Area of Registered Address: Dr Jacqueline Mitton (Chair, lay member) Deborah Hall (Registrant member) Gill Mullen (Lay member)

Transcription

1 Nursing and Midwifery Council Fitness to Practise Committee Substantive Meeting 21 September 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: Amanda Jane Anderson 00B0120E Sub part 1 - Adult England Misconduct Dr Jacqueline Mitton (Chair, lay member) Deborah Hall (Registrant member) Gill Mullen (Lay member) Suzanne Palmer Facts proved: Facts proved by admission: Facts not proved: Fitness to practise: Sanction: Interim Order: Charges 1(b), 2, 3(a), 3(b) & 3(c) None Charges 1(a) & 1(c) Impaired Caution Order for 2 years Not applicable 1

2 Details of charge: That you a Registered Nurse, 1. On the 19 June 2017, (a) Told Colleague A to send the night staff home when it was inappropriate to do so; (b) Laughed at Colleague A when he raised concerns with you regarding sending the night staff home; (c) Did not assist Colleague A for the last half hour of your shift. 2. On 13 July 2017 told Colleague A that you would not lift Resident A because she was too fat and the hoist won t lift her or words to that effect. 3. On an unknown date in July 2017 on answering a buzzer pressed by Resident B, (a) Did not assist Resident B when she explained she needed to go to the toilet; (b) Told Resident B in a loud voice to use the commode ; (c) Left Resident B s room without assisting Resident B. And in light of the above your fitness to practice is impaired by reason of your misconduct. 2

3 Decision on Service of Notice of Meeting The panel was informed at the start of this hearing that written notice of this meeting had been sent to Ms Anderson s registered address by recorded delivery and by first class post on 2 August The panel took into account that the notice letter provided details of the allegation, the date after which the meeting would take place and, amongst other things, information about Ms Anderson s right to send a written response to the allegations and/or other documentary information to be considered by the panel at the meeting. The panel accepted the advice of the legal assessor in relation to the requirements about service of the notice of meeting as set out in Rules 11A and 34 of the Nursing and Midwifery Council (Fitness to Practise) Rules 2004, as amended ( the Rules ). The panel was informed that the notice which was sent to Ms Anderson had been returned by Royal Mail after it remained uncollected at the delivery office local to Ms Anderson s registered address. It was mindful that the Rules only require the notice to be sent, rather than delivered, and that it is the responsibility of every registrant to ensure that their contact details on the register remain up to date and effective. The panel noted that at one stage Ms Anderson had been represented by the Royal College of Nursing. However her representative at the Royal College of Nursing had written to the NMC on 13 April 2018 indicating that they were no longer acting for her and that all future correspondence should be sent direct to Ms Anderson at her registered address. The panel further noted that on 14 February 2018 Ms Anderson s former representative at the Royal College of Nursing had written to the NMC explaining that: 3

4 [Due to personal circumstances Ms Anderson] has not been able to work in a nursing capacity since the order was imposed. Our member has now decided that she will not be returning to a career in nursing She is keen to engage with the proceedings. [PRIVATE] The panel noted that it seemed that, despite being keen to engage with the proceedings in February 2018, Ms Anderson had now disengaged. It appeared that she had not responded to any further correspondence sent to her by the NMC, including the Case Management Form. It further appeared that she may not have received the notice of this meeting. However, as already mentioned, in order for service to be effective, the Rules do not require the notice to have been delivered, merely to have been sent. In the light of all of the information available, the panel was satisfied that Ms Anderson had been served with notice of this meeting in accordance with the requirements of Rules 11A and 34. Decision on the facts and reasons In reaching its decisions on the facts, the panel considered the bundle of documentary evidence adduced in this case. This included witness statements, with accompanying exhibits, from: Colleague A, a Senior Carer employed by Eagle Nursing Home; Resident B, a resident at Eagle Nursing Home; Colleague C, the Registered Manager of The Manor Nursing Home (which the panel understood to be a different nursing home owned by the same company which owned the Eagle Nursing Home) The panel heard and accepted the advice of the legal assessor. 4

