Conduct and Competence Committee Substantive Hearing

Transcription

1 Conduct and Competence Committee Substantive Hearing January 2016 Nursing and Midwifery Council, 2 Stratford Place, Montfichet Road, London, E20 1EJ Name of registrant: Amanda Mary Young NMC Pin: 93C2567E Part(s) of the register: Registered Nurse Sub-part 1 Mental Health 11/03/1996 Area of registered address: Somerset Type of case: Misconduct Panel members: David Kyle (Chair, Lay member) Victoria Heilbron (Registrant member) Miran Uddin (Lay member) Legal Assessor: Nigel Pascoe Panel Secretary: Nilima Ali Representation: Nursing and Midwifery Council (NMC): Represented by Aja Hall, Case Presenter, instructed by the NMC Regulatory Legal Team Miss Young: Miss Young was not present and not represented Page 1 of 45

2 Facts found proved: 1, 2 (in its entirety) and 3 Facts found not proved: N/A Fitness to practise: Impaired Sanction: Striking-off order Interim Order: Interim suspension order: 18 months Page 2 of 45

3 Determination on service The panel received information from Ms Hall on behalf of the Nursing and Midwifery Council ( NMC ) that the Notice of Hearing had been served in accordance with The Nursing and Midwifery Council (Fitness to Practise) Rules Order of Council 2004 ( the Rules ). The panel accepted the advice of the legal assessor. The Notice of Hearing was sent by first class post and recorded delivery on 8 December 2015 to Miss Young s registered address, as recorded on WISER, the system supporting the NMC s Register. It contained the correct and relevant details of the hearing. The Notice of Hearing had been delivered and signed for in the name of Young on 9 December The panel concluded that service had been effected in accordance with Rules 11 and 34. Determination on proceeding in the absence of Miss Young The panel then considered whether to exercise its discretion to proceed in Miss Young s absence, in accordance with Rule 21(2)(b). The panel had regard to all the information before it. It heard submissions from Ms Hall and accepted the advice of the legal assessor. Ms Hall invited the panel to proceed in the absence of Miss Young, pursuant to Rule 21(2)(b). She submitted that Miss Young had been properly served with the Notice of Hearing in accordance with the Rules and that it would be in the interests of justice to proceed today. Ms Hall explained that the allegations in this case were now almost four years old. She informed the panel that the reason for the delay in scheduling this case for a substantive hearing was because Miss Young s case was originally linked to that of three other registered nurses. Miss Young appeared at criminal court and, as such, the NMC s investigation was put on hold. Once the criminal proceedings had concluded, the NMC Page 3 of 45

4 reviewed Miss Young s case. At that particular time, Miss Young was engaging with the NMC and the NMC made attempts to agree certain matters with her, in order to progress this case to an approved outcome. Ms Hall explained that Miss Young was, early on in the proceedings, represented. At that stage, she had indicated that she was suffering from ill health, and she provided evidence to that effect (the last piece of which was submitted in December 2013). On 24 June 2015, the NMC s case officer received a telephone call from Miss Young. After confirming her identity on the telephone, Miss Young asked the case officer to speak to her mother. Miss Young s mother informed the case officer that she does not want anyone calling her daughter from the NMC as this causes her stress. The NMC received a signed letter from Miss Young on 21 July 2015, where she spoke of the criminal proceedings against her. She also indicated that she did not intend to work as a registered nurse and she asked the NMC not to contact her in the future. She said that contact from the NMC was affecting her health and wellbeing. No further correspondence had been received from Miss Young until October 2015; this was an unsigned letter dated 10 October 2015, which was in response to a letter from the NMC (dated 15 September 2015) regarding case management. Ms Hall confirmed that she, too, had made an attempt to contact Miss Young by telephone. During the course of that conversation, Miss Young explained that she wanted nothing more to do with these proceedings. On 7 January 2016, an was sent to Miss Young in relation to obtaining hearing attendance details. Miss Young did not reply to this . Ms Hall submitted that Miss Young was, recently, notified of how the NMC intended to present its case at the hearing, and she was sent a copy of the bundle of evidence, and witness statements, to be relied upon. Page 4 of 45

5 Ms Hall submitted that the NMC had taken all steps to engage Miss Young in these proceedings. She submitted that, on the basis of the correspondence from June 2015 to the present day, it was evident that it was Miss Young s wish not to attend the hearing and not to be contacted further. Furthermore, there had been no request for an adjournment. She submitted that, on the basis of the above, the panel could properly conclude that an adjournment would be unlikely to secure Miss Young s attendance on a future date. Ms Hall informed the panel that there are seven witnesses due to give live evidence on behalf of the NMC. In all of those circumstances, Ms Hall invited the panel to proceed in the absence of Miss Young. The panel, in considering this matter, had regard to the public interest in the expeditious disposal of the case, the potential inconvenience caused to a party or any witnesses to be called by that party, and fairness to Miss Young. The panel gave careful regard to the guidance of Lord Bingham of Cornhill in the case of R v Hayward, Jones and Purvis [2001] EWCA Crim 168 and exercised the utmost care and caution in coming to its decision. The Royal Mail Track & Trace printout confirmed that the recorded delivery Notice had in fact been delivered and signed for on 9 December Early on in these proceedings, Miss Young had been engaging with the NMC and was represented. In June 2015, Miss Young had indicated, through her mother, that she no longer wished to communicate with the NMC. Numerous attempts were subsequently made by the NMC to engage her in these proceedings. She was sent a copy of the bundle of evidence, including witness statements, upon which the NMC intended to rely. Page 5 of 45

