Conduct and Competence Committee Substantive Hearing Monday 23 May 2017 Wednesday 25 May 2017

Transcription

1 Conduct and Competence Committee Substantive Hearing Monday 23 May 2017 Wednesday 25 May 2017 Nursing and Midwifery Council, 2 Stratford Place, Montfichet Road, London, E20 1EJ Name of Registrant Nurse: Mrs Glenn Domopoy NMC PIN: 03C0137O Part(s) of the register: RN1, Registered Nurse Sub Part 1 Adult Nursing 7 March 2003 Area of Registered Address: England Type of Case: Misconduct Panel Members: Anne Booth (Chair - Lay member) Pauline Esson (Registrant member) Rama Krishnan (Lay Panel member) Legal Assessor: Panel Secretary: Susan Monaghan Hassan Reese Registrant: Nursing and Midwifery Council: Present and represented by Michael Lavers, Represented by Chris Scott, Counsel, instructed by NMC Regulatory Legal Team. Facts proved by admission: 1a, 1b, 1c, 1d and 2 Fitness to practise: Impaired Sanction: Conditions of Practice order 12 months Interim Order: Interim Conditions of Practice Order 18 months 1

2 Details of charge: That you, a registered nurse, whilst working as the Staff Nurse at St James University Hospital, Leeds: 1. On 4 April 2016 at approximately 7.20 am in relation to the administration of IV Co-Amoxiclav to Patient A you: a. Failed to ensure the process of administration of the medication was independently checked by a second accredited person; b. Failed to conduct an allergy check and/or risk assessment prior to administration of the medication; c. Failed to conduct a patient identity check prior to administration of the medication; d. Incorrectly administered the medication to Patient A when it should have been administered to Patient B. 2. Your actions at charge 1d above caused or contributed to the death of Patient A. And, in light of the above, your fitness to practise is impaired by reason of your misconduct. Background 2

3 On 06 July 2016, you were referred to the NMC by your employer, Leeds Teaching Hospitals' NHS Trust in relation to an incident on 4 April 2016 on the Respiratory Care Unit at St James' Hospital, Leeds. You were a senior nurse on the night shift in question. You made a medicines administration error in that you administered intravenous ('IV') Co-Amoxiclav, an antibiotic medication containing amoxicillin, to Patient A. Patient B was the patient for whom that medication was prescribed. Amoxicillin is a type of penicillin. Patient A was allergic to penicillin and was wearing a red wrist band, which is used in the Trust to denote that the patient in question has an allergy or allergies. Patient A's allergy to penicillin was recorded on the prescription chart. As a result of the allergy to penicillin, Patient A should not have been given Co-Amoxiclav. Shortly after you administered the IV Co-Amoxiclav, Patient A deteriorated acutely and suffered respiratory arrest followed by cardiac arrest. Cardio pulmonary resuscitation was attempted but was unsuccessful and Patient A died. HM Coroner's post mortem established the case of death as anaphylaxis due to the administration of amoxicillin. During the Trust's local investigation, you admitted that you saw that Patient A was wearing a red wrist band but did not take any action because you had seen a prescription chart when you made up the IV medication and you knew that the prescription chart contained no recorded allergies. At the bedside and prior to administering the IV medication, you did not establish Patient A's identity either by checking his wrist band or by asking Patient A his name and date of birth. Although Patient A was breathing via a tracheostomy, and therefore unable to communicate verbally, he is said to have been alert and communicating via a note book and/or flip book of words and symbols. Decision on the findings on facts and reasons: 3