5 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 a panel is satisfied that it is more likely than not that the incidents occurred as alleged. Background The charges in this case arose during Ms Anderson s employment as a nurse at Eagle Nursing Home ( the Home ). It seems that Ms Anderson was working during the night shift on June She was the nurse in charge of that shift, working alongside a number of carers. It seems that there were approximately 23 residents in the Home at the time, two of whom required one-to-one care. It was not entirely clear from the documentation what the normal shift hours would be for the night shift, but it appeared to be from 19:30 to 07:00. It seems that on the following day shift on 19 June 2017, staffing numbers were lower than expected. According to the evidence of Colleague A, there were two carers and one registered nurse on duty during that shift, when there should have been six carers and one registered nurse. Moreover, Colleague A says that a few of the residents were still wet and not dressed from the night shift when he arrived for his shift at 06:30. It is alleged that at 07:00 Ms Anderson told Colleague A to send home the care staff from the night shift who were responsible for one-to-one care. It is further alleged that when Colleague A raised concerns with Ms Anderson about doing so, she laughed at him. It is further alleged that she did not assist Colleague A during the last half hour of her shift. Colleague A wrote a letter of complaint about this incident on 25 June He sent the letter to Colleague D, who was the Registered Manager of the Home. In his complaint 5

6 he also made a number of more general complaints about his perception of Ms Anderson s attitude towards him. It is further alleged that on 13 July 2017 Ms Anderson made a comment to Colleague A that she would not lift Resident A because she was too fat and the hoist won t lift her, or words to that effect. Colleague A does not appear to have made any separate complaint about this alleged comment. It is further alleged that on an unknown date in July 2017, there was an incident involving Resident B on a night shift when Ms Anderson was working as a nurse. Resident B had had a fall earlier that month during which she had hurt her arm. She was therefore having difficulties getting out of bed independently in order to go to the bathroom. It is alleged that Resident B needed to use the toilet during the night, so she pressed her buzzer to call for assistance. It is alleged that Ms Anderson went to her room and that when Resident B explained that she would like to go to the toilet, Ms Anderson said, in a loud voice and an abrupt manner, Use the commode and then left the room without providing any assistance to Resident B. Resident B, who subsequently wet the bed before eventually being given assistance by a carer, made a written complaint about this incident on 17 July On 19 July, following receipt of Resident B s letter of complaint, Colleague C (Registered Manager of a different nursing home) held what was called a dismissal meeting with Ms Anderson. She conducted this meeting on behalf of the Home s Registered Manager, Colleague D. On being informed that she was being dismissed, Ms Anderson objected to the lack of any formal process and left the premises saying that she intended to talk to her union representative. It appears that her employment at the Home ended on that date. The panel considered each charge and made the following findings: 6

7 Charge 1a: 1. On the 19 June 2017, a) Told Colleague A to send the night staff home when it was inappropriate to do so; This charge is found not proved. The evidence in support of this charge came from Colleague A. In his witness statement he said: On 19 June 2017, l was the only carer on duty when l arrived at around 06:30. At around 06:50 another carer arrived which meant there were two of us to cover 2 residents who required one to one care and 21 further residents. A few of the residents were still wet and not dressed from the night shift so would require attention. At exactly 7am, the registrant told me to send the night staff home who were responsible for one to one care. I explained to the registrant that I could not send them home yet as we were dealing with the other residents and so we couldn't physically cover the one to one residents as well. I said that we needed to arrange some cover before we could relieve the night staff. The registrant just laughed at this and walked away to tell the night staff they could go home. The registrant refused to help during the half an hour until the day nurse arrived. She was just sitting in the office eating chocolate. This left the home with extremely low numbers of staff on duty. There should have been 6 care staff and a Registered nurse on duty. However, there were only 2 care staff until around dinner time. In his original letter of complaint to Colleague D dated 25 June 2017, Colleague A said: At bang on 7 am Amanda found me and told me to relive (sic) the night staff on one to one care I told her that at this time I was unable to as we were dealing with other 7

8 residents and that there was only myself and [another carer] on shift (at which she laughed) and that we couldn t physically cover the one to ones and deal with the other residents as well so I needed to arrange some cover first as there was an extremely unsafe level of staffing. At this point I did send a message to the management yet got no reply at all on what to do. Amanda then wet (sic) off and told the night-staff they could go home regardless of the very low staffing levels. Amanda refused to help us in anyway shape or form in the half an hour until the day nurse arrived The panel noted that Ms Anderson had not responded to the allegations, provided any documentary observations or information, or responded to the case management form. In the absence of any response, there was no challenge to the evidence of Colleague A and the panel saw no reason to disbelieve what he said, although it noted that there were some discrepancies between his account in his witness statement for these proceedings and his original complaint. The panel therefore accepted, on the balance of probabilities, that Ms Anderson did instruct Colleague A to send night staff home (or at least instructed him to relieve them and sent them home herself, which would have the same effect). The issue was whether she did so, as is alleged in charge 1(a), in circumstances when it was inappropriate to do so. The panel noted that the precise timings were difficult to establish from the evidence. It seemed that the night shift hours were from 19:30 to 07:00. It was not clear at what time day shift staff were scheduled to start their shift. There was no evidence whatsoever to establish what the normal policy/procedure was at the Home in the event that staff did not attend for a shift. There was no information about what was expected of the nurse in charge in such a situation. In the absence of such information, the panel was unable to form any conclusion about whether or not it was inappropriate to send the night staff home at 07:00. It may well have made life difficult for the day staff to do so, and the panel could understand 8

