Fitness to Practise Committee Substantive Hearing 31 October- 2 November 2017

Transcription

1 Fitness to Practise Committee Substantive Hearing 31 October- 2 November 2017 Nursing and Midwifery Council, Regus Belfast, Forsyth House, Cromac Square, Belfast BT2 8LA Name of Registrant Nurse: NMC PIN: Part(s) of the register: Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Mrs Cunningham: Alina Luiza Ionita 14J0017C Registered Nurse - Adult Nursing Northern Ireland Misconduct Barbara Stuart (Chair, Lay member) Sandra Lamb (Registrant member) David Boyd (Lay member) Caroline Maguire Aoife Kennedy Present and not represented Nursing and Midwifery Council: Represented by Yusuf Segovia, counsel, NMC Regulatory Legal Team. Facts proved: 2, 3, 4, 5 Facts proved by admission: 1, 6, 7, 8, 9 Facts not proved: 10 Fitness to practise: Sanction: Impaired Caution order (5 years) 1

2 Details of charges (as amended): That you, a registered nurse on a night shift on January 2017; 1) Slept on duty; [found proved by admission] 2) Allowed one or more care assistants to sleep on duty; [found proved] 3) Left the treatment room door open; [found proved] 4) Left cupboards in the treatment room unlocked; [found proved] 5) Left medication unattended; [found proved] 6) Signed Patient A s MAR chart to indicate that you had administered one or more of the following medications at 07:00 on 24 January 2017, when you had not: a) 1500mg Adcal; b) 25mg Atarax; c) 8mg Bethahistine; d) 305mg Ferrous Fumarate; e) 500mg Levetiracetam; f) 75mcg Levothyroxine; g) 10mg Metoclopramide; h) 100mg Phenytoin Sodium; i) 25mg Pregabalin; j) 5mg Ramipril; k) 100mg Sertraline; l) 1200mg Slow Sodium modified release; m) 400mg Tegretol; n) 100mcg QVAR inhaler; [found proved by admission] 2

3 7) Signed Patient B s MAR chart to indicate that you had administered one or more of the following medications at 06:00 on 24 January 2017, when you had not; a) 6000ml Sodium Chloride Irrigation Solution 0.9%; b) 10ml Fluoxetine (20mg/5ml); c) 1010mg Ascorbic Acid with Zinc tablet; d) One Hyoscine Hydrobormide patch (1mg/72 hours); e) 250mg Solvazinc effervescent tablet; f) 20ml Baclofen sugar free oral solution (5mg/5ml); g) 1500ml Jevity RTH Liquid; [found proved by admission] 8) Signed Resident C s MAR chart to indicate that you had administered one or more of the following medications when you had not: a) on 23 January 2017: i) at 20:00 5ml Pholcodine; ii) at 20:00 3 tablets Co-Beneldopa; iii) at 23:00 40mg Simvastatin; b) At 08:00 on 24 January 2017: i) 5ml Pholcodine; ii) 125mg Co-Beneldopa; [found proved by admission] 9) Signed Resident D s MAR chart to indicate that you had administered one or more of the following medications at 06:00 on 24 January 2017, when you had not: a) 30mg Lansoprazole; b) 50ml Baclofen sugar free oral solution; c) 5ml Domperidone suspension (5mg/5ml); d) 1000ml pack Jevity Promote RTL Liquid; e) 15ml Lactulose solution ( g/ml); 3

4 f) 0.5ml Risperidone liquid (1mg/ml); g) 10ml Ranitidine oral solution (150mg/ml); h) 20000ml water for irrigation; i) One Hyoscine Hydrobromide patch (1mg/72 hours); [found proved by admission] 10) Your actions at one or more of charges 6-9 were dishonest in that: a) You knew that signing a MAR chart indicated the administration of medication to a patient; and b) You knew the medication had not been administered; and c) You intended to mislead any person reading the MAR chart into believing that the medication had been administered. [found not proved] AND in light of the above, your fitness to practise is impaired by reason of your misconduct. 4