4 Following the reading of the charges, Mr Lavers on your behalf told the panel that you admitted the facts of charges 1 and 2. Accordingly the panel found all of the charges proved by way of admission. Mr Lavers further informed the panel that you admit misconduct and that your fitness to practise is currently impaired. Submission 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. The NMC has defined fitness to practise as a registrant s suitability to remain on the register unrestricted. The panel heard oral evidence from one witness called on behalf of the NMC: Ms 1,who was a Senior Sister at Leeds General Infirmary at the relevant time and had been appointed to investigate the circumstances around this incident. The panel found Ms 1 to be a credible and reliable witness who explained to the panel the culture within the relevant ward as opposed to other wards within that hospital. She accepted that at the time, you were remorseful as to what happened. Mr Scott reminded the panel that there is no burden of proof at this stage and the decision on misconduct is for the panel s independent judgement. Mr Scott referred the panel to the case of Roylance v General Medical Council (no. 2) [2000] 1 AC 311 which defines misconduct as a word of general effect, involving some act or omission which falls short of what would be proper in the circumstances. He reminded the panel that, in order to constitute misconduct, any departure from proper standards must be serious. 4

5 In his submissions Mr Scott invited the panel to take the view that your actions amounted to a breach of The Code: Professional standards of practice and behaviour for nurses and midwives (2015) ( the Code ). He then directed the panel to specific paragraphs and identified where, in the NMC s view, your actions amounted to misconduct. Mr Scott submitted that your failings in respect of the charges found proved relate to your disregard for Trust s Policies, the NMC Code of Conduct and the NMC s Standards for medicine management. He submitted that your actions fell seriously short of what was proper in the circumstances. He submitted that there was a culture on the ward where nurses had established their own practices of administering medication, contrary to the Trust policy on this. Mr Scott submitted that even by those inadequate standards, you still fell far short of what was expected. He submitted that your conduct in relation to the charges amounts to serious and significant breaches of the standards expected of a registered nurse, and therefore amounts to misconduct. He then moved on to the issue of impairment, and addressed the panel on the need to have regard to protecting the public and the wider public interest. This included the need to declare and maintain proper standards and maintain public confidence in the profession and in the NMC as a regulatory body. Mr Scott referred the panel to the case of Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin). Mr Lavers on your behalf submitted that you have admitted all of the charges. He also submitted that you accept that the errors made amount to misconduct and impairment. With regards to impairment, Mr Lavers submitted that this was a one-off incident against an otherwise unblemished career. He referred the panel to the various testimonials which have been provided on your behalf. He submitted that you have shown appropriate insight, remorse and regret. He told the panel that you are mortified about what happened. Mr Lavers submitted that you have admitted your mistakes from the 5

6 very outset and that you have been co-operative at every stage with both the Trust internal investigation and these proceedings. He submitted that you were re-assessed after the incident, and signed off as competent in medicines administration by the medicines management team. He submitted that you had no opportunity to show remediation over a lengthy period of time as you were only able to practise for 6 weeks following the incident. The panel heard and accepted the advice of the legal assessor. The panel adopted a two-stage process in its consideration, as advised. First, the panel had to determine whether the facts found proved amount to misconduct. Secondly, only if the facts found proved amount to misconduct, the panel would decide whether, in all the circumstances, your fitness to practise is currently impaired as a result of that misconduct. It took into account all the evidence before it including your recent reflective pieces and a number of testimonials submitted on your behalf. Decision on misconduct In determining whether the facts found proved amount to misconduct the panel had regard to the terms of the Code and the NMC Standards for medicines management. The panel, in reaching its decision, had regard to the public interest and accepted that there was no burden or standard of proof at this stage and exercised its own professional judgement. The panel was of the view that your actions fell significantly short of the standards expected of a registered nurse, and amount to misconduct. In coming to this conclusion, it determined that you had breached several standards, specifically : The Code (2015) 6

7 1 Treat people as individuals and uphold their dignity To achieve this, you must: 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, and 7 Communicate clearly 7.2 take reasonable steps to meet people s language and communication needs, providing, wherever possible, assistance to those who need help to communicate their own or other people s needs 7.3 use a range of verbal and non-verbal communication methods, and consider cultural sensitivities, to better understand and respond to people s personal and health needs 19 Be aware of, and reduce as far as possible, any potential for harm associated with your practice To achieve this, you must: 19.1 take measures to reduce as far as possible, the likelihood of mistakes, near misses, harm and the effect of harm if it takes place 19.4 take all reasonable personal precautions necessary to avoid any potential health risks to colleagues, people receiving care and the public 20 Uphold the reputation of your profession at all times To achieve this, you must: 20.1 keep to and uphold the standards and values set out in the Code NMC Standards for medicines management 7

