Nursing and Midwifery Council: Fitness to Practise Committee. Substantive Order Review Hearing

Transcription

1 Nursing and Midwifery Council Fitness to Practise Committee Substantive Order Review Hearing 31 May 2018 Nursing and Midwifery Council, 2 Stratford Place, Montfichet Road, London, E20 1EJ Name of registrant: NMC PIN: Part(s) of the register: Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Jayne Steel: Nursing and Midwifery Council: Order being reviewed: Outcome: Jayne Steel 09J0007E Registered Midwife Midwifery (September 2009) England Lack of Competence David Newman (Chair, lay member) Judith Robbins (Registrant member) Georgina Foster (Lay member) Nigel Ingram Edmund Wylde Present, not represented Represented by Hannah Smith, Case Presenter Suspension Order (3 months) Conditions of Practice Order (12 months) to come into effect at the end of 16 July 2018 in accordance with Article 30 (1) 1

2 Decision and reasons on review of the current order The panel decided to replace the current suspension order with a conditions of practice order for a period of 12 months. This order will come into effect at the end of 16 July 2018 in accordance with Article 30 (1) of the Nursing and Midwifery Order 2001 (as amended) (the Order). On 14 March 2014 a panel of the Conduct and Competence Committee (CCC) made you the subject of a conditions of practice order for two years. On the 10 March 2016 this case was reviewed by another CCC panel and the order was varied and extended by a further two years. On the request of the NMC, this case was reviewed early on 27 March 2017 by a CCC panel who varied and continued the conditions of practice order. On 8 March 2018, this case was reviewed by a Fitness to Practise Panel, who imposed a suspension order for three months. The current order is due to expire at the end of 16 July The panel is reviewing the order pursuant to Article 30(1) of the Order. The charges found proved which resulted in the imposition of the substantive order were as follows: That you, whilst employed as a band 5 midwife at Brighton and Sussex University Hospitals NHS Trust, did not demonstrate the standard of knowledge, skills and abilities required to practise without supervision in that you: 1. On 24 to 25 July 2010 whilst caring for Patient A you: (a) (b) (c) (d) Failed to recognise a Post-Partum Haemorrhage Failed to examine Patient A adequately or at all to locate the cause of the haemorrhage Left Patient A unattended while she was haemorrhaging Failed to call for assistance 2

3 (e) Failed to provide an adequate 'CHAPS' handover to Ms 2 when requested to do so (f) Did not access Spencer Wells Forceps from the delivery pack within the birthing room as would have been appropriate in the circumstances. (g) Failed to adequately prepare a Syntocinon infusion when requested by a colleague to do so (h) Provided the anaesthetist with an inaccurate figure for the amount of blood lost by Patient A (i) Your note keeping was inadequate 2. On 31 July 2010 whilst caring for Patient B you: (a) (b) (c) (d) (e) Failed to adequately monitor the foetal heart rate Sent Patient B's mother out of the room to seek assistance rather than summoning assistance yourself Failed to immediately clamp and cut the umbilical cord following birth Did not take umbilical cord gases when requested to do so Left Patient B unattended whilst she was haemorrhaging 3. Whilst undergoing a period of developmental practice between September 2010 and December 2010 you did not demonstrate that you had the necessary competencies to be capable of working unsupervised, more particularly, but not limited to: (a) (b) (c) (d) Your record keeping was at times inadequate in emergency situations You failed to fully record observations on the 'MEOWS' charts as required. On a date unknown when asked by Supervisor of Midwives Ms 4 what painkillers you would give to a patient in pain after 3

4 (e) (f) childbirth you raised the possibility of Oramorph, which was contra-indicated in the circumstances On a date unknown you failed to administer fluids to a patient who had received an epidural On a date unknown you were unable to distinguish between the foetal heart rate and the mother's heart rate 4. Whilst undergoing a period of supervised practice between January 2011 and June 2011 you did not demonstrate that you had the necessary competencies to be capable to working unsupervised, more particularly, but not limited to: (a) On 8 February 2011 in respect of a premature birth you failed to: (i) Immediately clamp and cut the umbilical cord after birth (ii) Take the cord gases (iii) Give the patient syntometrine to minimise blood loss (b) On 16 February 2011 in respect of a patient in the care of you and Ms 3: (i) Failed to articulate sufficiently that an induction was recommended after finding meconium in the patient's waters (ii) Failed to carry out any or any adequate vaginal examination before being prompted (iii) Did not appreciate the importance of conducting a vaginal examination before administering syntocinon (iv) Inappropriately increased the rate of syntocinon (v) Your record keeping was inadequate (c) On 10 March 2011 in respect of a patient in the care of you and Ms 3: 4

