Conduct and Competence Committee Substantive Hearing 6 9 March 2017 Nursing and Midwifery Council, 2 Stratford Place, Montfichet Road, London, E20 1EJ

Transcription

1 Conduct and Competence Committee Substantive Hearing 6 9 March 2017 Nursing and Midwifery Council, 2 Stratford Place, Montfichet Road, London, E20 1EJ Name of Registrant Nurse: Gofaone Makuku NMC PIN: 04A0079O Part(s) of the register: Registered Nurse Sub Part 1 Adult Nursing 7 January 2004 Area of Registered Address: England Type of Case: Misconduct Panel Members: Louise Rose (Chair Lay member) Christine Callender (Registrant member) Richardo Childs (Lay member) Legal Assessor: Lachlan Wilson Panel Secretary: Charlotte Richardson Registrant: Present and represented by David Claxton, instructed by the Royal College of Nursing (RCN) Nursing and Midwifery Council: Represented by Ben Zurawel, counsel, instructed by NMC Regulatory Legal Team. Facts proved: 3/4, 7c Facts proved by admission: 1, 5, 6, 7a, 8 Facts not proved: 2, 7b Fitness to practise: Sanction: Interim Order: Impaired Caution Order 18 months N/A 1

2 Details of charge: That you, a registered nurse and whilst employed as a Senior Carer with Gold Care Homes ( the Company ) in St Katharine s House ( the Home ): 1. On or around 21 May 2014 incorrectly completed Resident A s care record: was washed and dressed this morning, skin and pressure areas intact but vulnerable, when this care had not been provided to Resident A. 2. Your actions at charge 1 above, were dishonest in that you intended to give a false impression that this care had been delivered. 3. On or around 11pm on 20 May 2014 slept whilst on duty, and/ or in the alternative 4. Took steps to facilitate sleeping whilst on duty May 2014, in that you: a. Remained in a chair b. Allowed the room to remain dark c. Did not speak to or communicate with colleagues or residents for several hours 5. Slept on shifts other than specified in charges 3 and/or Did not obtain written consent from the Company or the Home to undertake regular work with Abingdon Court Care Home. 7. In May 2014 also worked at Abingdon Court Care Home thereby placing residents at risk by; a. working shifts back to back b. leaving shifts early and arriving late in order to attend the follow on shift c. sleeping on shifts. 8. Did not obtain written authorisation from your manager at Abingdon Court Care Home to undertake work with the Home. And, in light of the above, your fitness to practise is impaired by reason of your misconduct 2

3 Decision and Reasons on application for special measures under Rule 23 Mr Zurawel made an application for special measures to be put in place during Ms 1 and Mr 2 s oral evidence. He asked the panel to allow screens to be used. Mr Zurawel informed the panel that Ms 1 and Mr 2 had indicated to him that they were very concerned about being in the same room as you, as they found you intimidating. Mr Zurawel submitted that the use of screens would be appropriate to ensure Ms 1 and Mr 2 are comfortable to allow them to give evidence to the best of their ability and better assist the panel. Mr Claxton did not oppose the application but questioned whether the use of screens was necessary. The panel accepted the advice of the legal assessor. The panel was mindful of Rule 23 of the Nursing and Midwifery (Fitness to Practise) Rules 2004 ( the Rules ) which states: (2) After seeking the advice of the legal assessor, and upon hearing representations from the parties, the Committee may adopt such measures as it considers necessary to enable it to receive evidence from a vulnerable witness. The panel appreciated that giving oral evidence at an NMC hearing is difficult and that it is important that witnesses are able to give their evidence as clearly and comfortably as possible so that the panel are able to make the best decision they can. The panel therefore determined that allowing the use of screens while Ms 1 and Mr 2 gave their evidence was a proportionate measure to take and allowed the application. 3