6 From June 2015, Miss Young had consistently maintained that she did not wish to participate in these proceedings. There had been no request for an adjournment. The panel considered that adjourning the hearing would serve no purpose, as it would be unlikely to secure Miss Young s attendance on a future occasion. The allegations in this case are serious. In that regard, the panel was mindful of the extent of the disadvantage to Miss Young in not being present to give her account of events, and the personal and professional impact any adverse findings may have against her. However, the panel was also mindful of the public interest in the expeditious disposal of cases. There are seven witnesses, due to give evidence on behalf of the NMC, who would be inconvenienced by an adjournment of these proceedings. The allegations in this case date back to February 2012 and the panel was mindful that any continued delay in these matters could further impact upon the witnesses recollection of events. The panel was satisfied that Miss Young was aware of the hearing and that she had chosen not to attend. In all of the circumstances, the panel concluded that it was in the public interest to proceed today, and that it would not be unfair to Miss Young to hear the case in her absence. For all these reasons the panel determined to proceed in the absence of Miss Young. Charges read That you, whilst employed as a Registered Nurse at Somerset Partnership NHS Trust: 1. On or around 3 February 2012 incorrectly administered 175mg denzapine to Patient A as opposed to the prescribed 12.5mg denzapine. 2. On or around 8 February 2012: 2.1. Incorrectly administered 4200mg denzapine to Patient A; Page 6 of 45

7 2.2. Failed to identify concerns regarding Patient A s raised pulse and blood pressure within the RIO progress notes; 2.3. Failed to contact the Prescriber about Patient A s raised pulse rate; 2.4. Failed to respond to concerns raised by Patient A s mother. 3. Your conduct as set out in charge 2.1 caused or contributed to the death of Patient A. And as a result of the above, your fitness to practise is impaired by reason of your misconduct. Determination on facts The background to this case was presented as follows: On 5 March 2012 the NMC received an from Avon & Somerset police confirming that they were investigating the death of Patient A, who died as a result of the administration of an overdose of denzapine on 8 February At the relevant time, Miss Young was working as a Band 6 Community Psychiatric Nurse, with the Home Treatment Team, the Crisis Team in Yeovil, Somerset Partnership NHS Trust ( the Trust ), having been employed in this role for approximately 16 years. This role involved visiting patients at their home address to provide support and medication, advice and monitoring. Patient A was a 22 year old man who had been diagnosed with paranoid schizophrenia, which had developed some years earlier. At the material time, Patient A was prescribed, and had been self-administering, 700mg denzapine daily. The generic name for this medication is clozapine but it also has brand names of clozaril (tablet form) and denzapine (liquid form). The particular brand of clozapine in this case is denzapine, which was dispensed at a concentration of 50mg/ml. In order to assist Patient A s Page 7 of 45

8 compliance with his medication, it was prepared for him in single 14ml bottles (700mg), one to be taken each day. Patient A would receive 28 days supply of the medication (28 bottles, one to be taken daily). By 3 February 2012, Patient A had stopped taking denzapine for a period in excess of 48 hours as he had not collected the supply dispensed to him following a required blood test on 31 January As a result, he needed to be re-titrated onto denzapine, commencing with a low dose of 12.5mg which would be increased gradually to the required therapeutic dose of 700mg. During the period of retitration, members of the Home Treatment Team visited Patient A at his home to administer the increasing doses of denzapine. Ms 7, Pharmacist, put a retitration plan in place. This was approved by Doctor 2, Consultant Psychiatrist based at the Holly Court Psychiatric Unit (part of the Trust). Doctor 2 approved the retitration chart and prescribed denzapine to be administered daily. This was as follows: 12.5mg denzapine once daily 3 February mg denzapine once daily 4 February mg denzapine once daily 5 February mg denzapine once daily 6 February mg denzapine once daily 7 February mg denzapine once daily 8 February 2012 The same type of single dose bottle that Patient A had been using daily was to be used for the administration of denzapine. As the titrated daily dose would be much less than previously prescribed, the required amount of denzapine would be removed from the 14ml/700mg bottle using an oral syringe, and then administered to Patient A. Four nurses, including Miss Young, attended Patient A s home on various dates between 3 and 8 February Miss Young s visits took place on 3 and 8 February Page 8 of 45

9 During the course of a police interview, Miss Young was asked how she dispensed the medication on 3 February She confirmed that she used a 5ml oral syringe to administer 3.5ml denzapine from the bottle. She was of the view this was the correct amount, as 12.5mg denzapine was due to be administered that day. She believed that each 14ml bottle contained 50mg denzapine. Her calculation was as follows: 12.5mg is a quarter of 50mg. Therefore to administer 12.5mg, she needed to extract one quarter of the contents of the 14ml bottle, namely 3.5ml. Miss Young s calculation was incorrect. Each bottle contained 700mg/14ml denzapine, with a concentration of 50mg/1ml. Therefore, when Miss Young had administered what she thought to be 12.5mg, she had actually administered 175mg. On 8 February 2012, Miss Young attended Patient A s home to administer denzapine, the prescribed amount on that date being 300mg. For this purpose, she had given Patient A 6 x 14ml bottles of denzapine, amounting to 4200mg, applying the same calculation that she had used on 3 February On her return to the Unit, she left the empty bottles on the desk for later disposal. During the course of a police interview, Professor 1, Consultant Toxicologist, stated that in my opinion, if this last dose had not been given and clozapine dosage had either been stopped, or cut-back to what had been intended, i.e. 300 milligrams, I do not think [Patient A] would have died. It was alleged that Miss Young did not identify concerns regarding Patient A s raised pulse rate and blood pressure, as evident in the patient s RIO progress notes. Patient A s blood pressure and pulse were recorded as follows: 3 February 2012 BP 148/85, Pulse 92 5 February 2012 BP (sitting) 143/90, Pulse 114; BP (standing) 127/79, Pulse February 2012 BP 140/109, Pulse 131 Page 9 of 45

