Part(s) of the register: Registered nurse sub part 1 Adult nursing December 2002

Transcription

1 Fitness to Practise Committee Substantive order review meeting 22 May 2018 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of registrant: NMC PIN: Alison Jane Kett 99I1765E Part(s) of the register: Registered nurse sub part 1 Adult nursing December 2002 Area of registered address: England Type of case: Panel Members: Legal Assessor: Panel Secretary: Order to be reviewed: Outcome: Misconduct Helen Potts (Chair Lay member) Diane Corderoy (Registrant member) Alice Rickard (Lay member) David Marshall Anita Abell Suspension order for 12 months Conditions of Practice order for 8 months to take effect from the end of 13 June

2 Decision on Service of Notice of hearing The legal assessor informed the panel that written notice of this hearing had been sent to Ms Kett s registered address by recorded delivery and by first class post on 5 April The notice stated that the substantive order review meeting would take place on or after 8 May The panel accepted the advice of the legal assessor. In the light of all of the information available, the panel was satisfied that Ms Kett had been served with notice of this hearing in accordance with the requirements of Rules 11A and 34 of the Nursing and Midwifery Council (Fitness to Practise) Rules Decision and Reasons: The panel determined that Ms Kett s fitness to practise remains impaired. It decided to impose a conditions of practice order for 8 months to start at the end of 13 June This hearing was the first review of a 12 month suspension order imposed on Ms Kett s registration by a panel of the Conduct and Competence Committee on 9-12 May The order expires at the end of 13 June

3 Substantive hearing 9-12 May 2017 At the substantive hearing held in May 2017 the following charges were found proved: Charges (as amended) That you, a registered nurse, whilst employed by Hallmark Care Homes: 1 During the nightshift of 27 to 28 May 2016 you a) Did not administer the following medication prescribed to Resident A at 22:00 i. Ranitidine; ii. Simvastatin; iii. Sodium Valporate b) Did not administer the following medication prescribed to Resident B at 21:00 (charges 1(b) (iv) & (v)) and 22:00 (charges 1(b) (i), (ii) & (iii)) i. Amitriptyline Hydrochloride; ii. Amoxicillin; iii. Co-codamol; iv. Ferrous Fumarate; v. Simvastatin c) Did not administer the following medication prescribed to Resident C at 22:00 3

4 i. Adcal D3; ii. iii. iv. Dabigatran Etexilate; Donepezil Hydrochloride; Mirtazapine; v. Paracetamol d) Did not administer the following medication prescribed to Resident D at 22:00 i. Clinitas Carbomer; ii. iii. Donepezil Hydrochloride; Doxycycline e) Did not administer the following medication prescribed to Resident E at 22:00 i. Atorvastatin; ii. iii. iv. Calcium Carbonate with Colecalciferol; Donepezil Hydrochloride; Terbutaline f) Did not administer the following medication prescribed to Resident F at 22:00 i. Bisacodyl; ii. Mirtazapine; 4

5 iii. Nitrofurantoin 2 Did not administer the following medication prescribed to Resident G at 22:00; i. Chlorphenamine; ii. iii. Crotamiton Risperidone 3 In relation to the matters set out in Charge 1 above you recorded that the medication had been given when it had not; Background The matters giving rise to the charges arose whilst Miss Kett was employed by Hallmark Care Homes as a registered nurse. At the time of the alleged events Miss Kett was working as a nurse at the Home where she had been employed since March The Home is a care home for elderly residents with or without dementia, some of whom had disabilities requiring nursing care. It consisted of 2 floors with a total of 60 beds. On a night shift there would be two registered nurses on duty, one to cover each floor, with six healthcare assistants split between the two floors. Each of the two registered nurses on duty would be in sole charge of the floor to which they were assigned, and would be responsible for the administration of medication during the shift. 5