5 Decision and reasons on application to amend the charge The panel heard an application made by Mr Segovia, on behalf of the NMC, to amend the wording of charge 8. The proposed amendment was to change the time in charge 8(a)(iii) from 20:00 to 23:00. Mr Segovia submitted that the proposed amendment would accurately reflect the evidence. The original charge: 8) Signed Resident C s MAR chart to indicate that you had administered one or more of the following medications when you had not: a. at 20:00 on 23 January 2017: i. 5ml Pholcodine; ii. 3 tablets Co-Beneldopa; iii. 40mg Simvastatin; b. At 08:00 on 24 January 2017: i. 5ml Pholcodine; ii. 125mg Co-Beneldopa; The amended charge: 8) Signed Resident C s MAR chart to indicate that you had administered one or more of the following medications when you had not: d) on 23 January 2017: i) at 20:00 5ml Pholcodine; ii) at 20:00 3 tablets Co-Beneldopa; iii) at 23:00 40mg Simvastatin; 5

6 e) At 08:00 on 24 January 2017: i) 5ml Pholcodine; ii) 125mg Co-Beneldopa; You did not have any objections to this. The panel accepted the advice of the legal assessor that Rule 28 of the Rules states: 28. (1) At any stage before making its findings of fact, in accordance with rule 24(5) or (11), the Investigating Committee (where the allegation relates to a fraudulent or incorrect entry in the register) or the Fitness to Practise Committee, may amend (a) the charge set out in the notice of hearing; or (b) the facts set out in the charge, on which the allegation is based, unless, having regard to the merits of the case and the fairness of the proceedings, the required amendment cannot be made without injustice. (2) Before making any amendment under paragraph (1), the Committee shall consider any representations from the parties on this issue. The panel was of the view that such an amendment, as applied for, was in the interests of justice. The panel was satisfied that there would be no prejudice to you and no injustice would be caused to either party by the proposed amendment being allowed. It was therefore appropriate to allow the amendment, as applied for, to ensure clarity and accuracy. Decision and reasons on application pursuant to Rule 31: On day 3 of the hearing, you made an application to make submissions to the hearing via telephone as you were unable to attend after day 2 of the hearing. Mr Segovia did not object to this. 6

7 The panel accepted the advice of the legal assessor. The panel considered that there was no issue in you participating in the hearing via telephone after day 2 and therefore granted your application. 7

8 Background You began working at Longfield Care Home (the Home) as a registered nurse in Longfield is a nursing home for elderly and frail residents with care and support needs. A number of allegations were brought against you in relation to a night shift you worked at the Home on January It is alleged that you slept on duty, allowed care assistants to sleep on duty, left the treatment room door unlocked, left medication unattended, and that the signing for medication that had not been administered was dishonest. 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 Segovia, on behalf of the NMC and the evidence given and representations made by you. 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. The panel took into account all the oral and documentary evidence in this case. The panel heard oral evidence from two witnesses called on behalf of the NMC and from you: Mrs 1, Registered Home Manager at Ardlough Nursing Care Home Mrs 1 told the panel that on 24 January 2017 she carried out a night visit at the Home along with the Registered Manager, Mrs 2 at 04:20. The Registered Manager and Mrs 1 8

9 found you sleeping in the main lounge on an arm chair. You did not wake up when they entered. Mrs 1 told the panel that in the Home there is a system in place where each resident is issued with a hand held buzzer to use when assistance is needed. When the resident presses the button it alerts staff and a light flashes with a loud noise. Mrs 1 noticed three green buzzer lights on. She checked the rooms and all the residents were safe and asleep. Mrs 1 then went towards the small television room. She saw that the television was on but the volume turned down, and two care assistants on separate arm chairs appeared to be in a deep sleep. She stepped into the room and after a short period of time the two care assistants began to wake up. Mrs 1 then switched on the light and asked them to carry on with their duties. Both Mrs 1 and Mrs 2 then went back into the main lounge area and saw that you were still asleep. Mrs 2 checked the treatment room and saw that the door was left unlocked. She could see that the cupboard doors were left unlocked with the keys hanging from the locks. She saw a bottle of peg feed that was left out and a medicine cup with several tablets dispensed in it. Mrs 1 told the panel that a medicine cup is used for the dispensing of medication prior to administration and is used for the dispensing of medication prior to administration and is used to prevent infections. Mrs 1 stated that the treatment room is where all the medication is kept including peg feed liquid foods and medical equipment. Within the treatment room are cupboards which are accessed with individual keys. Only the registered nurse has the keys to access the room, medicine trolley and cupboards. Mrs 1 stated that it is vital that the treatment rooms and its cupboard are locked at all times when the nurse is not inside due to the vulnerability of the residents and if left unattended a resident can potentially access medication causing serious risks. Mrs 1 stated that as she was standing at the doorway of the main lounge your phone alarm went off at 05:00 and she called Mrs 2. When she re-entered first Mrs 1 stated 9