9 Colleague A s frustration. However it was mindful that, as nurse in charge of the night shift, Ms Anderson would have had obligations to the night staff. There may conceivably have been implications in terms of the Working Time Regulations or the Home s contractual obligations towards its staff. The panel considered that it could not rely purely on the subjective opinion of Colleague A in order to establish whether or not it was appropriate to send staff home at the end of their shift at 07:00. The panel concluded that insufficient evidence had been adduced for it to be satisfied on the balance of probabilities that it was inappropriate to send the night staff home. It therefore found charge 1(a) not proved. Charge 1b: 1. On the 19 June 2017, b) Laughed at Colleague A when he raised concerns with you regarding sending the night staff home; This charge is found proved. The panel had regard to the evidence of Colleague A, already set out above. As before, the panel noted that no challenge had been made to Colleague A s evidence and there was no apparent reason to disbelieve his account. The panel accepted, therefore, that Ms Anderson had laughed in response to Colleague A informing her of his concerns about sending night staff home in the context of the staffing levels. The panel considered that it would be unduly semantic not to regard this as laughing at Colleague A when those concerns were raised, as is alleged in charge 1(b). The panel noted that there was an absence of evidence about the manner or precise context in which the alleged laughter took place. This would be a matter for 9

10 consideration at the next (misconduct) stage. As a matter of fact, however, the panel accepted on the balance of probabilities that Ms Anderson laughed at Colleague A as alleged. It therefore found charge 1(b) proved. Charge 1c: 1. On the 19 June 2017, c) Did not assist Colleague A for the last half hour of your shift. This charge is found not proved. The panel had regard to the evidence of Colleague A set out above. As with the previous charges, the panel noted the absence of any challenge to Colleague A s evidence and saw no reason to disbelieve his account. It did, however, note that there was a discrepancy between his accounts in these proceedings and in his original letter of complaint, in that the original letter of complaint made no reference to his allegation that Ms Anderson was sitting in the office eating chocolate during the relevant period. This detail, if true, was a surprising omission from Colleague A s contemporaneous statement and might possibly indicate an element of embellishment of his account in the later statement for these proceedings. The panel noted, however, that it was impossible to establish a clear timeline of events from Colleague A s evidence. It noted that he had not himself used the language set out in the charge of the last half hour of your shift. He had referred to the half hour period before the day nurse arrived. There was no information available to the panel about what time the day nurse was scheduled to arrive on this day, or at what time she actually arrived, and whether this was before or after the end of Ms Anderson s shift. 10

11 The panel further noted that even if Ms Anderson was still on duty, without further detail about context it was impossible to establish whether there was any obligation or expectation (as the charge implies) on her to provide assistance during this period. She may, for example, have been on a break (particularly if she was eating at the time as Colleague A alleges). She may have been writing up nursing notes or care plans prior to handover (particularly if she was in the office as Colleague A alleges). In the circumstances, the panel concluded that insufficient evidence had been adduced from which it was able to find this allegation proved on the balance of probabilities. It therefore found charge 1(c) not proved. Charge 2: 2. On 13 July 2017 told Colleague A that you would not lift Resident A because she was too fat and the hoist won t lift her or words to that effect. This charge is found proved. The only evidence in support of this allegation came from Colleague A who, in his witness statement for these proceedings, said: I remember seeing the registrant on around 13 July 2017 and she made a comment that she wouldn t lift resident [A] as she s too fat and the hoist won t lift her. As with the previous charges, the panel noted the absence of any challenge to Colleague A s evidence and saw no reason to disbelieve his account. The panel noted that it had been provided with no information about the detail of the alleged comment, or the context or manner in which it was made. The panel was mindful that these were issues for consideration at the next stage. However, as a matter of fact, it accepted on the balance of probabilities that Ms Anderson had made the 11