6 The Home operates a system of electronic medication administration records ( EMAR ). Each resident would have their own EMAR. The records would be accessed by the nurse carrying out the medication round using a laptop computer to which each user had a unique, secure login identity and password. According to the Home s normal policy and practice, the nurse would access the record of each resident in turn (the residents who were due to receive medication during that round would be indicated by their photographs appearing in colour on an entry screen, whereas those not due to receive medication, or who had already received it, would have a grey or black and white photograph). Having accessed the individual resident s record, the nurse would then see a series of boxes containing entries for each of the various medications due to be administered, giving information about the name and dose of the drug, the time it was to be administered and any special instructions. The actual medication was kept in blister packs for each individual resident, which were supplied to the Home on a 28 day cycle. Each resident s blister packs were kept in a separate divider of a filing system. The blister packs showed the name and date of birth of the resident in question and the date the medication in question was due to be administered, and were separated into different sections colour-coded for various times of the day (e.g. pink for the morning medication round and blue for the night-time medication round). The nurse would check the drug and dose against the EMAR record for the individual resident, then remove the medications from the blister pack and tick boxes on the EMAR system to confirm that they had dispensed the medication from the blister pack. The nurse would then take the medication to the resident in question and, once satisfied that it had been consumed, would return to the EMAR record and tick a further box to record that the medication had been administered. The nurse would then move on to the next resident. Some medications, such as liquids, powders and creams, were not contained in blister packs. These would be kept in their original containers in the drug trolley ready for administration to the resident during the medication round. 6

7 On the night shift of May 2016, Miss Kett was working as the nurse in charge of Swallow Avenue Unit ( the Unit ). She carried out a medication round, with entries on the EMAR system showing her as having signed (i.e. ticked the boxes confirming administration) for a number of medications for some 24 residents between approximately 20:45 and 22:30. The charges in this case arise from allegations that, in respect of 6 of those residents, Miss Kett signed the EMAR records to confirm the administration of the medication when she had not in fact administered it and in respect of one further resident she did not administer their medication. Miss Kett also made handwritten entries in the daily records for each of the 7 residents in question at about 04:00 on 28 May 2016, indicating that medications had been given. It is alleged that her actions in recording that the medication had been given, when it had not, were dishonest. Ms 1 is the Dementia Care Lead at the Home. She is not a registered nurse. She acts as a line manager for the Home s senior carers and carers. She is also a system administrator for the Home s EMAR system. On 28 May 2016, Ms 1 conducted the daily morning check of the EMAR system. The purpose of such checks was to monitor medication administration for the previous 24 hours and part of Ms 1 s duties as a system administrator was to oversee the system and amend records if medication had been missed. When Ms 1 was completing her daily morning checks for the previous 24 hrs on 28 May 2016, the EMAR system produced two alerts (relating to one incident) which indicated that the night medication for Resident G had not been administered. These alerts were produced because Resident G s medication had not been signed off on the EMAR system. 7

8 Ms 1 made enquiries with another member of staff and then went to the drug trolley to examine the blister packs. She discovered that the medication due to be administered to Resident G during the night shift in question was still in the blister pack in the drug trolley. She also discovered that the blister packs for Residents A, B, C, D, E and F still contained the medication due to be administered to those residents during the night shift of 27 to 28 May In order to prevent the EMAR system from continuing to generate alerts for the medication not given to Resident G, Ms 1 entered Miss Kett s initials in the relevant box for those doses, and made an exception note on the system to record that the medication had not been given. She then referred the matter for investigation. Ms 2 is employed by Hallmark Care Homes as a Peripatetic Clinical Care Manager. Her responsibilities include overseeing clinical issues in eight different care homes owned by Hallmark Care Homes. She is a registered nurse. She undertook an investigation into the matters alleged in this case and produced a report with her findings. As part of her investigation she interviewed Miss Kett. When initially questioned, Miss Kett was adamant that she had administered the medication to the residents in question, although she was then shown the blister packs which still contained the tablets and capsules due to be administered during the shift. She confirmed that she was aware of the Home s medication administration policy and the correct procedure to follow. She admitted that she had signed the EMAR at the same time for the residents to indicate that the medication had been administered, rather than updating the EMAR after administering medication to each resident. Determination on misconduct and impairment: The panel first considered whether the proven facts amounted, individually or collectively, to misconduct. In doing so, the panel considered only those charges which it found proved at the facts stage, namely charge 1 (in its entirety), charge 2 (in its entirety) and charge 3. 8

9 The panel bore in mind the definition of misconduct as advanced in the case of Roylance v General Medical Council (No 2) [2000] 1 A.C. 311 where misconduct is described 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 practitioner in the particular circumstances. When determining whether the facts found proved amount to misconduct the panel therefore had regard to the Code. The panel considered that the following provisions of the Code were engaged in this case: 1.2 make sure you deliver the fundamentals of care effectively 10.1 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 10.3 complete all records accurately 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 9