10 7 February 2012 BP 141/85, Pulse February 2012 BP 116/61, Pulse 115 The Maudsley Guidelines, as set out in the Trust s Guidelines for the initiation of Clozapine, recommends that the prescriber should be contacted if (among other factors) the patient s pulse rises above 100. It was the NMC s case that Miss Young made no contact with the prescriber on 8 February When Miss Young was asked, during the course of a police interview, why she did not raise the issue in relation to Patient A s raised pulse rate, she variously explained that this did not cause her any concern as the patient was obese, a smoker, drinking coffee and standing at the time. Ms Hall, on behalf of the NMC, summarised Miss Young s interviews to the police as follows: Miss Young made a catastrophic mistake in that she did not read the label on the bottles of denzapine (which, she said, appeared in an unusual form) and that her calculation of the medication was wrong. In reaching its determination on facts, the panel had regard to all the evidence adduced, including all the exhibited documents. It heard submissions from Ms Hall on behalf of the NMC. It accepted the advice of the legal assessor. The panel was aware that the burden of proof rests with the NMC and that the facts must be proved on the balance of probabilities. The panel heard oral evidence, on behalf of the NMC (together with their written statements), from the following witnesses: Professor 1, Consultant Toxicologist; Doctor 2, Consultant Psychiatrist at Holly Court Psychiatric Unit, the Trust; Mrs 3, Manager for the Home Treatment Team at Holly Court Psychiatric Unit, the Trust; Page 10 of 45

11 Mrs 4, Registered Nurse and qualified District Nurse; Ms 5, Nurse Prescriber at the Trust; Ms 6, Senior Team Manager of Yeovil Assessment Service (at Holly Court) at the material time; Ms 7, Senior Specialist Clinical Pharmacist at the Trust at the material time. The panel also accepted, into evidence, the witness statements of: Patient A s mother (signed and dated 16 November 2015); Ms 8, Support Team Recovery Worker on the Crisis Team in Yeovil (signed and dated 5 November 2015); Ms 9, Group Manager for Access and Information for Medicines and Standards, Medicines and Healthcare Products Regulatory Agency (signed and dated 22 October 2015); Doctor 10, then Home Office Pathologist (currently retired) (signed and dated 13 October 2015); and Ms 11, Director of Nursing and Patient Safety for the Trust (signed and dated 8 January 2016). The panel found all witnesses to be overall credible, consistent and reliable. The panel was satisfied that all witnesses did their best to assist, and were candid when they were unable to do so. With the exception of Ms 11, all the NMC witnesses had made statements to the police for the purposes of its investigation. In particular, Doctor 2, Ms 5, Ms 8, Ms 7 and Patient A s mother made statements during the early stages of the police investigation which started on 9 February Miss Young has not at any time appeared to dispute the evidence of the expert witnesses, Mrs 4, Professor 1 and Doctor 10, in the context of these proceedings. The evidence of all witnesses, as contained in their NMC witness statements, supported their accounts to the police. Page 11 of 45

12 Miss Young was not in attendance at this hearing. However, the panel had regard to her responses, given under caution and with the benefit of legal representation, to the police during the course of two interviews on 9 February and 10 September Insofar as the panel has relied upon Miss Young s admissions to the police, the panel took into account that on the morning after Patient A s death, Miss Young was made aware that she had made a significant mistake. Following this, she made no attempts to conceal or hide that fact. She admitted, from the outset, that she had misread the labels on the bottles of denzapine. The panel made the following findings of fact in respect of the charges: That you, whilst employed as a Registered Nurse at Somerset Partnership NHS Trust: The panel heard evidence from Mrs 3 and Ms 6, as well as Miss Young s account to the police in an interview, that in February 2012 Miss Young was employed as a registered nurse at the Trust. Miss Young told the police that she was working as a Community Psychiatric Nurse for the Home Treatment Team in the Crisis Team, in Yeovil. 1. On or around 3 February 2012 incorrectly administered 175mg denzapine to Patient A as opposed to the prescribed 12.5mg denzapine. Due to his health condition, Patient A had long been prescribed denzapine. He had attended the clozapine clinic at Holly Court from approximately March On 3 February 2012, it had transpired that Patient A had not taken denzapine for approximately 66 hours (last known dose 700mg taken at 22:00 on 31 January 2012). Following a telephone conversation with Patient A s named carer, Ms 12, Ms 7 made an entry in Patient A s RIO (electronic system) progress notes, on 3 February 2012, setting out that the patient s treatment should be re-initiated. A retitration programme was created by Ms 7, based on her knowledge of the medication as well as the manufacturer s guidelines. This programme was set out in a clozapine retitration chart, which required the retitration of the medication to begin with 12.5mg (0.25ml) and Page 12 of 45