4 Decision and Reasons on application under Rule 19 During the hearing, Mr Zurawel made a request that parts of the hearing of your case be held in private. He informed the panel that he would need to refer to Ms 4 s ongoing health concerns and that these elements of the hearing should not be heard in public, as Ms 4 s right to privacy was not outweighed by any public or private interest in having such details publicly divulged. Mr Claxton did not oppose the application. The panel were mindful that while Rule 19 (1) provides, as a starting point, that hearings shall be conducted in public, Rule 19 (3) states that the panel may hold hearings partly or wholly in private if it is satisfied that this is justified by the interests of any party or by the public interest. Having heard that there will be reference to the health of a witness, the panel determined to hold such parts of the hearing in private. Decision and Reasons on application pursuant to Rule 31 The panel heard an application made by Mr Zurawel under Rule 31 of the Rules to allow the written statement of Ms 4 into evidence. He submitted that although the NMC had made efforts to ensure she was present, Ms 4 was unable to attend [PRIVATE]. Mr Zurawel submitted that the evidence of Ms 4 is relevant as she exhibits much of the documentation and conducted an investigation. He submitted that any unfairness to you as a result of not being able to cross-examine Ms 4 could be mitigated by the panel attaching appropriate weight to Ms 4 s evidence where there was substantial dispute. He submitted that the statement of Ms 4 should be admitted as hearsay evidence, in accordance with Rule 31 of the Rules. 4

5 Mr Claxton, on your behalf, did not oppose the application, but directed the panel to relevant case law which offers guidance on how to approach the decision and how to treat the evidence if it is admitted. The panel heard and accepted the legal assessor s advice on the issues it should take into consideration in respect of this application. Rule 31 provides that, so far as it is fair and relevant, a panel may accept evidence in a range of forms and circumstances, whether or not it is admissible in civil proceedings. The panel gave the application in regard to Ms 4 serious consideration. The panel noted that Ms 4 s statement had been prepared in anticipation of being used in these proceedings and contained the paragraph This statement is true to the best of my knowledge and belief and was signed by her. At the time of making her statement, Ms 4 had expressed a willingness to attend the hearing, and the NMC had expected that she would attend. Owing to very unfortunate circumstances beyond Ms 4 s and the NMC s control, her attendance is not possible on this occasion and not foreseeable at any point in the near future. There is a public interest, and it is in the interests of all parties, that this matter is concluded within a reasonable period, and an indefinite adjournment, which was potentially an alternative course of action, would not assist either party. The panel accepted that the evidence of Ms 4 was relevant to the case, as she exhibits documents which provide context and clarity to the case. The panel considered that the majority of the evidence exhibited by Ms 4 was documentary, and was satisfied that, as a professional panel, it could properly assess the evidence in the absence of crossexamination and attach appropriate weight to it as a consequence. The panel also noted that there was a public interest in the issues being fully explored, which supported the admission of Ms 4 s evidence into the proceedings. In these circumstances, the panel came to the view that the evidence contained in Ms 4 s witness statement was relevant, and that it would be fair to accept into evidence the 5

6 written statement of Ms 4, but the panel would give what it deemed appropriate weight once it had heard and evaluated all the evidence before it. Decision on the findings on facts and reasons In reaching its decisions on the facts, the panel considered all the evidence adduced in this case together with the submissions made by Mr Zurawel, on behalf of the NMC and those made by Mr Claxton on your behalf. The panel heard and accepted the advice of the legal assessor. The panel was aware that the burden of proof rests on the NMC, and that the standard of proof is the civil standard, namely the balance of probabilities. This means that the facts will be proved if the panel was satisfied that it was more likely than not that the incidents occurred as alleged. Background The charges arose whilst you were employed as a Senior Carer for the Company at the Home, working on the unit which cared for dementia patients. It is alleged that you undertook back to back 12 hour shifts while working at the Home and also at Abingdon Court Care Home, where you worked as a registered nurse, and thereby put residents at risk. It is specifically alleged that you left shifts early and arrived late in order to accommodate both working patterns and that, in your night shifts at the Home, you slept on duty. While working at the Home, it is also alleged that you pre-emptively completed a resident s care record to indicate that you had washed and dressed her and checked her skin and pressure areas, when the care had not been provided and that in doing so you were dishonest as you intended to give the false impression that this care had been given. It is further alleged that you slept on a specific shift, on the night of the 20/21 May 6