10 20.1 keep to and uphold the standards and values set out in the Code. The panel also considered Miss Kett s conduct engaged the following provision of the NMC: Standards for Medicines Management: Standard 8: Administration 2.10 you must make a clear, accurate and immediate record of all medicine administered, intentionally withheld or refused by the patient... The panel was mindful that not every departure from the relevant standards will be sufficiently serious that it can properly be characterised as misconduct going to fitness to practise. However in this case, the panel was satisfied that Miss Kett s actions fell sufficiently far short of what would be proper in the circumstances that they did amount to misconduct. The panel considered that patients were entitled to have their medication administered effectively and Miss Kett had failed to administer medication to 7 residents in the same medication round. Those residents were vulnerable, in the sense that they were in a residential home where many of the residents suffered from dementia and would not be in a position to remember that they needed their medication, so would be reliant on nurses to provide it for them. Although no actual harm had been caused to any of those residents, there was the potential for harm to all of them. By way of particular examples, the panel heard evidence from Ms 2 that: Resident A could have suffered a seizure as the result of the omission of sodium valproate, which was an anti-epileptic medication; 10

11 Resident B was being treated for a chest infection and it was important that her antibiotics (amoxicillin) were administered to complete the course of treatment; Resident C could have suffered a stroke or mini stroke as a result of not receiving dabigatran etexilate, which is a blood thinning medication; Resident D was also receiving antibiotics (doxycycline) for an infection and it was important to complete the course of treatment; Resident F could have become unsettled as a result of not receiving mirtazapine, which is a medication to treat depression; Resident G could have become unsettled as a result of not receiving chlorphenamine and crotamiton, which are medications to treat itching and skin irritation. The panel further noted that Miss Kett s errors in this case had arisen because she had engaged in poor or sloppy practice in the administration and recording of medication. She was aware of the proper systematic procedure, which was designed to avoid mistakes of this kind being made and/or to allow them to be identified immediately, and did not follow it. On her own admission, Miss Kett had disregarded that procedure and had completed EMARs for a number of patients at a single time, rather than completing each one immediately after administering medication to that patient. She had also allowed herself to become distracted during the medication round. The panel was mindful that these failings occurred during a single medication round during a single shift, and indeed all occurred within a very short window of time within that medication round. However, they involved administration and/or recording errors in respect of 7 separate residents and 26 separate medications. The panel acknowledged that each individual medication error, in isolation, would not necessarily be sufficiently serious to amount to misconduct. However, viewed cumulatively, and in the context of the poor and sloppy practice which caused them, 11

12 the panel considered that Miss Kett s failings in respect of charges 1, 2 and 3 were sufficiently serious to amount to misconduct. Panel s decision on impairment The panel then went on to consider whether Miss Kett s fitness to practise is currently impaired by reason of her misconduct in relation to the proven charges. The panel was mindful that impairment of fitness to practise has no statutory definition. However, the Nursing and Midwifery Council defines fitness to practise as a registrant s suitability to remain on the register without restriction. The panel was also mindful that a finding of a breach of the code or of misconduct does not automatically lead to a finding of current impairment: impairment is a separate judgment which the panel must make. The panel had regard to the case of CHRE v NMC and Grant [2011] EWHC 927 and took into account the guidance provided by Mrs Justice Cox to panels deciding whether fitness to practise is impaired, namely that panels should not lose sight of the need to protect the public and to declare and uphold proper standards of conduct and behaviour so as to maintain public confidence in the profession (paragraph 90 of the judgment). Mrs Justice Cox went on to make the point that the panel should consider not only whether the practitioner continued to represent 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 circumstances of the case (paragraph 101). The panel also took note of the guidance formulated by Dame Janet Smith in her Fifth Report to the Shipman enquiry, approved in Grant, on the approach to be taken 12