10 that she saw you take your phone out of your pocket and turn it off. She told the panel that you then stretched putting your arms above your head and turned. She stated that when you saw Mrs 1 you said Good Morning. Mrs 2 asked you to come to the manager s office and discussed policies, procedures and risks with her. An investigation interview was conducted. Following this, you were then instructed by the Home Manager to complete your morning duties, including the medication round. You did this unsupervised. The Regional Manager was contacted and you were suspended with immediate effect. Mrs 1 escorted you out of the building at approximately 08:00. The panel considered Mrs 1 was a credible witness and spoke clearly and confidently from memory. Mrs 2, Registered Manager at the Home Mrs 2 told the panel that the Home consists of three units. There is a registered nurse with two care assistants on each unit who work in shift patterns from 08:00 to 20:00 and 20:00 to 08:00. Mrs 2 stated that, prior to the alleged events, you worked at the Home for approximately 6 months and worked 5 to 6 nights weekly. Mrs 2 stated that the responsibilities of the registered nurse on night duty are to manage the care assistants and ensure that the Home is secure and safe for the residents. The Registered Nurse is also responsible for the dispensing and administering of medication including setting up and monitoring peg feeding equipment which is then recorded on a MAR sheet. She told the panel that only the registered nurse has the keys to access the treatment rooms where residents medications are safely kept. On 24 January 2017 Mrs 2 carried out a night visit to the Home with Mrs 1 at 04:20. She stated that they found you in the main lounge reclined in a reclining arm chair sleeping. Mrs 2 then went to the small lounge where they saw the two care assistants asleep on separate chairs. They woke up shortly after. 10

11 When Mrs 2 went back to the main lounge she checked the treatment room and noticed the door was left unlocked and all the cupboard doors had keys hanging from the locks. She noticed that medication for Resident B was left on a medication trolley. That medication should have been administered at 23:00 the previous night. Mrs 2 then checked the MAR sheets and noticed that the medication for Resident D was signed for, the medication left out in the treatment room was clearly pre-prepared for a resident named Resident A and the peg feed for Resident B. The medication for Resident A was due to be administered at 07:00 that day. The Home s policies do not allow for nurses to pre-sign residents MAR charts or administer medication before the prescribed time. Mrs 2 stated that as you began to wake up your phone alarm went off at 05:00 and you switched it off. Mrs 2 then asked you to go to her office and you were suspended and escorted out of the building at approximately 08:00 after you had completed your morning duties. The panel considered Mrs 2 was a credible and reliable witness and appeared to have a clear recollection of relevant events. Your evidence The panel heard evidence from you under oath. You stated that you were not aware that the two care assistants were sleeping in the small lounge and that at no stage did you tell them that they could sleep whilst on duty. In relation to leaving the treatment room unlocked, you stated that you did not recall doing this, but that it would have been usual for you to go in and out of the treatment room while on duty. You told the panel that you didn t use the treatment room cupboards that night, and these were used only to keep extra stock. You stated that you did not check whether the cupboards were locked. You stated that the lock for the key cupboard in the treatment room was broken at the time. In relation to leaving medication unattended, you told the panel that you did leave medication in cups in the treatment room alongside a bottle of peg feed. However, you stated that these were not in reach of any of the residents as none of them were mobile. 11

12 In relation to signing for medication that you had not yet administered, you told the panel that you did do this, but that you did not intend to be dishonest or mislead anyone. You stated that you did this because the morning round is often very rushed and, by signing the MAR sheet the night before, you would save time in the morning for other tasks. You stated that you would never intentionally mislead anyone, and that you were simply trying to pre-prepare by signing the MAR sheet. You stated that you intended to give the medication in the morning at the due time. You told the panel that you were having personal difficulties at home at the time of the events which meant that you had a lack of sleep and could not afford to take time off work. You stated that these difficulties have now been resolved. The panel considered that your evidence was credible and clear on some issues. However, it considered that you were unclear in your recollection of other issues. It considered that you recalled events as best as you could. At the start of this hearing you admitted the following charges: 1) Slept on duty; 6) Signed Patient A s MAR chart to indicate that you had administered one or more of the following medications at 07:00 on 24 January 2017, when you had not: a. 1500mg Adcal; b. 25mg Atarax; c. 8mg Bethahistine; d. 305mg Ferrous Fumarate; e. 500mg Levetiracetam; f. 75mcg Levothyroxine; g. 10mg Metoclopramide; h. 100mg Phenytoin Sodium; i. 25mg Pregabalin; 12

