Conduct and Competence Committee Substantive Hearing

Transcription

1 Conduct and Competence Committee Substantive Hearing March 2016 Nursing and Midwifery Council, 2 Stratford Place, Montfichet Road, London, E20 1EJ Name of registrant: Natalie Ann Powell NMC PIN: 12F2958E Part(s) of the register: Nurse sub part 1 RNC: Children s nurse, level 1 2 November 2012 Area of registered address: Leicester Type of case: Misconduct/Lack of Competence Panel members: Nicholas Cook (Chair, Lay member) Jennifer Pennington (Registrant member) Janet Blundell (Lay member) Legal Assessor: Robert Frazer Panel Secretary: Nilima Ali Representation: Nursing and Midwifery Council (NMC): Represented by Georgia Whiting, Case Presenter, instructed by the NMC Regulatory Legal Team Page 1 of 64

2 Miss Powell: Miss Powell was not present and not represented Facts found proved: 1.1, 2, 4.1, 4.2, 9, 10, 11, 12.1, 12.2, 13, 14.1, 15.1, 15.2 and 16 Facts found not proved: 1.2, 3, 5.1, 5.2, 6.1, 6.2, 6.3, 7, 8 and 14.2 Fitness to practise: Impaired Sanction: Striking-off order Interim Order: Interim suspension order: 18 months Page 2 of 64

3 Determination on service The panel received information from Ms Whiting on behalf of the Nursing and Midwifery Council ( NMC ) that the Notice of Hearing had been served in accordance with The Nursing and Midwifery Council (Fitness to Practise) Rules Order of Council 2004 ( the Rules ). The panel accepted the advice of the legal assessor. The Notice of Hearing was sent by first class post and recorded delivery on 2 February 2016 to Miss Powell s registered address as recorded on WISER, the system supporting the NMC s Register. It contained the correct and relevant details of the hearing. The panel concluded that service had been effected in accordance with Rules 11 and 34. Determination on proceeding in the absence of Miss Powell The panel then considered whether to exercise its discretion to proceed in Miss Powell s absence, in accordance with Rule 21(2)(b). The panel had regard to all the information before it. It heard submissions from Ms Whiting and accepted the advice of the legal assessor. Ms Whiting invited the panel to proceed in the absence of Miss Powell, pursuant to Rule 21(2)(b). She submitted that Miss Powell had been properly served with the Notice of Hearing in accordance with the Rules and that it would be in the interests of justice to proceed today. Ms Whiting submitted that there had been no formal response from Miss Powell to the charges. The NMC had, however, received correspondence from Miss Powell. Ms Whiting referred the panel to an from Miss Powell, dated 9 March 2016, in which Miss Powell indicated that she would not be attending the hearing and that if they feel this meeting needs to go ahead, that is down to them. Page 3 of 64

4 Ms Whiting submitted that it was clear from the from Miss Powell that she was aware of this hearing and that she had chosen voluntarily to absent herself. Ms Whiting explained that there are seven witnesses due to attend the hearing on behalf of the NMC. She invited the panel to have in mind the impact that any delay may have on the witnesses memories of the alleged incidents. Ms Whiting further submitted that there had been no request from Miss Powell for an adjournment. She submitted that, on the basis of the above, the panel could properly conclude that an adjournment would be unlikely to secure Miss Powell s attendance on a future date. In all of those circumstances, Ms Whiting invited the panel to proceed in the absence of Miss Powell. The panel, in considering this matter, had regard to the public interest in the expeditious disposal of the case, the potential inconvenience caused to a party or any witnesses to be called by that party, and fairness to Miss Powell. The panel gave careful regard to the guidance in the case of R v Hayward, Jones and Purvis [2001] EWCA Crim 168 and exercised the utmost care and caution in coming to its decision. Miss Powell, in her to the NMC dated 9 March 2016, confirmed that she would not be in attendance at this hearing. There had been no request for an adjournment. The panel considered that adjourning the hearing would serve no purpose, as it would be unlikely to secure Miss Powell s attendance on a future occasion. The panel was mindful of the extent of the disadvantage to Miss Powell in not being present to give her account of events, and the personal and professional impact any adverse findings may have against her. However, the panel was also mindful of the Page 4 of 64

5 public interest in the expeditious disposal of cases. There are seven witnesses, due to give evidence on behalf of the NMC, who would be inconvenienced by an adjournment of these proceedings. The allegations in this case date back to March 2013 and the panel was mindful that any continued delay in these matters could further impact upon the witnesses recollection of events. The panel was satisfied that Miss Powell was aware of the hearing and that she had chosen not to attend. In all of the circumstances, the panel concluded that it was in the public interest to proceed, and that it would not be unfair to Miss Powell to hear the case in her absence. For all these reasons the panel determined to proceed in the absence of Miss Powell. Application to hear matters in private Ms Whiting made an application to hear matters concerning Miss Powell s health and personal circumstances, as and when they would arise in the hearing, in private. The panel accepted the advice of the legal assessor, who referred the panel to Rule 19 of the Rules, which governs public and private hearings: 19. (1) Subject to paragraphs (2) and (3) below, hearings shall be conducted in public. (3) Hearings other than those referred to in paragraph (2) above may be held, wholly or partly, in private if the Committee is satisfied (a) having given the parties, and any third party from whom the Committee considers it appropriate to hear, an opportunity to make representations; and (b) having obtained the advice of the legal assessor, that this is justified (and outweighs any prejudice) by the interests of any party or of any third party (including a complainant, witness or patient) or by the public interest. Page 5 of 64