13 when considering impairment. The guidance suggests that it may be helpful to panels to consider whether their findings of fact in respect of misconduct show that the registrant s fitness to practise is impaired in the sense that he or she has in the past and/or is liable in the future to act in such a way as to: Put a patient or patients at unwarranted risk of harm; Bring the profession into disrepute; Breach one of the fundamental tenets of the profession; Be dishonest. The panel considered that the first, second and third limbs of this guidance were engaged by Miss Kett s past actions and omissions which gave rise to the proven charges in this case. It considered that the fourth limb was not engaged in this case. The panel considered that, as has already been set out in relation to misconduct above, the omission of the medication for Residents A to G had placed those residents at unwarranted risk of harm, albeit that no actual harm was caused. The panel considered that the profession had been brought into disrepute by Miss Kett s failings in providing effective care to those vulnerable residents, and by the poor and sloppy practices which led to those failings. The panel further considered that Miss Kett s failings had breached a fundamental tenet of the profession, namely to deliver the fundamentals of care effectively. The panel was mindful that poor practice on the part of Miss Kett had resulted in her making errors in the fundamental and basic nursing skill of the administration and recording of medication. In reaching its decision as to whether Miss Kett was liable to act in such a way again in future, the panel had careful regard to the issues of insight, reflection and remorse, whether the conduct is capable of remedy, whether it has been remedied and whether it is likely to be repeated in the future. 13

14 The panel considered that it had evidence of only very limited insight on the part of Miss Kett into her failings. During the investigatory interview conducted by Ms 2 at the Home, Miss Kett had acknowledged her failure to follow proper procedure in respect of the administration and recording of medications. She had also asked whether any of the residents had come to any harm as a result of her actions. In her to the NMC dated 21 April 2017, she had acknowledged that her actions could have caused harm: While I see that my actions could have been harmful, there was never any malice or dishonesty on my part ever. I would never have knowingly harmed anyone in my care. However the panel noted Ms 2 s evidence that, at the investigatory meeting, Miss Kett had not appeared to demonstrate remorse or insight into the potential consequences of her failings. The panel considered that there was insufficient evidence of her insight into the seriousness of her failings, their potential impact on patients, colleagues, her employer and the nursing profession as a whole, and the importance of adhering to procedure. The panel also considered that there was no evidence of remorse. The panel considered that failings of the nature involved in this case are eminently capable of being remedied through a process of retraining and supervision in relation to the administration and recording of medication, and demonstration of insight and safe practice in relation to adherence to procedure. However, there was no evidence of any of these remedial steps having been taken in this case. In her dated 21 April 2017 Miss Kett had stated that nursing and healthcare are not in my future. I will not be renewing my registration. 14

15 In her of 21 April 2017, Miss Kett also said, I was a competent and committed nurse for many years, but that is now over. The panel bore in mind that these failings occurred within a very short space of time in a single medication round during a single shift, and that, on the evidence before it, it appeared that Miss Kett had a hitherto unblemished career. However, the panel noted that there were multiple failings within this short episode, and that they arose as a result of poor and sloppy practice and a failure to adhere to procedures designed to avoid errors of this kind. In the absence of evidence of sufficient levels of insight and remorse, and of remediation, the panel considered that there remained a risk of repetition. The panel therefore concluded that, at this time, were Miss Kett to return to unrestricted practice as a nurse, she remained liable, in future, to repeat her failings and therefore to act in such a way as to put patients at unwarranted risk of harm, bring the profession into disrepute and breach fundamental tenets of the profession. The panel therefore concluded that Miss Kett s fitness to practise is currently impaired by reason of her misconduct. In addition, the panel had regard to the wider public interest. It considered that members of the public would be seriously concerned if there were to be no finding of impairment in a case where this number of medications were missed, in relation to vulnerable residents, due to poor and sloppy practice, and in circumstances where there was very little evidence of insight or remorse and no evidence of remediation. The panel therefore considered that a finding of impairment was necessary on wider public interest grounds, in order to declare and uphold proper standards within the nursing profession, and that public confidence in the profession and in the NMC as its regulator would be undermined if a finding of impairment were not made. 15

16 Accordingly, the panel concluded that Miss Kett s fitness to practise is currently impaired. Determination on sanction The panel had regard to the mitigating and aggravating features of the case. These had already been set out comprehensively within the panel s earlier determination on impairment. However the panel considered that the aggravating and mitigating factors could be summarised as follows: Aggravating factors: Miss Kett s failings related to administration and/or recording errors in respect of 7 separate residents and 26 separate medications; The residents were vulnerable, living in a residential home where many residents suffered from dementia and would not be in a position to remember that they needed their medication, relying on nurses to provide it for them; Miss Kett s omissions put 7 patients at unwarranted risk of harm; There was very limited evidence of insight into the failings and no evidence of remorse or remediation; There appeared to be a lack of acceptance of responsibility on Miss Kett s part. The panel considered that the mitigating factors could be summarised as follows: There was no actual harm to patients; 16