7 2014, or otherwise attempted to sleep, by sitting in a chair, in the dark, and without speaking or communicating to colleagues or residents for several hours. In reaching its decisions on the facts, the panel took into account all the oral and documentary evidence in this case. The panel heard oral evidence from 3 witnesses called on behalf of the NMC: Ms 1 and Mr 2, who were employed as carers at the Home and worked shifts with you, and Mrs 3, the manager of the Abingdon Court Care Home. The written statement of Ms 4, the manager of the Home at the time who conducted the Home s internal investigation, was also accepted into evidence. The panel also heard evidence from you under oath. The panel considered the oral evidence of the witnesses. In relation to Ms 1, the panel acknowledged that the allegations occurred nearly 3 years ago and that Ms 1 was being asked about one fairly unremarkable shift in a 23 year career at the Home. This inevitably explained a number of inconsistencies in Ms 1 s evidence and made her appear less reliable on matters where there had not been a contemporaneous account. The panel considered that Mr 2 was very fair when giving his evidence. He acknowledged when he was unable to remember certain things and was very clear about what he was and was not sure about. The panel considered him to be a credible and reliable witness who did his best to assist the panel. The panel also considered that Mrs 3 was a credible and reliable witness who was consistent, clear and honest when she could not remember certain details. The panel considered that she was very fair to you and provided valuable context to some of the allegations. The panel considered that you were clear about some aspects of your evidence, but inconsistent and contradictory in others. The panel accepted, as with the other 7

8 witnesses, that a significant amount of time has passed since the allegations, and that this situation is very stressful for you. It also noted that at times you found it difficult to understand some of the questions put to you. At the start of this hearing you admitted charges 1, 5, 6, 7a and 8. These were therefore announced as found proved by way of admission. The panel then went on to consider the remaining charges and made the following findings. It also made findings in relation to charge 5. Charge 2: 2. Your actions at charge 1 above were dishonest, in that you intended to give a false impression that this care had been delivered. This charge is found NOT proved. The panel very carefully considered the test for dishonesty, which first requires an action to objectively be considered dishonest by ordinary and honest nurses, and then requires a finding that you yourself recognised that it would be considered dishonest. The panel considered your evidence regarding the circumstances in which you recorded the care which you had not yet provided. It accepted your evidence that, at 06:45 on the morning of 21 May 2014, while completing notes for other patients, whose care you had provided, you mistakenly made an entry in Resident A s notes but did not seek to alter the note because you intended to provide the care which you had recorded shortly thereafter. The panel also accepted that you would have ensured this care was provided to Resident A, had you not unexpectedly been relieved from duty at 07:00. The panel considered that an ordinary honest nurse, who was fully aware of the circumstances, would not consider that you had acted dishonestly. Accordingly, the first 8

9 limb of the dishonesty test was not satisfied. The panel considered that your actions were rushed and careless, but was not satisfied that this met the required threshold for dishonesty. The panel accordingly found the charge not proved. Charge 3: 3. On or around 11pm on 20 May 2014 slept whilst on duty This charge is found proved. The panel has considered separately the distinction which had been drawn to its attention between the words, shift and duty used in the charges against you. The panel has concluded that there is, in fact, no distinction between these two words in the context of the charges against you, but in any event, the distinction contended for by Mr Claxton on your behalf is immaterial to the panel s findings on this charge. The panel accepted the evidence of Ms 1, which had been supported by a written statement produced at the time. The panel noted that Ms 1 was clear that she did not write or sign that statement, but that she was happy to confirm the accuracy of its content, under affirmation in oral evidence. It was Ms 1 s clear account that she saw you asleep at times which will have exceeded your break of one hour s duration indeed that you were asleep on the night of 20/21 May 2014 from 11 pm to the early hours of the morning. Further, it was Mr 2 s evidence that you did sleep on duty on occasions, albeit he could not be certain as to dates and times. Further, the documentary evidence showed that you had earlier on 20 May worked a 6 and a half hour shift at Abingdon Court Care Home. Accordingly, the panel was satisfied on the balance of probabilities that you did sleep whilst on duty on the 20 May Charge 4: 9

10 and/or in the alternative 4. Took steps to facilitate sleeping whilst on duty on May 2014 in that you: a. Remained in a chair b. Allowed the room to remain dark c. Did not speak to or communicate with colleagues or residents for several hours Having found charge 3 proved, the panel did not need to consider this alternative charge as it is clearly expressed in the alternative. Charge 5: 5. Slept on shifts other than those specified in charges 3 and/or 4 At the outset of the hearing, you admitted this charge, on the basis that there is a distinction between duty as alleged in charge 3/4 and shift as alleged in this charge. You explained that you did sleep while on shift, but only during your break, which is not while you are on duty. The panel did not accept that there is a distinction between duty and shift, but it did accept the oral evidence of Ms 1, Mr 2, and you that, despite what the formal policies said, it was generally accepted by management that staff were allowed to sleep during their breaks, on the basis that they were not paid for this hour. However, the panel found, relying on the evidence of Mr 2, that you did sleep for longer than an hour on at least some of your shifts in addition to the night of 20 May The panel also noted that there were other occasions that you had worked back to back shifts, and found it more likely than not that you had slept for the 3 hours + alleged by Mr 2. 10