13 gradually to be increased in order to bring Patient A back up to his previous therapeutic dose of 700mg. It was also agreed that the single daily dose bottles previously used by Patient A would be used to supply the denzapine during the retitration programme. As Ms 7 was aware that the bottles in question contained 14ml denzapine, she specifically identified, in the retitration chart, the reduced volumes of denzapine required to be taken from such a bottle each day. Ms 7 also explained this in the RIO progress notes. During the course of a police interview, Miss Young explained that she had attended Patient A s home on 3 February 2012 to administer the introductory dose of 12.5 milligrams. She said that she spoke with a colleague, Ms 13, Community Psychiatric Nurse, and asked her Help me do the maths on this, if I want to give 12.5 milligrams how many mls do I give? She went on to state we both agreed that from the bottle, if there was 14mls per 50 milligrams then we would need to give 3.5 mls. And we both came to that conclusion. Miss Young was asked how she had dispensed that medication, and she confirmed that she used a 5ml oral syringe to administer 3.5ml of medication from the denzapine bottle, which she believed to contain the prescribed amount of 12.5mg denzapine. Miss Young explained that all of these bottles [of denzapine] contained 50mgs. They re all identical. It says 14mls which is 14mls of denzapine 50 milligrams when I looked at that to dispense it, and I checked it and checked it and checked it, my understanding of that bottle would mean 14mls of clozaril per 50 milligrams in strength. That s how I would understand that bottle The panel had regard to the entry made by Ms 7 on 3 February 2012, on Patient A s RIO progress notes. In that entry, Ms 7 explained the need for Patient A to be re-titrated onto his medication, set out the retitration plan, and stated the labels on [Patient A s] supply of Denzapine liquid will state 700mg (14ml) at night, so for the purposes of this re-titration these should be ignored and the re-titration chart used. Page 13 of 45

14 In the panel s view, Ms 7 provided a clear written instruction that the dosage on the bottles should be ignored, and the retitration chart followed. Mrs 3 and Ms 5 stated that a hard copy of Ms 7 s retitration chart was made and kept in Patient A s file. Both confirmed that there was an expectation that this paper file would have been taken to the patient s house by the registered nurse conducting the appointment, because they did not have remote access to the RIO system. That chart specifically identified the first dose of denzapine suspension as 12.5mg and the volume of denzapine oral suspension 50mg/ml was identified as 0.25ml. Ms 7 told the panel that she deliberately incorporated the column detailing the volume of denzapine oral suspension 50mg/ml, to avoid the calculation [being] redone every time [and] to emphasise the fact that it was such a low volume. The panel also had sight of the electronic prescription chart produced by Doctor 2. Doctor 2 set out the plan of retitration and the medication in question was identified as Denzapine 50mg/1ml oral suspension. The panel had regard to a photograph of a bottle of denzapine. The information written on the label on the bottle was 14ml Denzapine 50mg/ml oral suspension take 14mls at night via oral syringe. Miss Young admitted, during her police interview, that she had misread the labelling on the denzapine bottle. It was clear to the panel, on the basis of the evidence before it, that each bottle of denzapine contained 14ml, with each millilitre containing 50 milligrams (written as 50mg/ml), therefore containing a total of 700mg denzapine. As Miss Young had administered 3.5mls, this amounted to 175mg (3.5ml x 50mg) denzapine as opposed to the prescribed 12.5mg denzapine. The panel accepted Ms 7 s evidence that Miss Young s error was not one of medication or drug calculation, but rather an error in misreading the label on the bottle. Charge 1 was therefore found proved. Page 14 of 45

15 2. On or around 8 February 2012: 2.1. Incorrectly administered 4200mg denzapine to Patient A; The panel had regard to Patient A s electronic prescription chart on RIO, in which Doctor 2 had set out the retitration doses from 3 February 2012 to 8 February According to that chart, Patient A was to be administered 200mg denzapine on 8 February At some point, Ms 5 took over the prescribing responsibility. As she told the panel, she was mistaken in her understanding of where Patient A s retitration programme had reached and erroneously re-prescribed the dose to be administered on 7 and 8 February 2012 as 250mg and 300mg respectively. Miss Young confirmed, to the police, that she referred to Patient A s prescription chart, as created by Doctor 2, numerous times. She said that she did not use the retitration chart created by Ms 7 as we were told in the afternoon that [Doctor 2] had represcribed a new prescription on RIO I was told specifically by Doctor 2 s secretary it s [Ms 7 s retitration chart] been transferred onto RIO, go from the RIO prescription, and that s what I went from. She referred to a handwritten note on Ms 7 s retitration chart, which said *This is on e-medication on RIO which indicated to her that she was to use to electronic prescription chart. She also stated that she had not read Patient A s progress notes on RIO, from which the panel inferred that she had only looked at the electronic prescription chart. Miss Young confirmed, during a police interview, that on 8 February 2015 she gave Patient A six bottles of denzapine, thinking that each bottle contained 50mg clozapine in each 14ml bottle (therefore of the view that six bottles amounted to the prescribed 300mg). Miss Young stated that she did the maths and checked it out with [her] colleague [Nurse B] she agreed that they would need to give Patient A six bottles of denzapine. Miss Young explained that prior to leaving the clinic she questioned the volume of denzapine that she was going to administer. She said that she had spoken to a Support Page 15 of 45