6 The panel determined that Miss Powell s right to privacy in matters concerning her health and personal circumstances outweighed the general public interest. It therefore acceded to the application, only in relation to those matters relating to her health and personal circumstances. All other matters will be considered in public. Charges read That you, whilst employed at the University Hospitals of Leicester NHS Trust Children s Hospital between 12 November 2012 and 25 February 2014, failed to demonstrate the standards of knowledge, skill and judgement required to practise without supervision as a Band 5 Children s Nurse in that: 1. On the May 2013 night shift, you: 1.1 used your mobile phone in sight of patients on one or more occasions. 1.2 left the ward during a break without providing any/any sufficient handover. 2. On 10 March 2013, you did not adequately maintain Patient B s fluid balance. 3. On 18 March 2013, you administered the wrong dose of IV antibiotic to Patient C. 4. On 7 April 2013, you did not administer the following prescribed medications to Patient D: 4.1 Captopril. 4.2 Frusemide. 5. On 12 April 2013, you: Page 6 of 64

7 5.1 did not check Patient E s blood sugar between approximately 8am and midnight. 5.2 Did not complete Patient E s fluid balance chart. 6. On 18 and 19 May 2013, you: 6.1 did not give a sufficiently detailed handover in respect of Patients D, E and F. 6.2 did not complete/complete in sufficient detail care plans in respect of Patients D and E. 6.3 did not complete/complete in sufficient detail observation charts in respect of Patients D, E and F. 7. On 25 May 2013, you administered the incorrect IV fluids to Patient H, in that you administered 0.9% sodium chloride and 5% dextrose when you should have administered 0.9% sodium chloride, 5% dextrose and 10mmol potassium. 8. On 30 May 2013, you recorded the incorrect IV fluid rate on Patient I s fluid balance chart, in that you recorded it as 26 mls an hour when in fact it was running at 126 mls per hour. 9. On 1 August 2013, you did not to respond appropriately when Patient J was desaturating. 10. On 10 August 2013, you drew up Clarithromycin for Patient J, when Co- Amoxiclav was prescribed. 11. On 16 August 2013, you did not recognise that Patient L s eye drops were out of date. 12. On 17 August 2013, you: Page 7 of 64

8 12.1 did not recheck Patient M s temperature and/or take a full set of observations when you had been instructed to do so did not communicate appropriately with Patient M and/or their mother. 13. On 23 August 2013, you did not respond appropriately when Patient N was having a seizure. 14. On 24 August 2013, you: 14.1 drew up the wrong strength of Nystatin Suspension for Patient O did not Nystatin Suspension was to be administered via nasogastric tube. 15. On 24 August 2013, whilst caring for Patient P, you: 15.1 did not notice that Patient P was not breathing did not seek assistance when Patient P s saturation was alarming. 16. On 25 August 2013 you, did not administer a prescribed dose of Nystatin to Patient Q. AND in light of the above, your fitness to practise is impaired by reason of your lack of competence or, in the alternative, your misconduct Application to amend charges 3, 7 and 14.2 Ms Whiting made an application to amend charges 3, 7 and 14.2 to read as follows: 3. On 16 March 2013, you administered the wrong dose of IV antibiotic to Patient C. Page 8 of 64

9 7. On 24 May 2013, you administered the incorrect IV fluids to Patient H, in that you administered 0.9% sodium chloride and 5% dextrose when you should have administered 0.9% sodium chloride, 5% dextrose and 10mmol potassium. 14. On 24 August 2013, you: 14.2 did not recognise Nystatin Suspension was to be administered via nasogastric tube. Ms Whiting submitted that the proposed amendments did not alter the substance of the charges, but simply clarified the true nature of those charges. She contended that the amendments would not cause Miss Powell any injustice or prejudice. The panel accepted the advice of the legal assessor, who referred the panel to Rule 28 of the Rules: 28. (1) At any stage before making its findings of fact the Conduct and Competence Committee, may amend (a) the charge set out in the notice of hearing; or (b) the facts set out in the charge, on which the allegation is based, Unless, having regard to the merits of the case and the fairness of the proceedings, the required amendment cannot be made without injustice. Miss Powell was not in attendance at this hearing, nor was she represented. She was, therefore, unaware of the proposed amendments. That being said, the panel was satisfied that the amendments were not substantive in nature and did not, in any way, alter or impact upon the gravamen of the charges. The panel was further satisfied that the nature of the allegations were not unfamiliar to Miss Powell. Page 9 of 64