8 Standard 2: Checking 2 As a registrant you are accountable for your actions and omissions. In administering any medication, or assisting or overseeing any self-administration of medication, you must exercise your professional judgement and apply your knowledge and skill in the given situation. As a registrant, before you administer a medicinal product you must always check that the prescription or other direction to administer is: 2.1 not for a substance to which the patient is known to be allergic or otherwise unable to tolerate 2.2 based, whenever possible, on the patient s informed consent and awareness of the purpose of the treatment 3 And that you have: 3.1 clearly identified the patient for whom the medication is intended Standard 8: Administration 2 As a registrant, in exercising your professional accountability in the best interests of your patients: 2.1 you must be certain of the identity of the patient to whom the medicine is to be administered 2.2 you must check that the patient is not allergic to the medicine before administering it 8

9 2.4 you must be aware of the patient s plan of care (care plan or pathway) In coming to its decision, the panel also took into account the Trust policies. It was also of the view that your actions fell significantly short of the standards expected, and that your actions amounted to breaches of the Trust policy on Positive Identification of Patients Policy. Specifically it noted: 3 Positive identification of the patient refers to a process of ensuring that the patient to be treated is the patient for whom the treatment is intended. All health care providers have primary responsibility for checking/verifying a patient s identity. Failure to correctly identify patients can lead to medication errors, transfusion errors, testing and investigating errors, wrong site surgery and wrong patient procedures. 3.1 Choosing the correct patient When treating a patient, it is the responsibility of the health care worker to make sure it is the intended patient. This should be done both verbally with the patient as far as possible by asking what is your name and date of birth? Staff must always ask patients to state their name and date of birth, the patient should not be passively asked ie are you the patient as this can lead to patient misidentification if the patient mishears the member of staff. 3.2 Checking against patient documentation Once the patient s name and date of birth have been given by the patient this must be cross referenced to the patient case notes/accompanying documentation e.g. request forms, consent forms, prescriptions 7 Red Alert wristband 9

10 All patients must be asked if they are allergic to anything on admission or prior to treatment if the patient has a history of allergy then a red alert wristband must be worn. The panel in making its decision took into account that you had fully admitted the charges. Nevertheless, you breached a fundamental and basic nursing skill in that you failed to identify Patient A before administering medication. You also failed to follow the Trust policy of having a second independent checker before administering intravenous medication. You failed to conduct an allergy check on Patient A even though he was wearing a red wristband which should have alerted you to the necessity to carry out further checks that you had the right patient and the correct medication. Prior to administering the incorrect medication, you had had a number of opportunities to stop and check that you had the right patient. For example, you saw that Patient A was wearing a red wristband, you ignored this essential warning sign and administered to him, the medication that was intended for Patient B. You failed to check Patient A s medication chart on which it recorded his allergy to penicillin. For the above reasons, the panel was of the view that you breached fundamental tenets of the nursing profession. The panel in making its decision noted that there was culture which existed within the ward to administer IV medication without a second checker contrary to the Trust policy. As a nurse, you are responsible for your own practice and by your own actions, you did nothing to challenge this culture. Furthermore, you had signed off to confirm you understood the Injectable Medicines Code in May 2014 when all staff were reminded of this policy after a patient had been given the wrong medication by another member of staff. Notwithstanding this reminder, you did not follow the correct procedure. In all the circumstances the panel concluded that your actions and omissions fell seriously short of the standards reasonably expected of a registered nurse and were sufficiently serious to amount to misconduct. 10