17 The events occurred within a very short window of time within a single medication round during a single shift; There was no evidence of any previous issues in relation to Miss Kett s fitness to practise; These events could therefore be regarded as an isolated and short-lived episode in a hitherto unblemished and lengthy nursing career. The panel had regard to its findings at the previous stages in this case. It bore in mind its finding at the impairment stage that, in the absence of evidence of sufficient levels or insight and remorse, and of remediation, there remained a risk of repetition of misconduct of the type involved in this case. It further bore in mind its finding that the misconduct had involved poor practice and failure to adhere to procedure, which had resulted in Miss Kett making multiple errors in the fundamental and basic nursing skill of the administration and recording of medication. The panel first considered whether to take no action. It concluded that this would not be sufficient to protect the public or satisfy the wider public interest in this case. To take no action would not protect the public from the risk of harm arising from any repetition of the failings. Neither would it adequately mark the failings in this case. It would therefore not serve to declare and uphold proper professional standards and thereby maintain public confidence in the nursing profession and the regulatory process. The panel also considered that the imposition of a caution order would not be a sufficient sanction to protect the public or satisfy the public interest considerations in this case. The panel was mindful of the guidance in the ISG 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. 17

18 The panel had regard to the fact that it considered that Miss Kett had displayed only limited insight, particularly into the potential consequences of her actions for patients, colleagues, her employer and the nursing profession as a whole, and the importance of adhering to procedure. In addition, the panel bore in mind that it had already determined that there remained a risk of repetition of her misconduct until such time as Miss Kett could demonstrate that her failings have been remedied. In those circumstances, the panel considered that a caution order would not be sufficient to protect the public from the risk of harm arising from any repetition of the failings, to declare and uphold proper professional standards, or to maintain public confidence in the profession and the regulatory process. The panel next considered whether placing conditions of practice on Miss Kett s registration would be a sufficient and proportionate response. The panel was mindful that any conditions imposed must be proportionate, practicable, measurable and sufficient to protect the public from harm. It had regard to the factors set out in the relevant paragraphs of the ISG which indicate when such an order may be appropriate. The panel considered that there were identifiable areas of nursing practice that required assessment or retraining in this case, namely the administration and recording of medication. The panel was mindful of its earlier finding that failings of this nature are eminently capable of being remedied through a process of retraining and supervision, and demonstration of insight and safe practice. There was no evidence in this case of harmful deep-seated personality or attitudinal problems or of general incompetence. In theory, therefore, the panel considered that this was a case in which it would be possible to formulate workable conditions of practice which would be sufficient to protect the public, would adequately mark the seriousness of the failings, and would satisfy the wider public interest considerations in this case. 18

19 However, Miss Kett had expressed a clear intention not to return to the nursing profession. Moreover, she had demonstrated only very limited insight into her failings and there was no evidence that she had, thus far, taken any steps to remedy them. The panel therefore considered that there was no evidence to suggest that Miss Kett was, at this time, able or willing to respond positively to retraining or to comply with any conditions imposed on her practice. The panel considered that it was unfortunate that Miss Kett had chosen not to attend the hearing, with the consequence that these issues could not be explored with her by the panel. The panel concluded that it was not possible to formulate workable, practicable conditions of practice which would satisfactorily address the concerns identified in this case, and that a conditions of practice order would not be an appropriate sanction. Having concluded that a conditions of practice order was not appropriate, the panel considered whether to impose a suspension order. It had regard to the guidance contained in the ISG as to when a suspension order may be appropriate. The panel bore in mind that this was a single instance of misconduct and that there was no evidence of harmful deep-seated personality or attitudinal problems. The panel was mindful that Miss Kett s failings were remediable, although she had not yet demonstrated that they had been remedied. It bore in mind that there was no information before it from Miss Kett to demonstrate that she has developed sufficient insight or taken steps to remedy her misconduct. However, the panel also took into account that there was no evidence of any previous or subsequent misconduct of a similar, or indeed any, nature. It appeared that this was a single, isolated and shortlived episode in an otherwise unblemished and lengthy career. The panel was mindful that, but for the absence of evidence of insight and willingness to embark on a process of remediation, it would have considered a conditions of practice order an appropriate and sufficient sanction. 19

