea. Ms Silvanos did not wait for a colleague to arrive. Further Ms Silvanos omitted to record the fall or follow the required policy following the fall. This was compounded by her failing to report the fall during handover at the end of the shift. The panel took the view that had she taken either of these steps, relevant information would have been communicated much earlier, and a different approach to Patient A s care at the time may have been considered. The panel found that Ms Silvanos actions did fall seriously short of the conduct and standards expected of a nurse and amounted to misconduct. Decision on impairment The panel next went on to decide if as a result of this misconduct Ms Silvanos fitness to practise is currently impaired. Nurses occupy a position of privilege and trust in society and are expected at all times to be professional. 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: Page 16 of 25

17 In determining whether a practitioner s fitness to practise is impaired by reason of misconduct, the relevant panel should generally consider not only whether the practitioner continues to present a risk to members of the public in his or her current role, but also whether the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular circumstances. Mrs Justice Cox went on to say in Paragraph 76: I would also add the following observations in this case having heard submissions, principally from Ms McDonald, as to the helpful and comprehensive approach to determining this issue formulated by Dame Janet Smith in her Fifth Report from Shipman, referred to above. At paragraph she identified the following as an appropriate test for panels considering impairment of a doctor s fitness to practise, but in my view the test would be equally applicable to other practitioners governed by different regulatory schemes. Do our findings of fact in respect of the doctor s misconduct, deficient professional performance, adverse health, conviction, caution or determination show that his/her fitness to practise is impaired in the sense that s/he: a. has in the past acted and/or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and/or b. has in the past brought and/or is liable in the future to bring the medical profession into disrepute; and/or c. has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the medical profession; and/or Page 17 of 25

18 d.... The panel finds that by leaving vulnerable patients unattended, Ms Silvanos did place them at unwarranted risk of harm. By failing to record Patient A s fall or to follow the required Trust policy and failing to report the fall for five days after the event, Ms Silvanos did bring the profession into disrepute and breached fundamental tenets of the profession. The panel took the view that Ms Silvanos has shown some insight into her failings in that she recognised the impact of her misconduct on Patient A, her colleagues and the profession as a whole. Ms Silvanos did submit some references and testimonials, however, the panel found them to be of limited weight as it was not clear whether the authors of the documents were aware of the detail of the charges Ms Silvanos faced. Ms Silvanos gave the panel some information about training she had undertaken on falls. However, the panel noted no evidence of any training on record keeping. Ms Silvanos gave the panel information about her personal circumstances at the time of the events in question. [PRIVATE]. The panel is of the view that there is a risk of repetition based on the limited [PRIVATE] and the limitations of her remediation. The panel was also informed that other concerns have been raised about Ms Silvanos fitness to practice which are currently being screened by the NMC. The panel was not therefore in a position to say that there has been no further concerns raised since these incidents. The panel bore in mind that the overarching objectives of the NMC are to protect, promote and maintain the health, safety and well-being of the public and patients, and to uphold and protect the wider public interest. This includes promoting and maintaining public confidence in the nursing and midwifery professions and upholding the proper Page 18 of 25

19 professional standards for members of those professions. The panel determined that, in this case, a finding of impairment on the grounds of patient safety and in the public interest was also required. Having regard to all of the above, the panel was satisfied that Ms Silvanos fitness to practise is currently impaired. Determination on sanction: The panel has considered this case and has decided to make a conditions of practice order. The effect of this order is that Ms Silvanos name on the NMC register will show that she is subject to a conditions of practice order and anyone who enquires about her registration will be informed of this order. In reaching this decision, the panel has had regard to all the evidence that has been adduced in this case. It also had regard to the submissions of Mr Collis and the written representations which Ms Silvanos provided. Mr Collis submitted that sanction is a matter for the panel s professional judgement. He reminded the panel of its earlier findings and highlighted the evidence submitted in relation to Ms Silvanos personal mitigation. Mr Collis submitted that whilst personal mitigation should be considered, in proceedings such as this, the primary consideration is public protection and the public interest. The panel accepted the advice of the legal assessor. The panel has borne in mind that any sanction imposed must be appropriate and proportionate and, although not intended to be punitive in its effect, may have such consequences. The panel had careful regard to the NMC s Sanctions Guidance ( SG ) published by the NMC. It recognised that the decision on sanction is a matter for the panel, exercising its own independent judgement. The panel identified the following mitigating factors: Page 19 of 25

20 Ms Silvanos made early admissions to the charges found proved Ms Silvanos has demonstrated some insight into her failings Ms Silvanos has expressed significant remorse for her actions At the time of the incident which gave rise to the charges, Ms Silvanos was working in an environment with inadequate staffing levels and a challenging work pattern Ms Silvanos was experiencing significant personal circumstances which impacted on her behaviour at the relevant time Ms Silvanos has provided positive references and testimonial, albeit it is not clear that the referees were aware of the detail of the charges The panel identified the following aggravating factors: Ms Silvanos actions posed a risk to vulnerable patients Ms Silvanos has yet to fully remediate her failings The panel first considered whether to take no action but concluded that this would be inappropriate. To take no further action would not place restrictions on Ms Silvanos practice and so would not protect the public. Next, in considering whether a caution order would be appropriate in the circumstances, the panel took into account the NMC s 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 considered that Ms Silvanos misconduct was not at the lower end of the spectrum and that a caution order would be inappropriate. To impose a caution order would place no restriction on Ms Silvanos practice and so would not protect the public. The panel next considered imposing a conditions of practice order. The panel noted that all of the misconduct in this case is remediable and there are identifiable areas of Ms Silvanos practice which would benefit from re-training. There are no harmful personality or deep-seated attitudinal issues in this case and there is no evidence of general Page 20 of 25