10 In respect of charges 3 and 7, the charges as presently drafted referred to the dates the alleged incidents were reported. The proposed amendments however identified the dates that the alleged incidents were said to have occurred. In respect of charge 14.2, the panel was of the view that the addition of the word recognise simply corrected a technical deficiency in the charge. The panel was satisfied that the amendments would not cause Miss Powell any unfairness or prejudice. It therefore acceded to Ms Whiting s application. Accordingly, charges 3, 7 and 14.2 were amended as proposed. Application to amend charge 10 Ms Whiting made an application to amend charge 10 to read as follows: 10. On 10 August 2013, you drew up Clarithromycin for a patient, when Co- Amoxiclav was prescribed. Ms Whiting submitted that there had been some difficulty in ascertaining the identity of the patient concerned in respect of this allegation. In order to address that difficulty, she invited the panel to amend the charge to refer to a patient. She submitted that the proposed amendment was not substantive in nature and that it would not cause Miss Powell any injustice or unfairness. The panel accepted the advice of the legal assessor, who referred the panel to Rule 28 of the Rules. Miss Powell was not in attendance at this hearing, nor was she represented. She was, therefore, unaware of the proposed amendments. That being said, the panel was satisfied that the amendment was not substantive in nature but rather it simply addressed the difficulty in ascertaining the identity of the patient in question. The panel was further satisfied that the nature of the allegation was not unfamiliar to Miss Powell. Page 10 of 64

11 The panel determined that the amendment would not cause Miss Powell any unfairness or prejudice. It therefore acceded to Ms Whiting s application. Accordingly, charge 10 was amended as proposed. Application to amend charge 6 Ms Whiting made an application to amend charge 6. She submitted that the schedule of anonymity adduced in the hearing referred to two different patients as Patient D, and a further two different patients as Patient E. She therefore applied to amend charge 6 to reflect the true identity of the patients. In making the application Ms Whiting guided the panel to various documents in the bundle which identified the patients names. She proposed that charges 4 and 5 remain the same, as the referred to the first of the two patients identified as Patient D and Patient E. Ms Whiting invited the panel to amend charge 6 to read as follows: 6. On 18 and 19 May 2013, you: 6.1 did not give a sufficiently detailed handover in respect of three patients. 6.2 did not complete/complete in sufficient detail care plans in respect of Patients D2 and E did not complete/complete in sufficient detail observation charts in respect of Patients D2, E2 and F. Ms Whiting acknowledged the lateness of her application, which followed the presentation of a schedule of anonymity. Ms Whiting submitted that there would be no injustice in making the amendments to charge 6 at this late stage. She contended that the proposed amendment properly reflected the true identity of the patients and would allow the panel fully to consider the Page 11 of 64

12 allegations. She further submitted that Miss Powell was already aware of the nature of the allegations and that the application would not cause any injustice or unfairness. The panel accepted the advice of the legal assessor, who referred the panel to Rule 28 of the Rules. Miss Powell was not in attendance at this hearing, nor was she represented. She was, therefore, unaware of the proposed amendments. This application was made at a late stage in the NMC s case on facts. The panel considered that there was, therefore, some onus upon the NMC to demonstrate that amending charges this late in the proceedings did not involve injustice. In respect of charge 6.1, the panel was not satisfied that the NMC has done so. The panel was concerned that Ms Whiting s proposed amendment to charge 6.1 widened the scope of the allegation to three unknown patients, thereby constituting a substantive change to the allegation. Ms 2 had attended the hearing already and gave oral evidence in respect of charge 6. Ms Whiting did not seek to present the schedule of anonymity at that stage, so as to allow Ms 2 to confirm which patients she referred to when speaking to the allegation. The panel was not satisfied that the proposed amendment could be made without any injustice or unfairness to Miss Powell. In those circumstances, the panel rejected Ms Whiting s application to amend charge 6.1. In respect of charges 6.2 and 6.3, the proposed amendments simply clarified the distinction between the patients named in charges 4 and 5 as against charge 6. Further, the proposed amendments brought in line the wording of the allegation with the evidence as contained in the bundle before it and in the schedule of anonymity. The panel was satisfied that the amendments would not cause Miss Powell any unfairness or prejudice. It therefore acceded to Ms Whiting s application. Accordingly, charges 6.2 and 6.3 were amended as proposed. Page 12 of 64

13 Proposed amendment to charge 9 The panel, of its own volition, considered amending charge 9 to remove the word to which was clearly superfluous. Ms Whiting made no objection. The panel accepted the advice of the legal assessor, who referred the panel to Rule 28 of the Rules. The panel was satisfied that the amendment would cause Miss Powell no injustice or unfairness. Accordingly, charge 9 was amended as proposed. Charges as amended That you, whilst employed at the University Hospitals of Leicester NHS Trust Children s Hospital between 12 November 2012 and 25 February 2014, failed to demonstrate the standards of knowledge, skill and judgement required to practise without supervision as a Band 5 Children s Nurse in that: 1. On the May 2013 night shift, you: 1.1 used your mobile phone in sight of patients on one or more occasions. 1.2 left the ward during a break without providing any/any sufficient handover. 2. On 10 March 2013, you did not adequately maintain Patient B s fluid balance. 3. On 16 March 2013, you administered the wrong dose of IV antibiotic to Patient C. 4. On 7 April 2013, you did not administer the following prescribed medications to Patient D: Page 13 of 64

14 4.1 Captopril. 4.2 Frusemide. 5. On 12 April 2013, you: 5.1 did not check Patient E s blood sugar between approximately 8am and midnight. 5.2 Did not complete Patient E s fluid balance chart. 6. On 18 and 19 May 2013, you: 6.1 did not give a sufficiently detailed handover in respect of Patients D, E and F. 6.2 did not complete/complete in sufficient detail care plans in respect of Patients D2 and E did not complete/complete in sufficient detail observation charts in respect of Patients D2, E2 and F. 7. On 24 May 2013, you administered the incorrect IV fluids to Patient H, in that you administered 0.9% sodium chloride and 5% dextrose when you should have administered 0.9% sodium chloride, 5% dextrose and 10mmol potassium. 8. On 30 May 2013, you recorded the incorrect IV fluid rate on Patient I s fluid balance chart, in that you recorded it as 26 mls an hour when in fact it was running at 126 mls per hour. 9. On 1 August 2013, you did not respond appropriately when Patient J was desaturating. 10. On 10 August 2013, you drew up Clarithromycin for a patient, when Co- Amoxiclav was prescribed. Page 14 of 64