13 j. 5mg Ramipril; k. 100mg Sertraline; l. 1200mg Slow Sodium modified release; m. 400mg Tegretol; n. 100mcg QVAR inhaler; 7) Signed Patient B s MAR chart to indicate that you had administered one or more of the following medications at 06:00 on 24 January 2017, when you had not; a. 6000ml Sodium Chloride Irrigation Solution 0.9%; b. 10ml Fluoxetine (20mg/5ml); c. 1010mg Ascorbic Acid with Zinc tablet; d. One Hyoscine Hydrobormide patch (1mg/72 hours); e. 250mg Solvazinc effervescent tablet; f. 20ml Baclofen sugar free oral solution (5mg/5ml); g. 1500ml Jevity RTH Liquid; 8) Signed Resident C s MAR chart to indicate that you had administered one or more of the following medications when you had not: a. on 23 January 2017: i. at 20:00 5ml Pholcodine; ii. at 20:00 3 tablets Co-Beneldopa; iii. at 23:00 40mg Simvastatin; b. At 08:00 on 24 January 2017: i. 5ml Pholcodine; ii. 125mg Co-Beneldopa; 9) Signed Resident D s MAR chart to indicate that you had administered one or more of the following medications at 06:00 on 24 January 2017, when you had not: a. 30mg Lansoprazole; b. 50ml Baclofen sugar free oral solution; c. 5ml Domperidone suspension (5mg/5ml); 13

14 d. 1000ml pack Jevity Promote RTL Liquid; e. 15ml Lactulose solution ( g/ml); f. 0.5ml Risperidone liquid (1mg/ml); g. 10ml Ranitidine oral solution (150mg/ml); h ml water for irrigation; i. One Hyoscine Hydrobromide patch (1mg/72 hours); These were therefore announced as proved by way of admission. The panel then went on to consider the remaining charges. The panel considered each charge separately and made the following findings on the balance of probabilities: 2) Allowed one or more care assistants to sleep on duty; The panel took into account the evidence of Mrs 1 and Mrs 2. Both witnesses confirmed that they found two care assistants who should have been under your supervision asleep in the small lounge. The panel noted your evidence that you did not expressly tell the care assistants at any stage that they could sleep whilst on duty. However, it considered that you were responsible for supervising them and, by sleeping yourself and failing to supervise, you allowed them to sleep on duty. Accordingly, the panel found charge 2 PROVED. 3) Left the treatment room door open; The panel noted Mrs 1 and Mrs 2 s evidence that they found the treatment room door unlocked. In your oral evidence you said you did not know whether you had left it unlocked, but you did not dispute the evidence of Mrs 1 and Mrs 2. The panel therefore considered that you did leave the treatment room door open. Accordingly, the panel found charge 3 PROVED. 14

15 4) Left cupboards in the treatment room unlocked; The panel considered the evidence from Mrs 1 and Mrs 2 that they found the cupboards in the treatment room unlocked. It took into account your evidence that you had not used the cupboards during your shift and they had been left unlocked by the previous nurse on duty. The panel considered that, even if the cupboards were unlocked when you commenced your shift, it was your responsibility by reason of your position to check the cupboards and lock them once you began your shift. The panel therefore considered that you did leave the cupboards in the treatment room unlocked. Accordingly, the panel found charge 4 PROVED. 5) Left medication unattended; The panel considered the evidence from Mrs 1 and Mrs 2. Mrs 2 stated: I saw a medication cup with approximately 8-10 tablets left in it. I also saw peg feed liquid that was left out. Upon checking the MAR sheets, the medication for Resident D was signed for, the medication left out in the treatment room was clearly pre-prepared for a resident named Resident A and the peg feed for another resident named Resident B. The panel considered that you had pre-prepared medication and left it unattended in the treatment room and that you had left the cupboards in the treatment room unlocked. Accordingly, the panel found charge 5 PROVED. 10) Your actions at one or more of charges 6-9 were dishonest in that: a) You knew that signing a MAR chart indicated the administration of medication to a patient; and b) You knew the medication had not been administered; and 15