21 incompetence, as Ms Silvanos has in the past shown that she is capable of safe and effective nursing practice. Although the panel noted that Ms Silvanos asserted a wish to leave the nursing profession, it also heard that Ms Silvanos is willing to respond to retraining. The panel had regard to the evidence relating to the course on managing falls which Ms Silvanos completed on 29 March It considered that this was evidence of her attempt to remediate her failings. The panel does have a reservation as to Ms Silvanos level of insight into the deficiencies in her practice, but it applied the principle of proportionality and balanced this against Ms Silvanos interests. The panel concluded that there are conditions of practice that could be formulated to address the risks in Ms Silvanos practice that would sufficiently protect the public whilst allowing Ms Silvanos the opportunity to remediate her practice and develop her insight. The panel did consider imposing a suspension order but was of the view that this would be disproportionate given that it has identified that Ms Silvanos misconduct is remediable. Ms Silvanos indication of her willingness to retrain has assured the panel that she will comply with conditions of practice. A suspension order would render Ms Silvanos unable to fully remediate the shortcomings in her practice and would prevent her from being able to return to safe and effective nursing practice. The panel determined that a period of 12 months is the appropriate length of this order. Ms Silvanos has attempted to remediate her failings in the past and this order should be for 12 months in order for Ms Silvanos to be able to demonstrate a sustained improvement in her practice. The panel imposed the following conditions of practice: 1. Before you return to practice you must successfully undertake a Royal College of Nursing accredited record keeping course within 3 months of the date on which these conditions become effective, and send a copy of your course certificate and a reflective piece of your learning, to the NMC, within 28 days of completing the course receiving them. Page 21 of 25

22 2. At any time that you are employed or otherwise providing nursing services, you must place yourself and remain under the supervision of a workplace line manager, mentor or supervisor nominated by your employer, such supervision to consist of: Working at all times on the same shift as, but not necessarily under the direct observation of, a registered nurse of band 6 or above who is physically present in or on the same ward, unit, floor or home that you are working in or on 3. You must work with your line manager, mentor or supervisor (or their nominated deputy) to create a personal development plan designed to address the concerns about the following areas of your practice: Record keeping Clinical communication and handover 4. You must meet with your line manager, mentor or supervisor (or their nominated deputy) at least every week for the first six weeks and at least monthly thereafter to discuss the standard of your performance and your progress towards achieving the aims set out in your personal development plan. 5. You must forward to the NMC a copy of your personal development plan within 28 days of the date on which these conditions become effective or the date on which you take up an appointment, whichever is sooner. 6. You must send a report from your line manager, mentor or supervisor (or their nominated deputy) setting out the standard of your performance and your progress towards achieving the aims set out in your personal development plan to the NMC every 3 months and at least 14 days before any NMC review hearing or meeting. Page 22 of 25

23 7. [PRIVATE]. 8. You must allow the NMC to exchange, as necessary, information about the standard of your performance and your progress towards achieving the aims set out in your personal development plan with your line manager, mentor or supervisor (or their nominated deputy) and any other person who is or will be involved in your retraining and supervision with any employer, prospective employer and at any educational establishment. 9. You must tell the NMC within 14 days of any nursing appointment (whether paid or unpaid) you accept within the UK or elsewhere, and provide the NMC with contact details of your employer. 10. You must tell the NMC about any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 14 days of you receiving notice of them. 11. a) You must within 14 days of accepting any post or employment requiring registration with the NMC, or any course of study connected with nursing, provide the NMC with the name/contact details of the individual or organisation offering the post, employment or course of study. b) You must within 14 days of entering into any arrangements required by these conditions of practice provide the NMC with the name and contact details of the individual/organisation with whom you have entered into the arrangement. 12. You must immediately tell the following parties that you are subject to a conditions of practice order under the NMC s fitness to practise procedures, and disclose the conditions listed at (1) to (11) above, to them. 1 Any organisation or person employing, contracting with, or using you to undertake nursing work. Page 23 of 25

24 2 Any agency you are registered with or apply to be registered with (at the time of application) to provide nursing services. 3 Any prospective employer (at the time of application) where you are applying for any nursing appointment. 4 Any educational establishment at which you are undertaking a course of study connected with nursing or midwifery, or any such establishment to which you apply to take such a course (at the time of application). Before the end of the period of the order, a panel will hold a review hearing to see how well Ms Silvanos has complied with the order. At the review hearing the panel may revoke the order or any condition of it, it may confirm the order or vary any condition of it, or it may replace the order for another order. A future reviewing panel would be helped by, in addition to evidence as to how Ms Silvanos has complied with the conditions, testimonials regarding her clinical practice and evidence of ongoing continuing professional development. Determination on Interim Order The panel has considered the submissions made by Mr Collis that an 18 month 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 conditions of practice order is necessary for the protection of the public and is otherwise in the public interest. The panel had regard to the reasons set out in its decision for the substantive order in reaching the decision to impose an interim conditions of practice order. It determined that not to do so would be inconsistent with its earlier findings. Page 24 of 25

25 The conditions for the interim order will be the same as those detailed in the substantive order. 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 conditions of practice order 28 days after Ms Silvanos has been sent the decision of this hearing in writing. That concludes this determination. Page 25 of 25