15 11. On 16 August 2013, you did not recognise that Patient L s eye drops were out of date. 12. On 17 August 2013, you: 12.1 did not recheck Patient M s temperature and/or take a full set of observations when you had been instructed to do so did not communicate appropriately with Patient M and/or their mother. 13. On 23 August 2013, you did not respond appropriately when Patient N was having a seizure. 14. On 24 August 2013, you: 14.1 drew up the wrong strength of Nystatin Suspension for Patient O did not recognise Nystatin Suspension was to be administered via nasogastric tube. 15. On 24 August 2013, whilst caring for Patient P, you: 15.1 did not notice that Patient P was not breathing did not seek assistance when Patient P s saturation was alarming. 16. On 25 August 2013 you, did not administer a prescribed dose of Nystatin to Patient Q. AND in light of the above, your fitness to practise is impaired by reason of your lack of competence or, in the alternative, your misconduct Determination on facts Page 15 of 64

16 The allegations related to a period of time when Miss Powell was employed as a band 5 nurse by the University Hospitals of Leicester NHS Trust ( the Trust ). Miss Powell was employed at the Children s Hospital ( the Hospital ) from 12 November 2012 until February Miss Powell completed a supernumerary period when she commenced her employment which included training, supervision and assessments. Following completion of her initial supernumerary period, Miss Powell made a number of clinical errors. The allegations are as follows: Charge 1 During the night shift of 16/17 May 2013 it was identified that Miss Powell had her mobile phone in her uniform pocket throughout the course of the shift and used it numerous times, in sight of patients, to send text messages. During the local investigation and in the disciplinary hearing, Miss Powel admitted that she had used her phone to send text messages whilst in the drug preparation area, between jobs and in sight of patients. She also acknowledged that she had been sending text messages whilst feeding a baby at the nursing station, which was in full view of the ward. Concerns were also raised that Miss Powell left the premises whilst on her break for approximately 45 minutes to drive a friend home, without handing over any of her patients and not having completed any nursing evaluations for her patients. Charge 2 A concern was raised by a colleague about the care Miss Powell had provided in relation to maintaining fluid balance of a child, Patient B, requiring gastronomy feeds. Charge 3 Page 16 of 64

17 An intravenous ( IV ) drug error occurred on 16 March 2013, whereby the wrong dose of IV antibiotic was administered by Miss Powell to Patient C. Charge 4 Patient D did not receive prescribed doses of Captopril and Frusemide when Miss Powell was responsible for their care. Charge 5 Patient E (a child) was admitted with viral encephalitis and low blood sugar. Emergency treatment was provided on admission. The patient was admitted to Ward 28 at around 13:00. Miss Powell did not check Patient E s blood sugar between 08:00 and midnight and did not complete the fluid balance chart. Charge 6 Concerns were raised about the poor quality of Miss Powell s handovers and her documentation, specifically on 18 and 19 May Charge 7 Miss Powell made a drug error on 24 May A bag of IV fluid in situ was incorrect and did not correlate with the prescription for Patient H. Charge 8 Miss Powell made a drug error on 30 May She was supervised setting up an antibiotic infusion by another staff nurse. The IV fluids already in situ were switched off for the duration of the antibiotic infusion. When the infusion had been completed the intravenous fluids were reconnected and the pump restarted. Miss Powell checked and recorded the rate on the fluid balance chart as 26 mls an hour when in fact it was Page 17 of 64

18 running at 126 mls per hour. The error was identified following handover when the wrong rate had been running for approximately two hours. Due to the continued concerns about Miss Powell s clinical skills, a formal capability process was commenced and she became supernumerary again on 31 May Miss Powell was suspended from administering IV medications or acting as second checker to any IV medications. Formal performance management was commenced and her practice was thereafter supervised at all times by another nurse. Miss Powell was transferred to work in a supernumerary capacity on Ward 14 in July 2013 from Ward 28. Restrictions were placed on her duties and clear objectives were set. It was agreed that she would have to go through drug assessments and competencies again to ensure that she was safe. Two mentors were appointed, Ms 5 and Ms 7, to supervise Miss Powell. Further errors occurred during August Charge 9 On 1 August 2013 Miss Powell informed a staff nurse, Ms 3, that Patient J was desaturating. Ms 3 went into the patient s room and noted that the patient was desaturating and provided treatment with oxygen which corrected the problem. When interviewed about this allegation Miss Powell recalled the incident but stated that she was unsure whether, in a supernumerary capacity, she was allowed to enter the patient s room and provide care. She reflected that she should have gone into the room and was able to explain what a trained member of staff should have done in the circumstances. Charge 10 Miss Powell was involved in a near miss medication error on 10 August 2013 when she drew up the wrong oral antibiotic, Clarithromycin, when the prescription was in fact for Page 18 of 64