11 Accordingly, whilst you have admitted this charge on the basis that you admit to falling asleep only in your break, the panel make the factual finding, on a balance of probabilities, that you have on other occasions slept on shifts for periods of time in excess of your break of one hour s duration. Charge 7: 7. In May 2014 also worked at Abingdon Court Care Home thereby placing residents at risk by: b. leaving shifts early and arriving late in order to attend the follow on shift This charge is found NOT proved The panel considered the time sheets for both care homes. It determined that there were occasions when you had left Abingdon Court Care Home early, however it could not see any occasions when you had been more than a few minutes late for your shift at the Home. The panel considered whether leaving Abingdon Court Care Home early placed residents there at risk. It noted that there were always other staff on shift on the occasions when you left early. It found no evidence that any residents had in fact been placed at risk. Further, Mrs 3 gave evidence that she had never received any complaints that your leaving early had ever compromised patient safety. She also suggested that it would be possible for you to hand over to the other nurses on duty at the time who could then, in turn, hand-over to the nurse on night duty. The panel therefore found the charge not proved. c. sleeping on shifts 11

12 This charge is found proved Having previously found that you had slept outside of your break while working at the Home, the panel went on to consider whether you had put residents at risk. The panel considered the potential dangers of not being immediately alert and available while on duty. The panel noted that if residents were wandering around, as the evidence suggests dementia patients sometimes do, you would not notice them and be able to respond to their needs if you were asleep. The panel also considered that there was a risk of both members of staff being asleep at the same time. The panel noted the evidence of Mr 2, in which he stated that on one occasion he had to wake you up when he wanted to take his break, and that when he returned you had fallen back to sleep. The panel was satisfied on the balance of probabilities that being asleep outside of your break hours did place residents at a risk of harm and accordingly found the charge proved. Submission on misconduct and impairment: Having announced its finding on the facts, the panel then moved on to consider, whether the facts found proved amount to misconduct and, if so, whether your fitness to practise is currently impaired. The NMC has defined fitness to practise as a registrant s suitability to remain on the register unrestricted. In his submissions, Mr Zurawel invited the panel to take the view that your actions amounted to a breach of The Code: Standards of conduct, performance and ethics for nurses and midwives 2008 ( the Code ). He directed the panel to specific paragraphs of the Code, and submitted that you had these when you had made an incorrect record, slept on duty, worked back to back shifts and disobeyed the policies of your employers which you had been trusted to abide by. 12

13 Mr Claxton, on your behalf, conceded that your actions in respect of charges 3, 5, 7a and 7c amounted to serious misconduct, but submitted this was not the case in respect of charges 1, 6 and 8. He submitted that you were not displaying a lack of integrity by failing to obtain written authorisation, certainly in respect of the Home as it is your evidence that the Home s management was aware of your other job. He also submitted that your actions at charge 1 did not amount to misconduct, given that the panel have found you made an honest mistake. You gave evidence as to your current impairment. You informed that panel that you first qualified as a nurse in Botswana in 1992 and worked as a nurse there before moving to the UK in You informed the panel that you are currently working at Winterbrook Care Home in Oxfordshire and have learned from the mistakes you made in your previous employment. You told the panel that your record keeping has improved and that when you have made mistakes when completing a resident s care records, you have immediately corrected them. [PRIVATE] You told the panel that you have now recognised the dangers you put residents in by working back to back shifts and sleeping on duty, and regret your actions. You informed the panel that you have since only held one position at a time, you ensure you get plenty of sleep during the day, and you would not endanger residents in this way again. On the issue of impairment, Mr Zurawel submitted that your actions had clearly put patients at risk and that you have only recently come to realise the impact of those actions. He submitted that the references and training certificate you have provided do not properly evidence a true attempt to remedy your practice, as they have only been obtained recently. He submitted that there remained a risk of repetition. He submitted that there was a public interest in a finding of impairment, as there is a need for the NMC to declare and uphold proper standards of conduct and maintain public confidence in the profession. 13