16 Team Recovery Worker in the office, and she commented to him that six bottles did seem rather a lot, even though they were small, and he said No, that s right because they took three out the other night. And as the doses were obviously increasing, it made sense that the number of bottles increased too. Miss Young went on to state So I administered the the Clozaril it came in six bottles and I thought it was a bit mean to make him drink out of all six so I put it into a glass tumbler so it would ve come to about eighty four mls, which actually doesn t look like too much in a glass, it s about an inch or two. After the appointment with Patient A, Miss Young and Nurse B returned to the clinic. Miss Young left the six empty bottles on the Home Treatment Team desk (for disposal). The panel took account of Miss Young s evidence to the police. She confirmed that, for the purpose of her appointment with Patient A on 8 February 2012, she looked at the electronic prescription chart on RIO. On the basis of this chart, she determined that Patient A was to be given 300mg denzapine. She confirmed that she did not read the RIO progress notes of 3 to 7 February 2012 because she was working under extreme pressure that day. Believing that each 14ml bottle contained 50mg denzapine, Miss Young calculated that Patient A therefore required six bottles. She told the police that she had in fact administered six times 700milligrams of Clozaril, which is toxic. On the basis of the evidence before it, the panel found charge 2.1 proved Failed to identify concerns regarding Patient A s raised pulse and blood pressure within the RIO progress notes; Page 16 of 45

17 In support of their written statements, Professor 1 and Doctor 2 gave detailed oral evidence in relation to the significant side effects of clozapine and the adverse reactions to it, which included a raised pulse rate and a drop in blood pressure. The Trust s Guidelines for the initiation of Clozapine, implemented in September 2011, set out the following: Patients must be reviewed on a face-to-face basis daily for the first 2 weeks after clozapine had been started and then subsequently the day after any dose increase Pulse, temperature and BP should be performed and recorded at each review. This is because potential physical problems are strongly related to dose increase. Maudsley Guidelines recommend the Prescriber should be contacted if: temperature rises above 38 C (quite common) or pulse rises above 100 (also common but needs monitoring in case of myocarditis) or postural drop of over 30mmHg or other serious side effects [ ] If any of the above occur, withhold Clozapine and contact prescriber for advice. Doctor 2 told the panel that a variable pulse and blood pressure would raise concerns. He explained that when a patient is being re-titrated onto denzapine, it is important for nurses involved in the patient s care to closely monitor the patient s pulse, blood pressure and temperature in line with relevant policy. Doctor 2 referred to the variable observations that were recorded within the RIO notes: 3 February 2012 blood pressure 148/85, pulse 92 5 February 2012 (sitting) blood pressure 143/90, pulse 114, (standing) blood pressure 127/79, pulse February 2012 blood pressure 140/109, pulse 131 Page 17 of 45

18 7 February 2012 blood pressure 141/85, pulse February 2012 blood pressure 116/61, pulse 115 With regard to the blood pressure and pulse rate recorded in the RIO progress notes made on 8 February 2012, Doctor 2 explained that these results, when checked against the results from the days prior to this, seem to be variable. If the blood pressure of 116/61 is compared to that recorded on 6 February; 140/109, they differ considerably. As does the pulse. In this situation I would make note of the variability between the observations. Due to the fact that denzapine can affect a patients pulse and blood pressure, these variations should have been noticed and I would suggest it should have raised a question as to why this was the case. I do not see anything within the RIO progress notes that raises any such concerns. In his oral evidence to the panel, Doctor 2 explained that his concerns were the very obvious rapid pulse [of 131] [and] the very considerable variability in [Patient A s] blood pressure the rapid pulse or blood pressure should have raised concerns. In my view, both should have resulted in contact with the prescriber. He said that whilst it was common in patients taking clozapine to have an elevated pulse, the Trust s guidelines made it clear that prescribers should be contacted when a patient s pulse rises to 100. He acknowledged that nurses were entitled to exercise their clinical judgement. He went on to state that whilst there were a number of factors that could raise a pulse rate (such as doing activities, feeling anxious or stressed, drinking caffeinated coffee, and the medication itself) the nurse in question should look at all factors and variables keeping an open mind about what the cause of any one observation might be Mrs 3 told the panel that the readings taken on 3 February 2012 would not cause any concern. She said that the readings taken on 5 February 2012 were slightly higher however these observations are certainly not significantly different that it would cause concern or need to be escalated at this point. In respect of the readings taken on 6 February 2012, Mrs 3 stated that the blood pressure would not raise concern however the pulse is slightly higher In respect of the readings taken on 7 February 2012, Mrs 3 commented that these observations are not dissimilar to those Page 18 of 45