19 Co-Amoxiclav. This error was drawn to her attention by the nurse who checked the medication. When interviewed about this allegation Miss Powell was unable to identify why it had happened and was unable to say how she would change her practice to prevent a similar incident from occurring. Charge 11 On 16 August 2013, Miss Powell did not recognise that eye drops for Patient L were out of date by nearly three months. Charge 12 Miss Powell failed to recheck a child s (Patient M s) temperature or identify that their condition had deteriorated on the night shift of 17 August On admission, Patient M was found to have a borderline temperature. Miss Powell was advised by her mentor, Ms 5, to recheck the patient s temperature in an hour. The patient was placed on a saturation monitor which began to alarm later on in the shift. Miss Powell stated that this was due to a high heart rate and movement of the patient. The alarm self-resolved but this repeated on 2-3 occasions. Miss Powell took no further action. When Ms 5 reassessed the patient she identified that the patient was tachycardic, tachypnoeic and had increased respiratory effort. The patient s temperature was checked and it was found that the patient was pyrexial, which would have been a key contributing factor to why the patient was becoming unwell. Miss Powell admitted that she had not checked the patient s temperature. Charge 13 Miss Powell was involved in an incident where she did not respond appropriately to a child, Patient N, having a seizure on 23 August Patient N was experiencing facial twitching when Miss Powell walked into his cubicle. Miss Powell was asked by a healthcare assistant, Mrs 6, whether this was normal and if Patient N was fitting. Miss Powell responded that she was not sure and merely observed. Patient N s arm then Page 19 of 64

20 began to jerk and Mrs 6 asked whether she should alert another nurse. When asked about the incident, Miss Powell stated that she knew she should have alerted someone sooner. Charge 14 Miss Powell was involved in a near miss medication error on 24 August 2013 when she drew up the wrong strength of mouthwash for Patient O (the strength of the prescription did not correspond with the bottle). Furthermore she did not recognise that the prescription had been written up as requiring the mouthwash to be administered via a nasogastric tube, when it should have been administered orally. Charge 15 Miss Powell did not respond to a deteriorating child, Patient P, on 24 August She failed to recognise that the patient was not breathing when she attempted to feed him. When questioned she stated that she thought the patient was sleepy and so removed the bottle from his mouth and tried to wake him. She accepted that, on reflection, she should have called for help and could have activated the emergency buzzer. Charge 16 Miss Powell failed to administer a dose of Nystatin on 25 August 2013 to Patient Q. When this omission was identified it was too late for the dose to be given retrospectively because in fact the next dose was due. The accumulation of these events led to Miss Powell s superiors withdrawing her from delivering care and to remain at work in a supernumerary capacity undertaking the role of a healthcare assistant until the outcome of a further disciplinary hearing. Page 20 of 64

21 In reaching its determination on facts, the panel had regard to all the evidence adduced, including all the exhibited documents. It heard submissions from Ms Whiting on behalf of the NMC. It accepted the advice of the legal assessor. The panel was aware that the burden of proof rests with the NMC and that the facts must be proved on the balance of probabilities (civil standard of proof). The panel heard oral evidence, on behalf of the NMC (together with their written statements), from the following witnesses: Ms 1, Ward Sister of Ward 28 at the material time; Ms 2, Staff Nurse on Ward 28 at the Hospital; Ms 3, Staff Nurse on Ward 14 at the Hospital at the material time; Ms 4, Ward Sister (Ward 14) at the Hospital; Ms 5, Staff Nurse on Ward 14 at the Hospital; Mrs 6, Nursery Nurse at the Hospital; and Ms 7, Staff Nurse on Ward 14 at the Hospital. Miss Powell was not in attendance at this hearing and she had not provided any written responses to the allegations. The panel, however, had regard to Miss Powell s accounts given at a number of investigatory interviews, her statements and reflective pieces, all contained in the bundle of documents presented at the start of the hearing. The panel made the following findings of fact in respect of the charges: That you, whilst employed at the University Hospitals of Leicester NHS Trust Children s Hospital between 12 November 2012 and 25 February 2014, failed to demonstrate the standards of knowledge, skill and judgement required to practise without supervision as a Band 5 Children s Nurse in that: 1. On the May 2013 night shift, you: Page 21 of 64

22 1.1 used your mobile phone in sight of patients on one or more occasions. 1.2 left the ward during a break without providing any/any sufficient handover. The panel had sight of a handwritten statement from Ms 8, Healthcare Assistant, signed and dated 31 May Ms 8 reported that in the early hours of the morning (17 May 2013) Ms 9, Staff Nurse, had informed her that Miss Powell left the ward for her break. Miss Powell returned to the ward approximately one hour later. According to Ms 8, Miss Powell didn t seem to acknowledge that what she had done was wrong and dangerous. Ms 8 also reported that she had noticed Natalie was constantly on her phone, at one point she had brought a baby out to feed at the desk and was still constantly on her phone, even with parents walking past During the course of an investigatory interview dated 31 May 2013, Ms 9 stated that she had noticed that Miss Powell was constantly texting from the start of her shift. She told me that she was sending texts to a friend that she had recently met. At 3.00am Natalie asked if she could take a break and she said she would be going out She said she wanted to take her friend home She said Are you ok with that?, I said you can have your break. Ms 9 said that she had ensured that she had Miss Powell s mobile number so she could contact her if necessary. Ms 9 stated in that interview that Miss Powell did update her on her patients before she left the premises. The panel also had sight of a typed statement from Ms 9, signed and dated 10 June Ms 9 reported that on the night shift of 16/17 May 2013, at approximately 04:00, Miss Powell had requested to take her break. She informed Ms 9 that she would be leaving the premises to take someone home. Ms 9 informed Miss Powell that this was not a good idea as she was concerned about Miss Powell s personal safety and because the shift could be compromised if Miss Powell returned late from her break. Page 22 of 64