12 alleged comment, or words to that effect, to Colleague A. It therefore found charge 2 proved. Charge 3: 3. On an unknown date in July 2017 on answering a buzzer pressed by Resident B, a) Did not assist Resident B when she explained she needed to go to the toilet; b) Told Resident B in a loud voice to use the commode ; c) Left Resident B s room without assisting Resident B. This charge is found proved in its entirety. The panel considered charges 3(a), (b) and (c) together because the evidence about them was inextricably linked, and because 3(a) and 3(c) essentially appeared to amount to the same allegation. The panel had regard to the evidence of Resident B, who said in her statement for these proceedings dated 27 March 2018: On one occasion during a night in July 2017 I woke up and needed to go to the toilet. Due to the fact I had a fall earlier in the month, I hurt my arm so I was having a bit of a job getting out of bed to get the bathroom. As I needed to use the toilet, I decided to use my buzzer to call for assistance. I felt like I was pressing the buzzer for a solid hour. Unfortunately I was starting to get pains in my stomach and I wet the bed. I kept buzzing for help and eventually the registrant and a Healthcare Assistant came to my room. I held my hands out for the registrant to help me up but she just ignored me. The 12

13 Healthcare Assistant was really nice, she said don t worry to me and helped me change my clothes and changed the bed for me. In her original letter of complaint dated 17 July 2017, Resident B said: During one night I needed to go to the toilet so I used the nurse call buzzer to call for assistants (sic) to help me go to the toilet. I kept buzzing for assistants and after quite some time Nurse Amanda came into my room and I explained I would like to go to the toilet. She looked at me and quite rudely, abruptly and loudly said Use the commode and left my room without attempting to help me or requesting the night carers to assist me. I was unable to get myself out of my bed and subsequently wet my bed. I tried calling for assistance but no one came and I was left to lie in my own urine for ages. As with other charges, the panel noted that there had been no challenge to Resident B s evidence and the panel saw no reason to disbelieve her account. The panel noted that there were significant discrepancies between the two accounts she had given, including as to whether or not Resident B had already wet the bed before Ms Anderson came to the room, whether Ms Anderson told her to use the commode and whether a carer came to the room with Ms Anderson. However the panel did not think that these discrepancies undermined the core of her account, which was that she needed to use the toilet, asked Ms Anderson for assistance, and Ms Anderson did nothing to assist. The panel considered that the original complaint, which was made much closer to the time than the NMC witness statement, was more likely to contain the correct account, and was mindful that the passage of some 8 months may have impacted on Resident B s independent recollection of events by the time she came to give her NMC witness statement. The panel noted that the account given in the original complaint closely mirrored the allegations set out in the charge. 13

14 The panel accepted Resident B s account and found on the balance of probabilities that events occurred as she alleged in her original complaint. It therefore found charges 3(a), 3(b) and 3 (c) proved. Misconduct and impairment: Having reached its findings on the facts, the panel then moved on to consider whether the facts which it had found proved amounted to misconduct and, if so, whether Ms Anderson s fitness to practise is currently impaired by reason of that misconduct. The panel accepted the advice of the legal assessor. In reaching its decision, the panel bore in mind the overarching objective of the NMC to protect patients and to act in the wider public interest in declaring and upholding proper professional standards and maintaining public confidence in the profession and in the regulatory process. It bore in mind that there was no burden or standard of proof at this stage and exercised its own professional judgement. It further bore in mind that there is no statutory definition of fitness to practise. However, the NMC has defined fitness to practise as a registrant s suitability to remain on the register unrestricted. Decision on misconduct When considering whether the proven facts amounted to misconduct the panel had regard to the terms of The Code: Professional standards of practice and behaviour for nurses and midwives (2015). It bore in mind, however, that breaches of the Code do not automatically result in a finding of misconduct. The panel first considered charge 1(b). As it had noted at the facts stage, there was an absence of evidence as to the precise context of the laughter, or as to the manner, tone 14