16 c) You intended to mislead any person reading the MAR chart into believing that the medication had been administered. The panel took advice from the legal assessor on the Sureme Court case of Ivey v Genting Casinos (UK) Ltd t/a Crockfords [2017] UKSC 67 as to the appropriate test for dishonesty. The panel took into account your oral evidence and considered that you agreed that you knew that signing a MAR chart indicated the administration of medication to a patient, and that you knew the medication had not been administered. However, it took into account your evidence that you did this only to pre-prepare and save time on the morning medication round, and did not intend to mislead anyone by doing this. The panel did not consider that the act of signing a MAR chart indicating administration of medication to a patient when it had not been administered was of itself a dishonest act by the standards of ordinary decent people. The panel considered that, whilst this was very poor practice, it was not done with the intention to mislead anyone and did not amount to dishonesty. The panel therefore considered that your actions in charges 6-9 were not dishonest. Accordingly, the panel found charge 10 NOT PROVED. 16

17 Decision on misconduct and impairment: Having announced its finding on all the facts, the panel then moved on to consider whether the facts found proved amount to misconduct and, if so, whether your fitness to practise is currently impaired by reason of that misconduct. The NMC has defined fitness to practise as a registrant s suitability to remain on the register without restriction. The panel had regard to the submissions of Mr Segovia on behalf of the NMC and your evidence under oath. The panel also had regard to the from your current employer dated 1 November 2017, your reflective piece, your certificate of training and the testimonials from your previous employer in Romania dated March Mr Segovia submitted that you had breached a number of standards which put the residents in the Home at risk of potential harm. He invited the panel to consider the charges in the round and find misconduct. He submitted that the public could be at risk and that public confidence in the profession would be undermined if a finding of impairment were not found. He submitted that the public interest required a finding of impairment in this case. In your oral evidence you stated that you acknowledge your mistakes and that they fell below the standards expected of a qualified nurse. You spoke about ongoing health issues within your family at the time of events and stated that these had an impact on your failures. You told the panel that you are now working in a new job in a less pressured environment and a more manageable workload. You stated that you would not repeat the same mistakes, and that you are now extra cautious in your practice. The panel accepted the advice of the legal assessor. In determining whether your fitness to practise is currently impaired, the panel has borne in mind that this is a two stage process. It first considered whether the facts found proved in this case amount to misconduct and, if so, whether as a result of that misconduct, your fitness to practise is currently impaired. 17

18 The panel acknowledged that there is no burden or standard of proof at this stage of the proceedings and that the issues of misconduct and impairment remain matters for the independent judgment of the panel. In reaching its decision the panel bore in mind its duty to protect the public, to maintain public confidence in the profession and the regulatory process, and to declare and uphold proper standards of behaviour and conduct. The panel considered first whether the facts giving rise to the charges found proved amounted to misconduct on your part. This case involves the signing of MAR charts where medication had not been administered, failure to supervise care assistants, falling asleep whilst on duty, and failure to keep medicines safely and securely. This placed patients at risk of harm. The panel took account of the fact that this is the first time you have come before the NMC, and that your acts and omissions relate to an isolated incident. The panel took into account the nature of the failings. It considered that your failure to supervise care assistants and falling asleep on duty compromised the safety of the residents at the Home. It considered that leaving the treatment room and medicine cupboards unlocked could have potentially put residents at risk of harm. The panel considered that your failings fell seriously short of what is expected of a registered nurse. The panel considered that your actions breached the 2015 Code (The code: Professional Standards of Practice and Behaviour for nurses and midwives) ( the Code ): It considered that the following paragraphs of the Code had been breached: 1.2. Make sure you deliver the fundamentals of care effectively Complete all records at the time or as soon as possible after an event, recording if the notes are written some time after the event Take account of your own personal safety as well as the safety of people in your care. 18