23 Miss Powell insisted that she would be less than an hour. According to Ms 9, Miss Powell was determined to leave and had the arrangements made. Miss Powell was invited to an investigatory interview on 31 May During the course of that interview, Miss Powell explained that she had asked Ms 9 if she could leave the ward to drive a friend home, to which Ms 9 replied yes. Miss Powell stated that she was not aware at the time that Ms 9 had an issue with her request. She said that she left the ward at 04:00 and returned approximately 45 minutes later. Upon her return, Ms 9 told her that she was glad that she was back and that she was worried about Miss Powell s safety. Miss Powell confirmed that she did not give a patient handover before she left the ward and that she had not completed her clinical notes at that point. She also acknowledged that it was unsafe for her to leave Ms 9 on her own with 14 patients. During the course of that interview, Miss Powell confirmed that she was aware that the Trust s policy stipulated that staff members were not allowed to keep their mobile phone on their person. She admitted that she normally kept her mobile in her trouser pocket. She also admitted that, on the shift in question, she had used her mobile phone to send text messages in the drug area, in sight of patients, and that she possibly may have used her mobile phone whilst feeding a baby. She acknowledged that she did not consider the possibility of cross-infection/contamination when looking after patients whilst using her mobile phone. She also acknowledged that her conduct was unprofessional and in breach of her contractual obligations. On the basis of the evidence before it, including Ms 8 s statement, Ms 9 s account at the investigatory interview on 31 May 2013 and Miss Powell s responses in the investigatory interview on 31 May 2013, the panel found charge 1.1 proved. In respect of charge 1.2, the panel had regard to Ms 9 s response in the investigatory interview when she said that Miss Powell did update her on her patients before she left the premises. The evidence before the panel therefore suggested that Miss Powell did provide a handover to Ms 9 before she left the premises. There was no evidence Page 23 of 64

24 adduced by the NMC as to the adequacy or otherwise of that handover. Charge 1.2 was therefore found not proved. 2. On 10 March 2013, you did not adequately maintain Patient B s fluid balance. The panel had sight of an from Ms 2, Staff Nurse, dated 12 March In that Ms 2 reported the following: Received handover from [Miss Powell] for [Patient B] complex child on NG feeds, had only received 300mls of fluid throughout the day of 100mls three times with six hour intervals, patient had only passed urine once and was on laxatives which can have side effects of dehydration. Patient had detailed assessment, mum wanted milk feeds reducing as had previously not tolerated. On speaking to mum on the phone [Patient B] usually had water or juice bolus between feeds and was surprised these had not been given. I made plan overnight to give bolus of water ever [sic] three hours to hydrate [Patient B] The panel had sight of Patient B s clinical progress and evaluation sheet in which Ms 2 had recorded, at 05:40 on 11 March 2013, that was not happy with fluid intake so discussed with mum and decided to give 150mls of water every three hours overnight. Ms 2 told the panel that 300mls of fluid to Patient B, in the light of his needs and conditions, was completely inadequate. Miss Powell completed an internal written reflective statement in relation to this incident. In that statement she identified the following learning points: to ensure that she does a nutritional assessment before decision making; to ensure the care given is holistic and beneficial to the patient; and to ensure that she used all the information in clinical notes to determine a patient s fluid requirements. Page 24 of 64

25 The panel found Ms 2 to be a reliable and credible witness and the panel accepted her evidence. On the basis of her evidence, together with the written reflections of Miss Powell, the panel was satisfied on the balance of probabilities that charge 2 was found proved. 3. On 16 March 2013, you administered the wrong dose of IV antibiotic to Patient C. Ms 1 said that an intravenous ( IV ) drug error occurred on 16 March 2013, whereby the wrong dose of IV antibiotic was administered by Miss Powell to Patient C. The panel had sight of a DATIX incident form dated 18 March 2013, completed in relation to an incident which occurred on 16 March The following description of the incident was recorded: two day old baby admitted with? sepsis. Prescribed Cefotaxime and Amoxicillin QDS. 1 st dose given on CAU, 2 nd dose on ward 28 then identified that wrong protocol being followed and in fact the antibiotics should only be given twice a day in this age group. Miss Powell completed an internal written reflective statement (dated 27 March 2013) in relation to this incident. In that statement, Miss Powell identified that the IV drug was prescribed wrong. One was QDS and the other TDS. Both drugs should have been BD. The drug was given on that prescription but both had only been given once previously. She stated that the wrong section of the drug monograph had been checked the baby was one day old and should have been on the neonatal policy the wrong policy had been followed. She said that as a result of the incident, she had learned to check policy properly, don t feel rushed by other staff members and don t be afraid to speak up if feeling rushed. She went on to say that the incident occurred as a result of nerves. She explained that the member of staff who had been supervising her had talked her through the procedure. She stated that she should have taken more time to consider the policy, checked the dose independently, and should not have rushed nor been afraid to ask for time to work out the correct dose. Page 25 of 64