5 (i) (ii) (iii) (iv) (v) You did not prepare an adequate plan for the care of the patient You recorded in the patient's notes that she did not suffer from any allergies without first confirming that that was the case You got too close to the baby s head which may have given the impression that you would touch it before delivery in the birthing pool was complete You did not administer syntometrine You were unable to adequately assess the state of the patient's perineum after birth to see if stitching was required d) On 4 April 2011 in respect of a patient in the care of you and Ms 4: i) You did not immediately cut the umbilical cord after birth ii) You failed to adequately document the foetal heartbeat iii) You failed to administer syntometrine after birth e) On 11 April 2011 in respect of a patient in the care of you and Ms 3: i) You did not fill in the daily record sheet for the patient ii) You failed to record why you had been unable to listen to the foetal heart rate for one minute between contractions iii) You failed to record the foetal heart rate as an average iv) You failed to write and/or implement a reassessment for the patient v) vi) You failed to put sharps in the sharps bin 5

6 vii) viii) You inappropriately drained the patient s urine into an IV tray You did not check the resuscitaire machine on this occasion f) On 16 May 2011 in respect of a patient in the care of you and registered midwife Ms 5: i) The standard of your note keeping was inadequate ii) You did not articulate with sufficient clarity the rationale for the care you provided when requested to do so g) On 18 June 2011 in respect of patient(s) in the care of you and registered midwife Ms 6 i) You had to be prompted to commence CTG monitoring on a patient ii) You required assistance to monitor the foetal heart rate iii) You did not prepare the room for a possible episiotomy in adequate time iv) You did not communicate with the doctor when a patient had shoulder dystocia v) The manner of your note keeping was inappropriate vi) You left the labour room in an inappropriate manner h) On 27 June 2011 in respect of a patient in the care of you and Ms 6 your record keeping and/or time management was inadequate And, in light of the above your fitness to practise is impaired by reason of your lack of competence. The last reviewing panel determined the following with regard to impairment: 6

7 The panel has received no information as to Miss Steel s compliance with the conditions of practice order. She has not secured employment as a midwife and has not provided evidence of having maintained her midwifery skills and practice. The panel also noted that it has not received a reflective piece from Miss Steel to demonstrate her insight, remorse and remediation into her lack of competence. In light of this, the panel determined that Miss Steel still remains liable to repeat clinical failings of the kind found proved. The panel therefore decided that a finding of continuing impairment is necessary on the grounds of public protection. The panel bore in mind that its primary function was to protect patients and the wider public interest, which includes maintaining confidence in the midwifery profession and upholding proper standards of conduct and performance. The panel determined that, in this case, a finding of continuing impairment on public interest grounds is also required. For these reasons, the panel finds that Miss Steel s fitness to practise remains impaired. The last reviewing panel determined the following with regard to sanction: The panel first considered whether to take no action or to impose a caution order but concluded that either option would be inappropriate in view of the risk of repetition identified and seriousness of the case. The panel decided that it would be neither proportionate nor in the public interest to take no further action or to impose a caution order. The panel next considered the imposition of a further conditions of practice order. The panel considered the determination of the previous reviewing panel, dated 27 March 2017, which read: The panel was satisfied that you are engaged with the wider NMC proceedings and are committed to returning to work. The panel was of the view that a conditions of practice order is sufficient to protect patients and 7