19 16.3. Tell someone in authority at the first reasonable opportunity if you experience problems that may prevent you working within the Code or other national standards, taking prompt action to tackle the causes of concern if you can Take all steps to keep medicines stored securely Be aware at all times of how your behaviour can affect and influence the behaviour of other people. The panel was aware that not every act falling short of what would be proper in the circumstances, and not every breach of the Code, would be sufficiently serious that it could properly be described as misconduct. However, the Code clearly establishes the basic rules and standards ordinarily required to be followed by a registered nurse. The panel was satisfied that your acts and omissions fell far below the standard expected of a competent nurse and were sufficiently grave to amount to misconduct. The panel then went on to consider whether by reason of your misconduct your fitness to practise is currently impaired. The panel reminded itself that it should consider not only the risk that a registrant poses to members of the public, but also the public interest in upholding proper professional standards and public confidence in the NMC as a regulator, and whether those aims would be undermined if a finding of impairment were not made in the circumstances. The panel reminded itself of the guidance of Mrs Justice Cox in Council for Healthcare Regulatory Excellence v. NMC and Paula Grant [2011] EWHC 927 (Admin), adopting the test proposed by Dame Janet Smith in the Shipman enquiry: Do our findings of fact in respect of the doctor s [nurse 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 to act in the future so as to put a patient or patients at unwarranted risk of harm; and/or 19

20 b) Has in the past brought and/or is liable in the future to bring the 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 profession; and/or. d) The panel considered that these three limbs of the test were satisfied in this case. It had regard to whether your misconduct was easily remediable, whether it had been remedied and whether it is likely to be repeated. The panel considered that you have demonstrated insight into your failings. It had regard to your reflective piece and your oral evidence and considered that you acknowledged your failings, demonstrated genuine remorse, and explained how you would act differently in the future. It took into account the certificate of training confirming that you undertook and passed a staff induction on 2 and 5 June In addition, the panel received an from your current employer dated 1 November 2017 which stated that you have been working as a registered nurse at a private nursing home since 12 August 2017 with no concerns regarding your practice. The panel considered that you demonstrated insight and some remediation. However, it considered that your misconduct was of a serious nature, and you have been working in your current role for a short period of time. The panel was therefore not satisfied that your misconduct had yet been remediated. The panel decided that your behaviour seriously undermined the trust and confidence the public has in the nursing profession. For all the reasons thus far, the panel further determined that 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 circumstances. Accordingly the panel determined that your current fitness to practise is impaired by reason of your misconduct on both public protection and public interest grounds. 20

21 Determination on sanction: Having determined that your fitness to practise is impaired, the panel has considered what sanction, if any, it should impose. In reaching its decision, the panel has considered all the evidence provided, together with Mr Segovia s oral submissions on behalf of the NMC, and your oral submissions via telephone. The panel accepted the advice of the legal assessor. The panel has considered this case very carefully and has decided to make a caution order for a period of 5 years. 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. 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 Sanctions Guidance published by the NMC. It had regard to the need to protect the public as well as the wider public interest. It recognised that the decision on sanction is a matter for the panel, exercising its own independent judgement. Before making its decision on the appropriate sanction, the panel established the aggravating and mitigating features in your case. The panel considered the aggravating features to be: You were the registered nurse in charge on the night shift The panel considered the mitigating features to be: You made admissions to some of the charges There have been no previous findings against you during your 11 years as a registered nurse 21

22 You have demonstrated insight and some remediation You provided a reflective piece to the panel acknowledging your failings and demonstrating remorse You were experiencing difficult personal circumstances at the time of events The panel first considered whether to take no action but concluded that this would be inappropriate in view of the seriousness of the case. The panel decided that it would be neither proportionate nor in the public interest to take no further action. Next, in considering whether a caution order would be appropriate in the circumstances, the panel took into account the 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. You are now working in a less pressured environment with a better managerial structure in place. The panel noted that you have shown insight into your conduct, made admissions and have shown genuine remorse for your misconduct. The panel has been told that there have been no adverse findings in relation to your practice either before or since these incidents. Although the panel has found you impaired on public protection grounds, it has concluded that there is no risk to the public or patients which requires your practice to be restricted. The panel considered whether it would be proportionate to impose a more restrictive sanction. It concluded that a conditions of practice order would not be appropriate in the circumstances of your case. Your failures were not clinical, there is no evidence of general incompetence. The panel considered a suspension order and decided that it would be disproportionate in your case. It took into account that there was no actual patient harm, there was no evidence of harmful or deep-seated attitudinal problems, and that you have demonstrated remorse and insight. The panel has decided that a caution order would adequately protect the public. For the next 5 years your employer or any prospective employer will be on notice that your 22

23 fitness to practise had been found to be impaired and that your practice is subject to an order. 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 5 years would be the appropriate and proportionate response. It would mark not only the importance of maintaining public confidence in the profession, but also send the public and the profession a clear message about the standards required of a registered nurse. 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 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. 23