14 Mr Claxton, on your behalf, submitted that you have remedied your practice. This was demonstrated in your written statement and in your oral evidence, in which you recognised that you had made a poor decision to work back to back shifts, fuelled by your circumstances. You recognised the risk you had placed residents in and expressed remorse for your actions. He also directed the panel s attention to the training certificate provided which shows your attempts to remedy your practice in relation to record keeping, and your oral evidence in which you described similar scenarios in which you have adhered to best practice. Mr Claxton submitted that you have worked as a registered nurse for nearly 3 years since the incident, and, as evidenced by the testimonials from your current employers, no new concerns have been raised about your fitness to practise. Mr Claxton also submitted that this is not a case where a finding of impairment is required on public interest grounds alone, as this should be reserved for exceptionally serious circumstances and this high threshold was not met in your case. The panel has accepted the advice of the legal assessor which included reference to a number of relevant judgments including: Roylance v General Medical Council (No 2) [2000] 1 A.C. 311, Nandi v GMC [2004] EWHC 2317 (Admin), GMC v Meadow [2007] QB 462 (Admin), Ronald Jack Cohen v General Medical Council [2008] EWHC 581 (Admin) and Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin). The panel adopted a two-stage process in its consideration, as advised. First, the panel must determine whether the facts found proved amount to misconduct. Secondly, only if the facts found proved amount to misconduct, the panel must decide whether, in all the circumstances, your fitness to practise is currently impaired as a result of that misconduct. 14

15 Decision on misconduct When determining whether the facts found proved amount to misconduct, the panel had regard to the terms of The code: Standards of conduct, performance and ethics for nurses and midwives 2008 (the Code). The panel 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 considered the various allegations individually. In relation to charge 1, the panel determined that you had breached paragraphs 42 and 21 of the Code, as you had failed to keep clear and accurate records and, by so doing, misinformed colleagues as to the care you had provided to Resident A. However, the panel was mindful that this charge relates to a single incident and has found these actions to be rushed and careless. The panel also noted that the care you claimed you had provided related to personal care and was a less significant omission than, for example, the administration of medication. Whilst the panel considered your actions to be poor practice, it was not satisfied that a mistake of this level could be said to amount to falling significantly short of the expected standards. Accordingly, the panel did not conclude that it amounted to serious misconduct. The panel next considered charges 3, 5, 7a and 7c, which related to you sleeping on duty as a result of working back to back shifts at the Home and Abingdon Court Care Home. The panel considered that your actions in respect of these charges had put residents at risk of harm, and as such, you had breached the preamble of the Code which states that you must provide a high standard of practice and care at all times. The panel was satisfied that your actions amounted to serious misconduct in this respect. When asleep, you could not be aware of any residents requiring your immediate care or attention, and, given the evidence that you on at least one occasion slept while a colleague was on his break, effectively left the Home without any staff to look after the residents. 15

16 The panel then considered the allegations at charges 6 and 8, that you failed to obtain written consent from either of your employers to have a second job. The panel considered your evidence on this point. You stated that you initially began working at the Home as a bank nurse, working approximately one shift a fortnight, and that this was the case when you first began working at Abingdon Court Care Home. You also told the panel that your colleagues at the Home were aware that you had another job, as evidenced by Mr 2, although you admitted that you did not get written consent. You also stated that you believed the need to obtain written consent was connected to the conditions of your work permit which you no longer needed in May The panel accepted your explanation, as well as your evidence that you had not been provided with copies of the relevant policies at either home which confirmed this requirement. It considered that, in the circumstances, your actions did not fall seriously short of what would have been expected of you and did not amount to serious misconduct. The panel found that only your actions at charges 3, 5, 7a and 7c fell 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, your fitness to practise is currently impaired. The panel had regard to your oral evidence, written statement, and the references and training certificate you provided. The panel considered the case of Grant and its endorsement of the Shipman report, which identifies the following test as appropriate for assessing a healthcare practitioner s fitness to practise: 16