8 the wider public interest, but that the current order is too restrictive to allow you the opportunity to address the concerns around your practice and to return to practising safely and effectively as a midwife. The panel determined that a future reviewing panel would be greatly assisted by your provision of a written reflective piece prior to any review hearing. The panel considered that the previous reviewing panel had sent a clear signal to Miss Steel that although she had experienced difficulties in securing employment due to the terms of the previous conditions of practice order, she should make an effort to demonstrate attempts to remediate and provide evidence that she is capable of safe and effective practice as a midwife. It suggested that she provide a reflective statement to evidence her reflections on her lack of competence. The panel has not received the reflective piece, or any other indication that Miss Steel is complying with the current conditions to which she is subject. As a result, the panel had a real concern towards the safety of the public. The panel considered that, in the absence of such evidence, there remained a significant risk to public protection as a result of Miss Steel s failure to remediate her failings. Further the panel noted that Miss Steel has not practised as a midwife for a number of years and has not provided evidence of any effort to maintain her knowledge and skills. The panel are concerned that Miss Steel has not meaningfully engaged with these proceedings, albeit that she initially indicated a willingness to participate via telephone, she did not in fact follow through with that intent. Therefore, given Miss Steel s lack of satisfactory engagement with these proceedings, the panel concluded that a conditions of practice order is no longer appropriate or practicable. The panel concluded that, due to Miss Steel s lack of engagement with her regulator, no workable conditions of practice could be formulated which would protect the public or satisfy the wider public interest. 8

9 The panel determined, therefore, that a suspension order is the only appropriate sanction which would both protect the public and satisfy the wider public interest. The panel noted from Miss Steel s dated 20 February 2018, her assertion that she will not give up until I get a positive outcome from this situation. It further noted that she has been applying for healthcare roles. The panel would reiterate to Miss Steel that if she intends to return to practice as a midwife, she should provide evidence of her attempts to maintain her midwifery knowledge and skills and her attempts to secure employment or/and a place on a return to practice course. The panel further reminds Miss Steel that she should provide the panel with a reflective piece to demonstrate that she has reflected on her lack of competence. The panel recognised that a striking off order was open to it as Miss Steel has been subject to a conditions of practice order for more than two years consecutively. However, it determined that given her previous engagement with these proceedings and limited contact with the NMC since the last review in March 2017, a striking off order was not appropriate at this time. The panel are mindful that if Miss Steel does not meaningfully engage with the NMC going forward a future reviewing panel may consider imposing a striking- off order. Accordingly, the panel determined to impose a suspension order for a period of three months. It considered this to be the most appropriate and proportionate sanction available. The above reproduces the decision of the last panel, identifying you as Miss rather than Mrs Steel; you should have been referred to as Mrs Steel. Decision on current fitness to practise This panel has considered carefully whether your fitness to practise remains impaired. Whilst there is no statutory definition of fitness to practise, the NMC has defined fitness to practise as a registrant s suitability to remain on the register without restriction. In 9

10 considering this case, the panel has carried out a comprehensive review of the order in light of the current circumstances. It has noted the decision of the last panel. However, it has exercised its own judgment as to current impairment. The panel has had regard to all of the documentation before it. It has taken account of the submissions made by Ms Smith, on behalf of the NMC, and those made by you. Ms Smith informed the panel of the background to the case and took the panel through the relevant documentation. She submitted that it was clear from correspondence, between you and the NMC subsequent to the decision of the last reviewing panel, that the view of the last reviewing panel with regard to your engagement was perhaps based on a misunderstanding about whether you were available to participate in that hearing by telephone. She submitted that you had since made it clear that little had changed between the penultimate and last review hearing and could add little to those proceedings, but were open to answering questions at the last review hearing. Ms Smith invited the panel to consider whether the last reviewing panel s change of position was based on that misunderstanding. Ms Smith submitted that it was to your credit that you have continued to engage and attempted to remediate your practice, but that it hasn t proved possible for you to do so. Ms Smith invited the panel to bear in mind the considerations of previous panels and consider whether there was arguably an absence of change in circumstances. She submitted that there remains a risk of repetition of the behaviour in question, and that it would put patients at unwarranted risk of harm if you were allowed to return to practise as a midwife unrestricted. Ms Smith invited the panel to find that your fitness to practise remains currently impaired, on grounds of public protection. Ms Smith informed the panel of the sanctions available to it. She submitted that, as you appear to remain committed to practise as a midwife in the future, this case was not a situation where a panel might reasonably be invited to allow the current order to lapse; it would be inappropriate and, perhaps, inconsistent to take no further action. Ms Smith similarly submitted that the imposition of a caution order would be inappropriate, as it would not adequately protect the public. 10