26 The panel noted that no direct evidence had been adduced to demonstrate that Miss Powell had in fact administered the wrong dose of IV antibiotic to Patient C. The panel had regard to the DATIX incident form in which the result of the incident was described as a near miss. The Immediate action taken was reported as Drs informed. Prescription cancelled and re written. On this basis, the panel was not satisfied that, on the balance of probabilities, the allegation was proved. Accordingly, the panel found charge 3 not proved. 4. On 7 April 2013, you did not administer the following prescribed medications to Patient D: 4.1 Captopril. 4.2 Frusemide. The panel had sight of a DATIX incident form dated 11 April 2013, completed in relation to an incident which occurred on 7 April The following description of the incident was recorded: At approx. 10:00 when [staff nurse] was checking through patients drug chart noticed 05:00 and 06:00 medicines had not been given on the night shift by [Miss Powell]. The medicines in question were identified as Captopril and Frusemide. The panel was referred to a record of communication on 9 April 2013, in which it was recorded by Ms 1 that Natalie feels disappointed with herself regarding recent incident missing doses of Captopril and Frusemide Natalie able to reflect and explain how she will ensure drugs not missed in future Miss Powell completed an internal written reflective statement (dated 9 April 2013) in relation to this incident. In that statement Miss Powell described the incident as a complete accident and that there were no factors affecting my decision making. She said that she should have thoroughly checked my charts at the beginning and end of my shift to ensure that I had not missed anything. She described feeling very Page 26 of 64

27 disappointed and upset with herself. She recognised that she had risked the patient having problems with blood pressure and fluid output. She said that she was now more cautious about checking charts at the beginning and end of her shift, as well as double checking charts during the shift. On the basis of the evidence before it, and on the balance of probabilities, the panel found charge 4 proved. 5. On 12 April 2013, you: 5.1 did not check Patient E s blood sugar between approximately 8am and midnight. 5.2 Did not complete Patient E s fluid balance chart. Patient E was admitted with viral encephalitis and low blood sugar. Emergency treatment was provided on admission. The patient was admitted to Ward 28 at around 13:00. A DATIX incident form dated 15 April 2013 was completed in relation to these matters. The following description of the incident was recorded: Child with viral encephalitis. Low blood sugars on admission to CAU treated. Transferred to ward 28. Plan of care to monitor input / output The Lessons learned was identified as follows: To ensure that where indicated that all fluid input and output is monitored and recorded The panel had sight of Patient E s daily fluid balance chart, in which a doctor had recorded, at 04:00, that the patient s fluid input and output were to be monitored. Miss Powell completed an internal written reflective statement (dated 6 May 2013) in relation to these matters. In that statement, she recorded that I acted as I did as I have been handed over that a blood sugar reading had been done at 2pm. The patient in question was being taken for a CT scan and was to be sedated. I feel this may have Page 27 of 64

28 affected my decision making as I was prioritising the scan/sedation over the fluid balance overall. I should have taken the time to look at the documentation properly to be aware that a blood sugar had not been recorded and re-checked it to air [sic] on the side of caution. Miss Powell indicated that she should have been more thorough when reading the patient s notes and re-checked the blood sugar levels. She identified, in the statement, that the effects of her omissions were that Patient E s blood sugar levels were low and that IV fluids had to be commenced. However, no direct evidence had been adduced by the NMC to the effect that Miss Powell did not check Patient E s blood sugar between 8am and midnight. Equally there was no direct evidence that she was responsible for the completion of Patient E s fluid balance chart. The NMC did not specify the times that Miss Powell was on shift, or that she was indeed the nurse responsible. Therefore, on the balance of probabilities the panel found charge 5 not proved. 6. On 18 and 19 May 2013, you: 6.1 did not give a sufficiently detailed handover in respect of Patients D, E and F. 6.2 did not complete/complete in sufficient detail care plans in respect of Patients D2 and E did not complete/complete in sufficient detail observation charts in respect of Patients D2, E2 and F. The panel was referred to an from Ms 2 to Ms 1, dated 19 May 2013, in which she raised the following concerns: as requested regarding [Miss Powell] handover on 18/5/13 and 19/5/13 Needing to prompt for information on patients handover Page 28 of 64

29 Paperwork not completed with all details for several patients e.g. no risk assessment, Asked where this was. Fluid charts and diabetic charts with no patient details also not fully completed, pointed this out on both shifts On 18/5/13 Baby handed over not charting feeds as no concerns, mum worried and concerned needing support and reassurance. Assessment and care plan with some pages with no patient details, pointed this out. Care plans not in detail very minimal information, observed after handover/ Two patients with only HR and temp for obs no RR and sao2 also not all observations had tick boxes complete or initials, observed after handover. Diabetic patient handed over BM done but not supervised as should have been then asked patient what this was without checking monitor, explained this needed supervising. In her written NMC witness statement, Ms 2 explained that she had some concerns about Miss Powell s handovers. She recalled two occasions, on 18 and 19 May 2013, when Miss Powell needed to be prompted for information during her handover. Ms 2 said that paperwork was not completed with all details for several patients, including no risk assessments, and documents were not in the relevant folders. She further stated that there were fluid charts and diabetic charts with no patient details and not fully completed. Ms 2 said that she pointed this out to Miss Powell during both handovers. Ms 2 recalled that on 18 May 2013, Miss Powell handed over that for one patient she was not charting feeds and that there were no concerns. Ms 2 stated that the patient s mother was worried and concerned, needing support and reassurance. There were assessments and care plans which had no patient details recorded on them. The care plans completed by Miss Powell had very minimal detail. Observations were poorly documented ; not all observations had tick boxes or initials to show that they had been completed. Ms 2 further recalled that a diabetic patient on the ward was to be supervised but that Miss Powell had not done so. Miss Powell then asked the patient Page 29 of 64