17 Do our findings of fact in respect of the doctor s misconduct, deficient professional performance, adverse health, conviction, caution or determination show that his/her fitness to practise is impaired in the sense that s/he: a. has in the past acted and/or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and/or b. has in the past brought and/or is liable in the future to bring the medical profession into disrepute; and/or c. has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the medical profession; and/or d.... The panel was satisfied that by working back to back shifts and sleeping on duty, you had put patients at risk of harm, had brought the profession into disrepute, and had breached fundamental tenets of the profession, as you had failed to prioritise the needs of the residents in your care and provide a high standard of care at all times. The panel then considered the factors set out in Cohen and whether or not your conduct is capable of remediation, has been remediated, and is highly unlikely to happen again. The panel was satisfied that your conduct is capable of remediation and has been remediated. [PRIVATE]. The panel considered that despite your initial denial of the allegations, you showed a clear understanding of the dangers sleeping on duty posed to residents in your care and the impact it could have on your colleagues. The panel accepted your evidence that you currently only have one job and ensure you manage your time well so that you sleep during the day and are sufficiently rested for your night shifts. The panel also considered the references provided by your current employers and colleagues, which speak highly of your abilities and character, and address the concerns raised by the charges - one states that you are aware of [your] limitations and will never compromise the safety of the residents. 17

18 The panel considered, based on your remediation and insight, that there is a low risk of repetition of your actions, and therefore minimal risk to public protection. The panel then went on to consider whether a finding of impairment was necessary on the grounds of public interest. Nurses occupy a position of privilege and trust and must make sure that their conduct at all times justifies both their patients and the public s trust in the profession. In this regard the panel considered the judgement of Mrs Justice Cox in the case of Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin) in reaching its decision, in paragraph 74 she said: In determining whether a practitioner s fitness to practise is impaired by reason of misconduct, the relevant panel should generally consider not only whether the practitioner continues to present a risk to members of the public in his or her current role, but also whether the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular circumstances. 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/protect the wider public interest, which includes promoting and maintaining public confidence in the nursing and midwifery professions and upholding the proper professional standards for members of those professions. The panel determined that sleeping on duty, and thereby placing residents in your care at risk of harm, was unacceptable and necessitated a finding of impairment on public interest grounds in order to mark the seriousness of your misconduct. Having regard to all of the above, the panel was satisfied that your fitness to practise is currently impaired on the grounds of public interest. 18

19 Determination on sanction: The panel considered this case very carefully and decided to make a Caution Order for a period of 18 months. The effect of this order is that your name on the NMC register will show that you are subject to a caution order and anyone who enquires about your 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. 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 Indicative Sanctions Guidance ( ISG ) published by the NMC. It recognised that the decision on sanction is a matter for the panel, exercising its own independent judgement. The panel considered the aggravating and mitigating features. It considered the aggravating factors to be: The foreseeable harm you could have caused to residents in your care. The misconduct occurred on more than one occasion. It considered the mitigating factors to be: No subsequent concerns have been raised regarding your fitness to practise. You were in difficult personal circumstances at the time of the allegations. You have shown effective remediation of your practice. The panel first considered whether to take no action but concluded that this would be inappropriate given the panel s finding that the severity of your misconduct needs to be marked. It considered that the public interest in maintaining proper standards of conduct would not be served if no further action was taken. 19

20 Next, in considering whether a caution order would be appropriate in the circumstances, the panel took into account the Indicative 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 noted that you have shown insight into your conduct and provided evidence that you have remediated your practice, in the form of testimonials from 3 of your current colleagues, which support your effective practise and good character. The panel has been told that there have been no concerns regarding your practice either before or since these allegations and has found that there is only a low risk of repetition of your actions. The panel considered whether it would be proportionate to impose a more restrictive sanction and looked at conditions of practice. The panel concluded that no useful purpose would be served by a conditions of practice order, given its finding that the risk to the public is minimal, and that there are no practical conditions which could be put in place to address the specific misconduct in your case. The panel further considered that a suspension order would be wholly disproportionate in your case, given the mitigating factors and remediation you have demonstrated, and would deprive the public of an otherwise competent and caring nurse. The panel considered that a caution order would serve to mark the unacceptability of your actions to the public and reinforce the seriousness of the risk you subjected residents to to you. For the next 18 months, your employer or any prospective employer will be on notice that your fitness to practise has been found to be impaired and that your practice is subject to a restriction. Having considered the general principles above and looking at the totality of the findings on the evidence, the panel has determined that to impose a caution order for a period of 18 months would be the appropriate and proportionate response. At the end of this period the note on your entry in the register will be removed. However, the NMC will keep a record of the panel s finding that your fitness to practise had been 20

21 found impaired. If the NMC receives a further allegation that your fitness to practise is impaired, the record of this panel s finding and decision will be made available to any practice committee that considers the further allegation. This decision will be confirmed in writing. That concludes this determination. 21