11 On the subject of a conditions of practice order, Ms Smith invited the panel to consider that you have previously been subject to variations of a conditions of practice order for around 4 years, and you have clearly made some efforts during those periods of time to remediate your practice; however, you have been unable to do so. Ms Smith submitted that, were the panel to take the view that a conditions of practice order would adequately protect the public and that you should be given a further opportunity to remediate your practice, the panel may impose such a sanction. She further submitted that it might be prudent to indicate that it would not be feasible to impose a conditions of practice order indefinitely, and for the panel to indicate an endpoint to such a sanction. Ms Smith submitted that, if the panel were to find a conditions of practice order to be an inappropriate sanction, it should consider a suspension or striking off order. She further submitted that a striking off order would not be appropriate, unless and until you have been given fair warning and effectively a final chance to seek to remediate and address the shortcomings in your practice. You thanked the panel for considering your case and all of the documentation before it. You submitted that you would like to go away from today with something positive; you need support, as you do not know how to go forward to find where to do further training. You informed the panel that you trained at Brighton University in Eastbourne, and that your first hospital was Brighton and Sussex University Hospital, after which you moved down to the sister hospital in Brighton. You submitted that you have considered going back to the university, but so far have chosen not to do so. You would find it hard to return, as you had lost your job there, subsequent to your suspension. You informed the panel that you have tried to keep in touch with elements of midwifery; the problem is that you have to work in order to remediate your practice, and that you have lots of other commitments with your family. You remain committed to reading up on midwifery practice. Concerning the issue of the lack of telephone evidence before the previous panel, you submitted that you had been in your house all morning, and had said that if the panel 11

12 wanted to speak to you at all, you would be available. You submitted that a misunderstanding occurred which meant that the panel thought you were unavailable. Concerning your wish to start again, laid out in a statement dated 29 May 2018 which you provided to the panel, you submitted that you wish to do so as every time you go for an interview or look for support, it feels like you are blacklisted you gave a number of examples to the panel. You explained to the panel that when you first became a midwife, you had not been given the appropriate support and, subsequent to the two initial incidents, were placed under constant scrutiny which you found both difficult and stressful. You informed the panel that you had never been given the opportunity to flourish, but had had to work in what you considered to be high risk and stressful situations. You submitted that, upon finishing your training, you felt equipped for basic midwifery but had not received the support which most newly qualified midwives need. You informed the panel that the first incident occurred not long into your preceptorship: you started in November 2009 and the first incident occurred some 8 months later. During that time, you had only been working on the delivery suite and had no experience in any other clinical area. You told the panel that you feel very isolated as you really have nobody to support you or turn to, not for want of looking; you just want to have someone say we support you and give you six months to see how you get on. You said that you have yet to find that support. You concluded your submissions by confirming that you understand the necessity of return to practice courses. The panel heard and accepted the advice of the legal assessor. In reaching its decision, the panel was mindful of the need to protect the public, maintain public confidence in the profession and to declare and uphold proper standards of conduct and performance. 12

13 Determination on impairment This panel considered whether your fitness to practise remains impaired. It took into account all the documentation which you have provided, including your reflective piece and two testimonies. The panel also took into account the comprehensive chronology which you put before it, which begins on 29 November 2009 and details all the problems which you have faced, with a commentary, as well as the statement dated 29 May 2018, in which you summarise your wishes for the outcome of this review hearing. The panel noted that these describe the problems which have arisen at various stages of your career as a midwife, and comment upon the levels of support you have received and the various processes which you have been through both at the NMC and other disciplinary matters. While understanding the frustrations that you must feel over the events of the last few years, the panel considered that the reality is that you have not adequately remediated your failings as a midwife despite extensive prolonged and protracted attempts to do so. It noted that it had not been provided with evidence of any further training relevant to the charges found proved, and considered that your reflective piece focusses more on how you felt at the time of the incidents, rather than on why they occurred and how you would act differently in the future; in the reflective piece, you did not take responsibility for your actions and fell short of addressing the fundamental failings arising from the referral and how they might be remediated. Taking into account the seriousness of the charges proved as well as the matters referred to above, the panel determined that, as you have not demonstrated sufficient insight to remedy your clinical failings, your fitness to practise remains currently impaired; it made this finding on public protection grounds, as well as the wider public interest of maintaining public confidence in the profession and the NMC as regulator. Determination on sanction Having found your fitness to practise currently impaired, this panel then considered what, if any, sanction it should impose in this case. The panel noted that its powers are set out in Article 30 of the Order. The panel has also taken into account the NMC s 13