19 recorded on 3 February 2012 and would be regarded as within the normal limits. I would expect a man of [Patient A s] age to have slightly lower readings than this, but he was overweight and he did smoke and drink therefore it would be expected that he would have a slightly higher blood pressure and pulse. In respect of the readings taken on 8 February 2012, Mrs 3 stated the blood pressure is slightly lower to those recorded on 7 February 2012 but they are not unduly low. The pulse is slightly higher but again, not enough to raise immediate concern. For a man of [Patient A s] age, you would expect him to have a pulse rate within the range of However, given that he was not a fit man, this reading is not out of the ordinary. In their oral evidence to the panel, Mrs 3 and Ms 5 confirmed that the isolated readings of 8 February 2012, and the cumulative readings taken between 3 and 8 February 2012, would have caused concern such that they would have contacted the prescriber. Ms 5 went further to state that personally, I would have withheld the medication. Miss Young was, at the time, a nurse of 16 years experience. She told the police that she had previous knowledge of, and experience in, administering clozapine in tablet form and was well aware of the side effects of this medication. In the panel s view, in light of this experience, she would have been aware of the need to be particularly mindful of a patient s blood pressure, temperature and pulse rate. These specific observations were highlighted, in explicit terms, in the Trust s guidelines, of which Miss Young ought to have been aware. Miss Young attended Patient A s home on 8 February 2012, having last visited Patient A on 3 February Mrs 3 and Ms 5 told the panel that nurses were expected to read patients notes prior to conducting visits; in this case, Miss Young ought to have read the RIO progress notes. Doctor 2 told the panel that common sense would dictate that if a nurse was required to monitor a patient s physical state, you would read other records and consider them against your own assessment. Page 19 of 45

20 Miss Young confirmed in her police interview, dated 10 September 2012, that she had not read Patient A s progress notes in preparation for her visit to the patient, as she did not have the time to do so. Had she done so, she would have noted Patient A s raised pulse rate and the marked variability in his blood pressure. Having taken his pulse and blood pressure readings on 8 February 2012, she ought to have compared these to the readings previously taken; at that point, she should have withheld the medication and contacted the prescriber, as instructed in the Trust s guidelines. Doctor 2, Ms 7 and Ms 5 confirmed that Miss Young had not raised any concerns with them in relation to Patient A s raised pulse and blood pressure. Furthermore, Miss Young had made no record of any concerns on Patient A s RIO progress notes; there was, therefore, no indication that Miss Young had actually taken account of the previous readings, nor any suggestion that she had any concerns about the previous readings or about the readings that day. In the panel s view, the evidence of Doctor 2, Mrs 3 and Ms 5 established that there were identifiable concerns in relation to Patient A s pulse and blood pressure as at 8 February The panel concluded that Miss Young did have a duty, in light of the Trust s guidelines and her professional obligations as a nurse, to identify these as concerns. There was no record in the RIO progress notes indicating that she had done so. The panel has inferred on a balance of probabilities that she did not. Accordingly, the panel found charge 2.2 proved Failed to contact the Prescriber about Patient A s raised pulse rate; Doctor 2 and Ms 7 confirmed, in their oral evidence, that they had not received any contact from Miss Young in relation to Patient A s raised pulse rate. Doctor 2, Mrs 3 and Ms 7 accepted that registered nurses did exercise a degree of clinical discretion; however, they all confirmed that Miss Young ought to have complied Page 20 of 45

21 with the Trust s guidelines in the circumstances of Patient A s history and presentation on 8 February In her interview with the police, Miss Young explained that whilst Patient A s pulse was raised, on 8 February 2012, she was not concerned as he had been smoking, drinking coffee and standing (factors that she determined had contributed to the raised pulse rate). The Maudsley guidelines, incorporated within the Trust s own guidelines, recommended that the prescriber should be contacted if, amongst other factors, the pulse rises above 100. This was followed by an explicit Trust instruction that in such a case, withhold Clozapine and contact prescriber for advice. On this basis, Miss Young was required, by the Trust, to have contacted the prescriber when she noted that Patient A s pulse rate was 115. Neither Doctor 2 nor Ms 7 were contacted by Miss Young. Charge 2.3 was, therefore, found proved Failed to respond to concerns raised by Patient A s mother. In her interview with the police, Patient A s mother gave the following account of events: On 8 February 2012, Miss Young attended Patient A s home, with another nurse. Prior to giving the patient his medication, Miss Young asked Patient A s mother do you have a glass? Miss Young found a glass and placed it on a coffee table (in front of Patient A s mother). Patient A s mother was confused as she could not understand why Miss Young was using a glass. Miss Young showed her one of the bottles of the medication and said this is 800 mils. Miss Young then opened the bottle and tipped the contents into the glass. When Patient A s mother next looked at the glass, she noticed that it was half full. At that point, the patient had not taken any of his medication. Patient A s mother was surprised at the amount in the glass as the patient had never taken that amount before. She asked Miss Young why is [Patient A] having that much? Miss Page 21 of 45