30 what her blood sugar was rather than checking the monitor or carrying out her own assessment. Miss Powell was questioned about these matters during the course of her investigatory interview on 2 July When it was put to her that concerns had been raised that paperwork had not been completed and that full sets of observations had not been conducted, Miss Powell replied I don t know. In respect of charge 6.1, the only evidence before the panel was from Ms 2 who indicated that Miss Powell needed prompting for information on patients handovers. Ms 2 was unable to recall which patients this incident related to. There was no other documentary evidence to support this charge. The panel was not satisfied that the NMC had discharged the burden of proof to the requisite standard. Accordingly, the panel found charge 6.1 not proved. In respect of charge 6.2, the panel had sight of Patient D2 s care plan in which Miss Powell made the following entry on 18 May 2013, Do 4 hourly observations. Monitor input + output. Miss Powell provided no further details in her notes or explanation why certain actions were to be taken. The panel was referred to Patient E2 s care plan in which Miss Powell made the following entry on 18 May 2013, 2-4 hourly observations. Medications as prescribed. Feeding orally monitor feeds. Miss Powell provided no further details in her notes or explanation why certain actions were to be taken. There was evidence before the panel that Miss Powell had recorded information on the care plans for Patient D2 and Patient E2. No evidence was adduced, however, as to what information was required in order to complete the care plans in sufficient detail. The panel also noted that the level of detail and quality of the entries made by Miss Powell was similar to, and reflected in, the entries made by other members of staff in the same care plans. Page 30 of 64

31 On the balance of probabilities the panel therefore found charge 6.2 not proved. In respect of charge 6.3, the panel had sight of Patient D2 and Patient E2 s paediatric observation charts. The panel noted that the charts were complete but for the missing pain scores at 06:00. No evidence was adduced that Miss Powell was responsible for completing the pain scores at that time. In respect of Patient F s paediatric observation chart, the chart was again complete but for a missing pain score at 22:00. No evidence was adduced that Miss Powell was responsible for completing the pain score at that time. On the balance of probabilities the panel therefore found charge 6.3 not proved. 7. On 24 May 2013, you administered the incorrect IV fluids to Patient H, in that you administered 0.9% sodium chloride and 5% dextrose when you should have administered 0.9% sodium chloride, 5% dextrose and 10mmol potassium. A DATIX incident form dated 1 June 2013 was completed in relation to this incident. The following description of the incident was recorded: Patient on IV fluids when bag checked after shift swap noticed bag running not bag prescribed. Bag of fluid running was 0.9% sodium chloride and 5% dextrose, bag prescribed was 0.9% sodium chloride and 5% dextrose with 10mmol of potassium. Miss Powell was questioned about this incident during the course of her investigatory interview on 2 July She said that she was responsible for caring for Patient H and had been told that the fluids did not need to be changed but she had noticed potassium in the fluid. She stated that she thought she had seen red writing on the bag and assumed that it should be changed. She and another staff nurse then changed the bag. She confirmed that the bag was not checked properly. Whilst Miss Powell confirmed that the bag was not checked properly, the panel noted that there was no other evidence in support of this charge. Indeed the panel noted that Page 31 of 64

32 there was another member of staff involved in changing the bag and it was not clear to the panel which member of staff was responsible for the administration. The panel was not satisfied in the light of this evidence that the NMC had discharged its burden to the requisite standard and accordingly found charge 7 not proved. 8. On 30 May 2013, you recorded the incorrect IV fluid rate on Patient I s fluid balance chart, in that you recorded it as 26 mls an hour when in fact it was running at 126 mls per hour. Miss Powell was supervised setting up an antibiotic infusion by another staff nurse. The IV fluids already in situ were switched off for the duration of the antibiotic infusion. When the infusion had been completed the intravenous fluids were reconnected and the pump restarted. Miss Powell checked and recorded the rate on the fluid balance chart as 26 mls an hour when in fact it was running at 126 mls per hour. The error was identified following handover when the wrong rate had been running for approximately two hours. During the course of the investigatory interview, dated 31 May 2013, Ms 9 stated that she had set the IV pump at 26 mls. She confirmed that both she and Miss Powell had checked the rate and that they had drawn up the IV together. She said that Miss Powell had signed the drug chart to say that the correct dosage was 26 mls. A DATIX incident form dated 1 June 2013 was completed in relation to this incident. The following description of the incident was recorded: On checking a patients hourly IV rates and total towards start of shift I noticed the rate was incorrect. The drip rate read 126mls/hr when the rate prescribed was 26mls/hr. It went on to state that IV pump sent to medical physics to download and check where error occurred incorrect rate, unsure if nursing error or pump fault. Miss Powell was questioned about this incident during the course of her investigatory interview on 2 July She said that she had thought that she checked the IV fluid Page 32 of 64