11 Decision on impairment The panel next went on to decide if as a result of this misconduct, your fitness to practise is currently impaired. Nurses occupy a position of privilege and trust in society and are expected at all times to be professional. Patients and their families must be able to trust nurses with their lives and the lives of their loved ones. Nurses must make sure that their conduct at all times justifies both their patients and the public s trust in the profession. In this regard the panel considered the judgement of Mrs Justice Cox in the case of Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin) in reaching its decision. In paragraph 74 she said: In determining whether a practitioner s fitness to practise is impaired by reason of misconduct, the relevant panel should generally consider not only whether the practitioner continues to present a risk to members of the public in his or her current role, but also whether the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular circumstances. Mrs Justice Cox commended the following as the appropriate test for panels: Do our findings of fact in respect of the doctor s misconduct, deficient professional performance, adverse health, conviction, caution or determination show that his/her fitness to practise is impaired in the sense that s/he: 11

12 a. has in the past acted and/or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and/or b. has in the past brought and/or is liable in the future to bring the medical profession into disrepute; and/or c. has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the medical profession; and/or d. The panel found that your misconduct engaged a. b. and c. of the above test. As a result of your misconduct, by failing to identify the patient, by failing to ensure the presence of a second checker and by failing to check that the patient was allergic to any medication, your actions caused or contributed to the death of Patient A. Although your evidence when being investigated by the Trust, was that the shift was particularly busy, there was no evidence before this panel to suggest that it was any more busy than one would expect. On the contrary, you agreed to administer IV medication early to assist the oncoming day shift. It is clear from the evidence before the panel that you were deeply remorseful at the time of the event and continue to regret your actions. In considering your insight, the panel noted your reflective piece and your subsequent reading and training. It accepts that you have some insight into your misconduct in that you recognise the need to follow Trust policy and good practice, as follows: In future I would complete one task fully before commencing another. I would not bring anything intended for another patient to a different patient s bedside as I can see that it can be so easy to get distracted and make an error In future I will never administer a medicine without checking the patient s wristband directly prior to administering it 12

13 I have reflected upon how to handle interruptions and prioritising tasks. I know I should have gone back to the beginning each time I was interrupted and ensure I was focused back on the task at a hand. However, the panel was not given the opportunity to question you on your insight and as such remained concerned as to the extent of your insight. In particular, the panel noted that you stated I now would embed this into my daily practice regardless of the pressures or business of the ward. Although, the panel is aware that you worked safely for 6 weeks post this incident, that you have the support of your colleagues, the panel did not have before it sufficient evidence of you putting your stated intentions into practice. The panel noted that your reflective piece contained broad statements of why or how you came to make such a basic failing. In those circumstances, the panel considered that their remains a risk to patient safely. The panel also considered the public interest which includes maintaining confidence in the nursing profession and upholding proper standards of conduct and behaviour. It considered that confidence in the profession would be undermined if, having regard to the serious nature and consequences of your misconduct, a finding of impairment is required. The panel therefore concluded that your fitness to practise to be currently impaired on the grounds of public protection and public interest. Determination on sanction: Having determined that your fitness to practise is currently impaired, the panel considered what sanction, if any, should be imposed on your registration. 13

14 In reaching this decision, the panel has had regard to all the evidence that has been adduced in this case, together with the submissions of Mr Scott on behalf of the NMC, those by Mr Lavers on your behalf and also your own evidence. Under oath, you told the panel of your nursing background and recounted to the panel the circumstances of the incident. You stated that you accept full responsibility for the incident. You advised the panel that you have been working as a Health Care Assistant since November 2016 in a nursing home and said that you feel that you could now work in a nursing home and/or hospital, as a registered nurse. You also told the panel that you have recently been reading nursing journals and undertaken online training in order to keep your nursing knowledge up-to-date. You submitted that should such circumstances ever arise again in the future, you would be minded to challenge the working culture which existed during the time of the incident. Mr Scott submitted that determining the appropriate sanction is a matter for the panel's professional judgment. Mr Lavers on your behalf submitted that you have fully cooperated at all stages and have expressed a significant degree of remorse. He spoke of the context in which the misconduct occurred in relation to the incident. He submitted that had there been a second nurse present, the error you made would not have gone unseen or uncorrected. He submitted that this was a one-off incident, and told the panel that you had been practising for 14 years in the UK as a nurse prior to this incident. He referred the panel to positive testimonials submitted on your behalf. Mr Lavers submitted that this incident was unlikely to recur in the future. He also spoke of your personal and family circumstances. He invited the panel to impose a conditions of practice order. 14