22 Young did not explain, but said that will be alright, I know we will put a bit of water with it. Miss Young went to the kitchen and Patient A s mother heard the tap turn on. Miss Young returned with the glass but, according to Patient A s mother, the level of liquid in the glass had not increased by much. Miss Young then passed the glass to Patient A and he duly took his medication. When Miss Young and Nurse B left the house, Patient A asked his mother why did she give me that much medication? Patient A s mother was unable to explain why. At approximately 19:30, Patient A said he was going to bed, telling his mother that this medication makes me tired. Miss Young, in her police interview, confirmed that Patient A s mother raised concerns about the volume of medication; I will not lie. His mum said or was it yeah his mum said that looks like a lot. She said that Patient A s mother felt it looked like a lot; it looked like more than [Patient A] usually had. Miss Young reassured Patient A s mother by telling her that it had been diluted with water and that the dose of the medication had increased. Miss Young showed Patient A s mother a bottle and read out what it said on the bottle which was very clearly 14mls / 50milligrams and [she] explained that each of those bottles came with that amount in them. On the basis of the evidence before the panel, Patient A s mother had a long history of seeing her son take denzapine, in the form of one 14ml/700mg bottle per day. She had raised, with the Home Treatment Team, the fact that Patient A had not taken his medication for a number of days and was informed that because of this, they would have to start administration of it again on a lower dose. On 8 February 2012, Patient A s mother would have been aware that Patient A was being re-titrated onto his medication and that whilst the dose was slowly being increased, it was still lower than his usual therapeutic dose of 700mg. The panel was mindful that both accounts in respect of this allegation were hearsay. Neither Miss Young nor Patient A s mother were in attendance at this hearing to give evidence. However, the panel noted that each of their accounts were given to the police under caution on 9 February 2012, the day after the event in question. Page 22 of 45

23 Insofar as there is a difference of account as to when water was added to the glass, the panel preferred the evidence of Patient A s mother. In the panel s view, Miss Young s account could be said to be self-serving, as an attempt to explain her own conduct, in the knowledge that she had made a catastrophic mistake. Patient A s mother was alarmed at the quantity of the medication that was being prepared by Miss Young and had asked her why Patient A was having that much. Miss Young, as the registered nurse, had a duty to address the mother s concern. Her reply, that will be alright, I know we will put a bit of water with it did not address Patient A s mother s concern. The panel therefore found charge 2.4 proved. 3. Your conduct as set out in charge 2.1 caused or contributed to the death of Patient A. Professor 1, Consultant Toxicologist, was interviewed by the police for the purposes of its investigation. In his police witness statement, Professor 1 confirmed that a potentially fatal dose of clozapine in an adult who had not been taking clozapine regularly is 25 milligrams... Ingestion of 350 milligrams clozapine by a clozapine-naïve adult has proved fatal Unfortunately it seems that rather than 0.25 millilitres denzapine liquid (12.5mg clozapine) [Patient A] was given 3.75 millilitres (175 milligrams) on 3 February 2012 this was a potentially fatal dose of clozapine in someone who had not been taking clozapine regularly. That it did not kill [Patient A] is possibly due to the fact that he had last taken clozapine on 31 January 2012, hence it is likely that he retained some degree of tolerance to the drug. Professor 1 went on to state that on 8 February the information supplied suggests that he was given 6 vials denzapine liquids (42 millilitres [sic] of 50 milligrams per millilitre, i.e. a dose of 4200 milligrams clozapine). This is a massive overdose and not Page 23 of 45

24 surprisingly [Patient A] said he felt tired and went upstairs to bed. He collapsed and was found dead about an hour later Professor 1 concluded that although it is likely that clozapine and desmethylclozapine did accumulate in [Patient A] as a result of the repeated overdoses given to him, it is not possible say with any certainty whether this prior exposure made the fatal outcome after the final, massive overdose any more or any less likely. Suffice it to say that in my opinion if this last dose had not been given and clozapine dosage had either been stopped, or cut-back to what had been intended, i.e. 300 milligrams, I do not think [Patient A] would have died. He went on to state therefore it is [axiomatic] that the final overdose of clozapine more than minimally contributed to the death of [Patient A]. In his NMC witness statement, Professor 1 explained that: Even if Patient A had been given larger than prescribed doses of Denzapine in the days leading up to this death, he had clearly tolerated and survived all his previous doses. It is thus clear that in my opinion he would not have died had he not been given the dose of Denzapine on 8 February The fact that he did die on 8 February 2012 might have been made more likely as a result of accumulation of clozapine from previous doses of the drug, but he clearly tolerated all the previous doses To me, it is immaterial whether the concentration of clozapine in the suspension administered on 8 February 2012 was 14 milligrams per millilitre or 26 milligrams per millilitre of 50 milligrams per millilitre since in my opinion he would not have [died] without this last dose. In any event, even if the concentration of clozapine in the suspension in this last dose was as low as 14 milligrams per millilitre, this would still amount to a dose of 1176 milligrams, when the intended dose for that day was 300 milligrams. Page 24 of 45

25 In his oral evidence to the panel, Professor 1 stated that there was such a clear temporal relationship to [Patient A] being given that dose he went upstairs as he was tired and died an hour later He went on to say I m fairly confident that he would have survived the day before the overdose the previous day [7 February 2012] he did very well not to die as he was given about four times what his dose should have been. He said if we were in a coroner s court, I would say, on the balance of probabilities this final dose [4200mg denzapine] killed the patient. The post mortem examination report produced by Doctor 10, Pathologist, confirmed the cause of Patient A s death as Acute Clozapine toxicity. The panel accepted the evidence of Professor 1 who, in his expert opinion, stated that the overdose of 4200mg caused Patient A s death. Accordingly, it found charge 3 proved, in that Miss Young s actions, in incorrectly administering 4200mg denzapine to Patient A, caused his death. Determination on misconduct and impairment Following its findings on fact, the panel invited submissions on misconduct and impairment. Ms Hall referred the panel to the case of Roylance v General Medical Council (No.2) [2000] 1 AC 311, in particular to the judgment of Lord Clyde who described misconduct as a word of general effect, involving some act or omission which falls short of what would be proper in the circumstances. The standard of propriety may often be found by reference to the rules and standards ordinarily required to be followed by a medical practitioner in the particular circumstances. Ms Hall invited the panel to find that Miss Young s actions amounted to misconduct and that her fitness to practise is currently impaired. She referred the panel to parts of the NMC s publication, The Code: Standards of conduct, performance and ethics for nurses and midwives (May 2008) ( the Code ), in particular the preamble and paragraphs 8, Page 25 of 45