15 or tenor in which it was delivered/intended or received/perceived. The panel noted that laughter in the course of communication can, depending on context and the manner of its delivery, mean many different things. There would be a significant difference between, for example, sympathetic, ironic or sarcastic laughter between colleagues about the staffing levels at the Home on the one hand, or on the other hand a mocking or derogatory laugh about a colleague raising concerns. On the basis of the documentary evidence available, it was impossible for the panel to draw any conclusions about the nature and context of the laughter in this case. The panel considered that there was no material from which it was able to conclude that the laughter referred to in charge 1(b) amounted to a departure from proper professional standards, still less to the extent required for it to be characterised as misconduct. It concluded that charge 1(b) did not amount to misconduct. The panel next considered charge 2. As it had noted at the facts stage, there was an absence of evidence about the detail of the alleged comment, or the context or manner in which it was made. The panel noted that it would potentially be a subject of legitimate clinical comment between colleagues to say that a resident was too heavy for a hoist to be used safely without risking injury to the resident or to staff. It noted that the allegation was of the use of the words that Resident A was too fat or words to that effect. It was therefore unclear whether the word fat was actually used. Even if the word was used, there was insufficient evidence to establish whether the context in which it was being used was unprofessional or inappropriate to an extent which might be characterised as misconduct. For example, there was no evidence to suggest that it was used in the presence of, or directed towards, Resident A herself, or that it was anything other than a passing comment between colleagues. The panel was unable to draw any factual conclusions about the context or manner in which this comment was made. 15

16 The panel therefore considered that there was no material from which it was able to conclude that the comment referred to in charge 2 amounted to a departure from proper professional standards, still less to the extent required for it to be characterised as misconduct. It concluded that charge 2 did not amount to misconduct. The panel next considered charge 3. It noted that the essence of this charge was that a resident in Ms Anderson s care asked for her help with the basic care need of using the toilet, and that she failed to provide that assistance, resulting in her wetting the bed. This was in the context of a residential setting where the Home was in effect the resident s home. The panel considered that this amounted to a failure to treat resident B with dignity and respect and that it was conduct which breached the following provisions of the Code: 1. Treat people as individuals and uphold their dignity To achieve this, you must: 1.1 treat people with kindness, respect and compassion 1.2 make sure you deliver the fundamentals of care effectively 1.4 make sure that any treatment, assistance or care for which you are responsible is delivered without undue delay The panel was mindful that not every breach of the Code will result in a finding of misconduct. It bore in mind that this was a single incident. However it concluded that Ms Anderson s actions on this occasion were a sufficiently serious departure from what would be proper in the circumstances that they amounted to misconduct. The panel therefore concluded that the matters alleged in charge 3, but not the other proven charges, amounted to misconduct. Decision on impairment 16

17 Having concluded that Ms Anderson s actions as set out in charge 3 amounted to misconduct, the panel next went on to consider whether Ms Anderson s fitness to practise is currently impaired by reason of that misconduct. In this regard the panel had regard to the guidance given in 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 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. Mrs Justice Cox went on to say in Paragraph 76: I would also add the following observations in this case having heard submissions, principally from Ms McDonald, as to the helpful and comprehensive approach to determining this issue formulated by Dame Janet Smith in her Fifth Report from Shipman, referred to above. At paragraph she identified the following as an appropriate test for panels considering impairment of a doctor s fitness to practise, but in my view the test would be equally applicable to other practitioners governed by different regulatory schemes. The panel therefore had regard to the guidance formulated by Dame Janet Smith, and asked itself whether its findings in respect of misconduct in this case showed that Ms Anderson s fitness to practise is impaired in the sense 17

18 that she has in the past acted, and/or is liable in the future to act in such a way as to: a. place a patient or patients at unwarranted risk of harm; and/or b. bring the profession into disrepute; and/or c. breach one of the fundamental tenets of the profession; and/or d. act dishonestly. The panel considered that the second and third limbs of Grant were engaged in this case. It considered that by failing to provide assistance to a vulnerable patient in her care when she was asked to do so, Ms Anderson breached the fundamental tenet of the profession to treat patients with dignity and respect, and brought the profession into disrepute. The panel next considered whether Ms Anderson was liable to act in such a way again in future. In considering this issue, it considered what evidence was available to it about her professional history and personal circumstances, the extent to which her conduct is remediable and/or has been remedied, and the extent to which she has demonstrated any remorse or insight with regard to her conduct. The panel noted that because Ms Anderson has not engaged with these proceedings, there was an absence of evidence available to it in relation to these issues. In particular, there was no evidence of any remorse or insight, and no evidence of any remedial steps taken by her to address her conduct and provide assurance that she will conduct herself professionally in her future nursing practice. The panel noted that this was perhaps not altogether surprising given that, according to the letter from her representatives in February 2018, Ms Anderson has ceased work as a nurse and does not intend to return to a nursing career. 18