15 The panel accepted the advice of the legal assessor. The panel has borne in mind that any sanction imposed must be appropriate and proportionate, weighing the interest of the patients and public with your interests and taking into account the mitigating and aggravating factors in the case. Although not intended to be punitive in its effect, it may have such consequences. It has had regard to the NMC's Indicative Sanctions Guidance ("ISG"). It recognised that the decision on sanction is a matter for the panel, exercising its own independent judgement. The panel found the following aggravating and mitigating factors to be relevant: The aggravating factors are as follows: There were a number of breaches committed by you against the local policies NMC code and NMC Standards for medicines management You failed to check identity of Patient A You failed to act upon your observation that Patient A was wearing a red wrist band which indicated that he had an allergy You gave medication to the wrong patient You are an experienced nurse who made fundamental nursing errors in medicines administration The mitigating factors are as follows: You have a previously unblemished nursing career You have never sought to deflect blame for this incident You provided positive employment testimonials You made early admissions to the charges in these proceedings Your full engagement and participation in the NMC's proceedings You have demonstrated a significant degree of remorse You have shown some insight into your misconduct 15

16 The panel then turned to the question of which sanction, if any, to impose. It considered each available sanction in turn, starting with the least restrictive sanction and moving upwards. The panel first considered whether to take no action but it concluded that to take no further action would be inadequate to mark the seriousness of the misconduct in this case. Taking no further action would also not be in the public interest of declaring and upholding standards and maintaining public confidence in the profession. Next, in considering whether a caution order would be appropriate in the circumstances, the panel took into account the ISG, which states that a caution order may be appropriate where 'the case is at the lower end of the spectrum of impaired fitness to practise and the panel wishes to mark that the behaviour was unacceptable and must not happen again.' The panel considered that your misconduct was not at the lower end of the spectrum and that a caution order 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 impose a caution order given its findings at the impairment stage. The panel next considered whether placing conditions of practice on your registration would be a sufficient and appropriate response. The panel bore in mind that any conditions imposed must be proportionate, measurable and workable and must provide sufficient public protection. Having heard your evidence, the panel was concerned about your ability to communicate effectively with patients who have communication difficulties. When questioned about how you would now go about identifying a patient with communication difficulties, your answers were unsatisfactory. You told the panel that you would look at a patient's name on their bedroom door or refer to a patient list in the nursing home where you now work. You were not able to provide the panel 16

17 with any other method to provide assurance that you could satisfactorily identify such a patient. The panel was not fully satisfied that you are able to administer medication safely, as you did not recite the five rights of medication administration when questioned, namely right patient, right drug, right dose, right route, right time. In making its decision, the panel noted that there appears to be no harmful deep seated personality or attitudinal issues on your behalf. It considered that there was no evidence of general incompetence. It noted the positive testimonials provided on your behalf and took into account that your work is considered by those who worked with you including former line managers to be competent in general. It therefore determined that it could formulate appropriate, practicable and workable conditions of practice which would protect the public for the period they were in force and also satisfy the public interest. Prior to reaching a final decision, the panel considered a more severe sanction, by way of a suspension order. It bore in mind however that a suspension order would not address your failings in respect of the medicines administration. It noted your expressed willingness to retrain and return to unrestricted nursing practice. The panel was satisfied that it had identified the areas of your practise which are deficient but nevertheless capable of being remedied. The panel has therefore determined that a suspension order would be disproportionate in the circumstances. The panel was satisfied that conditions could address your deficiencies identified. The panel considered that a conditions of practice order for a period of 12 months would be an appropriate and proportionate sanction. This period of time will allow you to demonstrate that you are able to safely practise medicines administration and it would enable you to improve your communications skills. The panel determined to impose the following conditions of practice: 17