26 10, 22, 24, 26, 28, 32, 35, 39, 42 and 61. She also referred to the NMC s Standards for Medicines Management (April 2010), in particular standard 8, paragraphs 2, 2.5 and 2.7, and to the preamble of the NMC s Record keeping: Guidance for nurses and midwives (April 2010). Ms Hall submitted that the Code and the NMC s standards and guidance made clear what is expected of registered nurses. She submitted that the issues in this case concern basic nursing practice. She contended that Miss Young s conduct fell far below what was expected of a registered nurse in this case. Ms Hall reminded the panel that Patient A was new to the Home Treatment Team. In that regard, she submitted that greater care was required in this case. She submitted that retitration of denzapine liquid was out of the ordinary for Miss Young and for the Team. As such, Ms Hall submitted that Miss Young ought to have followed the relevant procedures and policy to the letter. In all of those circumstances, Ms Hall submitted that Miss Young s conduct was so serious as to amount to misconduct. As to impairment, Ms Hall referred the panel to the case of Cohen v General Medical Council [2008] EWHC 581 and to the observations 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) and the approach formulated by Dame Janet Smith in her 5 th Report on Shipman. Ms Hall reminded the panel of its finding that Miss Young s actions in incorrectly administering 4200mg of denzapine caused Patient A s death. Miss Hall submitted that medication administration is a basic nursing responsibility and as Miss Young did not take the necessary precautions in administering denzapine to Patient A, she breached a fundamental tenet of the profession and brought the profession into disrepute. Page 26 of 45

27 Ms Hall submitted that the public interest is a key consideration in this case. She informed the panel that Miss Young had not previously appeared before her regulator. She also reminded the panel of Mrs 3 s evidence as to her professional opinion and experience of Miss Young as a nurse. That said, Ms Hall submitted that the mistake made by Miss Young was catastrophic and fatal. As to remediation and insight, Ms Hall submitted that no evidence had been provided by Miss Young to demonstrate whether she had undertaken a medication administration course, engaged in supervision or undertaken a reflective exercise. In those circumstances, Ms Hall submitted that Miss Young had not remediated her misconduct. Ms Hall submitted that as the panel had not heard directly from Miss Young, it was not in a position to assess her current level of insight or remorse. Ms Hall submitted that this was very unfortunate incident that could have been avoided. She submitted that had Miss Young recognised and considered Patient A s high pulse rate, variable blood pressure and the concerns of the patient s mother, the outcome of this case could have been avoided. Ms Hall invited the panel to consider whether public confidence in the profession, and its regulator, would be undermined if a finding of no impairment were made. She submitted that, for the reasons set out in the cases of Cohen and Grant, Miss Young s fitness to practise is currently impaired by reason of her misconduct. She also submitted that if the panel made a finding of no impairment, this would be tantamount to a complete acquittal as the NMC has no power to warn a registrant. Summary of evidence Mrs 3 told the panel that the Home Treatment Team was unfamiliar with denzapine. Both Mrs 3 and Ms 7 explained that clozapine in tablet form was more commonly prescribed. Page 27 of 45

28 Mrs 3 and Ms 5 explained that they would have expected Miss Young to have read Patient A s RIO progress notes, the electronic prescription and the retitration chart prepared by Ms 7, before visiting him. Both witnesses said that a paper copy of the retitration chart would have been in his file, which Miss Young should have taken with her to the patient s home. Before administering the denzapine, Mrs 3 said that she would have expected Miss Young to re-check the retitration chart. Miss Young told the police that she had 16 years nursing experience. She said that in addition to her training in medication administration (upon qualifying as a nurse) she had also undertaken independent training, which included reading the Nursing Times, and keeping up to date via the internet and the BNF. In relation to clozapine, she also said that she had attended talks by the manufacturer s representatives. With regard to medication administration, Miss Young described herself as a cautious person I ve always checked more than once or twice and if I m still not happy I ve checked again and again. I ve always been very cautious with medication. Miss Young explained that whilst she had previous experience of administering clozapine (tablet form), she was not as familiar [with the liquid form of clozapine] as with the tablets. She said that it was rare and that she had only seen it used twice in her career. She said that she had not seen it used in the community, before Patient A. She told the police that she had, on one occasion, administered clozapine in liquid form to a patient (not Patient A), using an oral syringe. She said it appeared one bottle which was labelled Clozaril 50 milligrams hash one ml and from that one bottle the patient was titrating upwards and we d have to take out the specific amount that we needed using a syringe, and normally it goes up it s about 12.5 milligrams, 25 milligrams, 50, 75, 100 all the way up to the holding dose of whatever that patient needs. The bottle, on that occasion, was a large one; she said she had never seen small bottles of Clozaril that [Patient A] had before. She also stated that she had never titrated anyone in the community on liquid Clozaril. Miss Young told the police that whilst she understood the information on Patient A s retitration chart produced by Ms 7, we did not pay attention to that one, and the reason Page 28 of 45