14 Sanctions Guidance (SG) and has borne in mind that the purpose of a sanction is not to be punitive, though any sanction imposed may have a punitive effect. The panel first considered whether to take no action but concluded that this would be inappropriate in view of the risk of repetition identified and seriousness of the case. The panel decided that it would be neither proportionate nor in the public interest to take no further action. The panel then considered whether to impose a caution order but concluded that this would be inappropriate in view of the risk of repetition identified and seriousness of the case. The panel decided that it would be neither proportionate nor in the public interest to impose a caution order. The panel considered substituting the current suspension order with a conditions of practice order. It bore in mind your concern that an administrative failure at the last review hearing appears to have led to the imposition of a suspension order. This panel noted that previous panels have found you to be open, honest and credible and this panel was ready to take you at your word that there was a misunderstanding and that you had been willing to contribute to the last hearing by telephone. The panel therefore considered afresh whether a conditions of practice order would be sufficient, appropriate and workable in this case; it was greatly assisted by your attendance at this hearing. The panel considered that it would be possible to formulate practicable and workable conditions, which if complied with, may lead to your unrestricted return to practice and would serve to protect the public and the reputation of the profession in the meantime. The imposition of such an order is the nearest proportionate sanction to allow you to start again, whilst also appropriately protecting the public. The panel were impressed by your real determination to return to midwifery practice. The panel considered that the imposition of a conditions of practice order for a period of 12 months would allow you sufficient time to find a position and comply with the 14

15 conditions below, while reflecting your determination to return to the register as soon as possible. The panel decided that the public would be suitably protected as would the reputation of the profession by the re-implementation of the following conditions of practice: 1. At any time that you are employed or otherwise providing midwifery you must place yourself and remain under the supervision of a work place line manager, mentor or supervisor nominated by your employer, such supervision to consist of working at all times under the direct observation of a registered midwife of band 6 or above. 2. 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: i. fetal heart monitoring including CTG; ii. obstetric emergencies, including post-partum haemorrhage; iii. recognition of a deteriorating patient; iv. drug administration; and v. documentation. 3. You must meet with your line manager, mentor or supervisor (or their nominated deputy) at least every four weeks to discuss the standard of your performance and your progress towards achieving the aims set out in your personal development plan. 4. 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 You must send a report from your line manager, mentor or supervisor (or their nominated deputy) setting out the standard of your performance and

16 your progress towards achieving the aims set out in your personal development plan to the NMC 14 days prior to any NMC review hearing or meeting. 6. You must inform the NMC of any professional investigation started against you and /or any professional disciplinary proceedings taken against you within 14 days of receiving notice of them. 7. You must within 14 days of accepting any post or employment requiring registration with the NMC, or any course of study connected with nursing or midwifery, provide the NMC with the name/contact details of the individual or organisation offering the post, employment or course of study. 8. You must immediately inform the following parties that you are subject to a conditions of practice order under the NMC s fitness to practise procedures, and disclose the charges and a copy of the NMC decision letter setting out the conditions of practice and the panel s determinations in full: a. Any organisation or person employing, contracting with or using her to undertake midwifery work. b. Any agency you are registered with, or apply to be registered with to undertake midwifery work at the time of application. c. Any prospective employer for midwifery services at the time of application. d. 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. The panel considered that a suspension order would be a disproportionate measure, not necessary nor appropriate in this case. 16

17 This reviewing panel considered that a future panel would be assisted by: - Your attendance at the next reviewing hearing. - A reflective piece addressing the clinical concerns that lead to your referral, as in the charges found proved; these should include what went wrong at the time of the incidents, what the potential impact was on your patients, colleagues, and the reputation of the profession, and how you would manage such situations in the future. - Evidence of you keeping up to date with developments in the midwifery profession, as well as any relevant training. - A summary of your attempts and successes in finding a role related to midwifery. - Any further relevant references which you can provide before the next reviewing panel. This decision will be confirmed to you in writing. That concludes this determination. 17