18 1. At any time that you are employed or otherwise providing nursing services, you must place yourself and remain under the direct supervision of another registered nurse of band 6 or above when carrying out medicine administration for a minimum period of 4 weeks. 2. Thereafter, and upon being deemed competent in the administration of medication by your employer or nurse supervisor, you may work as a registered nurse on the same shift as, but not necessarily under the direct observation of, a registered nurse of band 6 or above who is physically present in or on the same ward, unit, floor or home that you are working in or on. 3 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: - Medicines administration - Communication 4 You must meet with your line manager, mentor or supervisor (or their nominated deputy) at least every 28 days to discuss the standard of your performance and your progress towards achieving the aims set out in your personal development plan; 5 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. 6 You must send a report from your line manager, mentor or supervisor (or their nominated deputy) setting out the standard of your performance and your 18

19 progress towards achieving the aims set out in your personal development plan to the NMC at least 14 days before any NMC review hearing or meeting. 7 You must undertake a course in communication skills which includes how to interact with people including those with communication difficulties. 8 You must tell the NMC within 14 days of any nursing appointment (whether paid or unpaid) you accept within the UK or elsewhere, and provide the NMC with contact details of your employer. 9 You must tell the NMC about any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 14 days of you receiving notice of them. a) You must within 14 days of accepting any post or employment requiring registration with the NMC, or any course of study connected with nursing, provide the NMC with the name/contact details of the individual or organisation offering the post, employment or course of study. b) You must within 14 days of entering into any arrangements required by these conditions of practice provide the NMC with the name and contact details of the individual/organisation with whom you have entered into the arrangement. 10 You must immediately tell the following parties that that you are subject to a conditions of practice order under the NMC's fitness to practise procedures, and disclose the conditions listed at (1) to (9) above, to them. 1 Any organisation or person employing, contracting with, or using you to undertake nursing work. 19

20 2 Any agency you are registered with or apply to be registered with (at the time of application) to provide nursing services. 3 Any prospective employer (at the time of application) where you are applying for any nursing appointment. 4 Any educational establishment at which you are undertaking a course of study connected with nursing, or any such establishment to which you apply to take such a course (at the time of application). Before the end of the period of the order, a panel will hold a review hearing to see how well you have complied with the order. At the review hearing the panel may revoke the order or any condition of it, it may confirm the order or vary any condition of it, or it may replace the order for another order Decision on interim order The conditions of practice order will not take effect until the end of the appeal period (28 days after the date on which the decision letter is served) or, if an appeal is lodged, until the appeal is concluded. The panel considered the submissions made by Mr Scott that an 18 month interim conditions of practice order should be made to cover the appeal period. He submitted that such an order is necessary for the protection of members of the public and is otherwise in the wider public interest. Mr Lavers did not oppose the application. 20

21 The panel heard and accepted the advice of the legal assessor and took account of the guidance issued to panels by the NMC when considering interim orders and the appropriate test as set out at Article 31 of The Nursing and Midwifery Order The panel considered that an interim order is necessary for the protection of members of the public and is otherwise in the public interest. It concluded that not to make such an order would be incompatible with the panel's earlier findings and with the substantive sanction that it has imposed. The panel decided to impose an interim conditions of practice order in the same terms for the same reasons as it imposed the substantive order and to do so for a period of 18 months in light of the likely length of time that an appeal would take to be heard. The effect of this order is that, if no appeal is lodged, the substantive conditions of practice order will come into effect 28 days after notice of the decision has been sent to you and the interim conditions of practice order will lapse. If an appeal is lodged then the interim conditions of practice order will continue until it is either revoked, extended by the High Court or until the appeal is determined. The panel's decisions will be sent to you in writing. That concludes this determination. 21