19 The panel noted that there was no evidence of any previous incidents of regulatory concern in Ms Anderson s career. There was some documentation in the bundle which suggested that other patients or colleagues may have raised complaints with her employer about her behaviour and/or attitude. There were minutes of a meeting held with her by Colleague D in June 2016 at which time it appeared that some colleagues had accused her of bullying them. However the panel was unable to attach any weight to that document. It noted from the minutes of the meeting that Ms Anderson had a very different perspective about the allegations and there was no material from which the panel was able to draw any conclusions about whether or not those past allegations were well-founded. It therefore disregarded them. The panel was therefore mindful that the incident was a single, isolated occurrence in a professional career otherwise free from regulatory concerns. The panel considered that this was relevant to the risk of repetition, in that an incident which is an isolated occurrence is inherently less likely to be repeated. Nevertheless, the absence of any evidence of remediation, or of insight into what was in the panel s view a serious incident, was of concern. The panel considered that there remained a risk of repetition in this case, albeit that the risk of repetition was relatively low. The panel therefore concluded on public protection grounds that Ms Anderson s fitness to practise is currently impaired. It also bore in mind the guidance in Grant that it should consider whether the public interest required a finding of impairment in this case. The panel considered that the public would be concerned, and public confidence in the profession and the regulatory process would be undermined, if no finding of impairment were made in a case involving a failure to provide basic care to a vulnerable resident in a residential setting. It therefore concluded that a finding of impairment was required on wider public interest grounds in addition to the grounds of public protection. For all the reasons set out above, the panel concluded that Ms Anderson s fitness to practise is currently impaired. 19

20 Dermination on sanction: The panel considered this case very carefully and decided to impose a Caution Order for a period of two years. The effect of this order is that Ms Anderson s name on the NMC register will show that she is subject to a caution order, and anyone who enquires about her registration will be informed of this order. In reaching this decision, the panel had regard to all the evidence that has been adduced in this case. The panel had careful regard to the NMC s Sanctions Guidance ( SG ) published by the NMC and accepted the advice of the legal assessor. It recognised that the decision on sanction is a matter for the panel, exercising its own independent judgement. It bore 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 considered that there was no evidence available to it which suggested that there were any particular aggravating or mitigating features in this case. It had regard to its earlier decision that there was a risk of repetition in this case but that the risk of repetition was relatively low, particularly given that this was an isolated occurrence on a single shift in a career otherwise without regulatory concern. The panel was mindful that this was a serious incident involving a breach of a fundamental tenet of the profession. Nevertheless, in all the circumstances set out in its decision on impairment, the panel considered that this was a case in which the impairment was towards the lower end of the spectrum of impaired fitness to practise. The panel first considered whether to take no action but determined that this would be inappropriate in view of the seriousness of the case. The panel concluded that the public interest considerations in this case required that the misconduct be marked by a sanction in order to declare and uphold proper professional standards and maintain public confidence in the profession and the regulatory process. 20

21 In considering whether a caution order would be appropriate in the circumstances, the panel took into account the SG, 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. For reasons already set out, the panel considered that this applied in the present case. It considered that given the relatively low risk of repetition in this case, the public would be sufficiently protected by a caution order, particularly because any employer engaging Ms Anderson s services as a nurse would be on notice of the caution order and would be alert to any potential issues with her practice. Moreover the panel noted that it is Ms Anderson s stated intention not to return to a nursing career and any residual risk of repetition therefore appears to be more theoretical than real. The panel considered that a caution order was a serious mark against Ms Anderson s professional name and that a relatively lengthy caution would be sufficient to send a clear signal to her, the profession and the public that her behaviour on this single occasion was unacceptable and must not be repeated. It would therefore serve to declare and uphold professional standards and maintain public confidence in the profession and the regulatory process. The panel considered that a period of two years would be appropriate and proportionate in the circumstances of the case. 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 in this case because the nature of the misconduct in this case was not readily susceptible to conditions. The panel considered that such an order was not necessary to protect the public and would not assist Ms Anderson s return to nursing practice. The panel further considered that a suspension order would be a disproportionate response to a single isolated incident of misconduct in all the circumstances of this case. 21

22 Having considered the general principles above and looking at the totality of the findings on the evidence, the panel determined that to impose a caution order for a period of two years would be the appropriate and proportionate response. At the end of this period the note on Ms Anderson s entry in the register will be removed. However, the NMC will keep a record of the panel s finding that her fitness to practise has been found impaired. If the NMC receives a further allegation that her 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. 22