20 Taking all of these matters into account, the panel determined that a period of suspension was the proportionate sanction which would protect the public while it was in force, adequately mark the misconduct, and be sufficient to satisfy the wider public interest considerations. A suspension order would send a clear signal to Miss Kett, to the profession and to the public, that her behaviour had been unacceptable. It would therefore adequately serve the public interest in declaring and upholding standards and in maintaining public trust and confidence in the profession. The suspension would also provide her with the opportunity to reflect upon the panel s findings and, should she wish to do so, to re-engage with the NMC process, in order to demonstrate the required development in her insight and willingness to engage with a process to take steps to remedy her failings. The panel gave consideration to making a striking off order. In line with the ISG the panel reflected on the following questions: Is striking-off the only sanction which will be sufficient to protect the public interest? Is the seriousness of the case incompatible with ongoing registration? Can public confidence in the professions and the NMC be sustained if the nurse or midwife is not removed from the register? The panel reminded itself that the purpose of a sanction is not to be punitive, and bore in mind that it must strike a fair balance between the interests of the registrant and the public interest. In the circumstances of this case, the panel did not consider that striking off was the only sanction sufficient to protect the public interest. The panel considered that Miss Kett s failings were isolated, remediable and were not incompatible with ongoing registration. It considered that to impose a striking-off order at this time would deprive the public of an experienced nurse and would deprive Miss Kett of the opportunity to reflect further on these events and to reconsider, should she wish to do so, her future intentions with regard to her nursing career. 20

21 In all the circumstances, the panel did not consider that public confidence in the profession and the NMC, as regulator, required Miss Kett s permanent removal from the register. On the contrary, the panel considered that to take such a step at this stage would be unduly punitive in effect, disproportionate and inappropriate. The panel was mindful that if Miss Kett continues to demonstrate an unwillingness to engage with the NMC and with a process of remedying her past failings, any future panel reviewing the situation at a review hearing would have all options open to it in terms of sanction. The panel therefore concluded that a suspension order was the appropriate and sufficient sanction in this case. In terms of the length of suspension, the panel determined that 12 months would be the appropriate and proportionate period. Such a period would adequately mark the seriousness of Miss Kett s misconduct and would satisfy the public interest in declaring and upholding proper professional standards and maintaining public confidence in the profession. It would allow a sufficient period for Miss Kett to reflect on the panel s findings and the issues of concern which have arisen in this case, and to take steps to demonstrate that she is capable of remedying her past failings. The panel was mindful that this order would prevent Miss Kett from working as a registered nurse. However it determined that any financial hardship suffered by Miss Kett was outweighed by the necessity to maintain public confidence in the profession and in the NMC as a regulator. The panel also noted that, at the present time, Miss Kett has expressed an intention not to work as a nurse in the future, and this order would therefore not appear to cause her any additional financial hardship. 21

22 Accordingly, the panel determined that the appropriate and proportionate sanction in this case would be a suspension order for a period of 12 months. Miss Kett will be notified of the panel s decision in writing. Her case will be reviewed before the expiry of the 12 month suspension period. Subject to any appeal, the suspension order will come into effect 28 days after the service of the notification of the panel s decision on her. A future reviewing panel would be assisted by: Miss Kett s attendance at, or engagement with, the review hearing, whether in person or otherwise; A written statement demonstrating Miss Kett s reflection on this episode and on the panel s findings, and demonstrating her insight into her failings, including what happened and why it happened, what she has learned from it, how she can ensure that it would not happen again, the potential consequences of her failings for patients, colleagues, her employer and the nursing profession as a whole, and her understanding of the importance of adherence to procedures; Evidence of any steps Miss Kett has taken since these events, or proposes to take, to remedy her failings; Evidence of any steps Miss Kett has taken to keep her professional knowledge and skills up to date while she has not been practising as a nurse, including any evidence of personal study or courses attended or undertaken online, in particular in relation to medicines management; Up-to-date references and testimonials in relation to any work she has undertaken, whether paid or unpaid and whether or not in a healthcare setting. 22

23 At the review, the reviewing panel, based on the evidence before it, will be able to impose any sanction which this panel could have imposed, including a striking-off order. Substantive order review panel 22 May 2018 Decision on impairment The panel accepted the advice of the legal assessor. The panel first considered whether this matter was suitable for a meeting as opposed to a hearing. The panel concluded the matter could be dealt with at a meeting as the issues to be decided are not complex, Ms Kett has provided written submissions for the panel to consider and there is no public interest that demands a hearing. The panel next considered whether Ms Kett s fitness to practise remains impaired. In reaching its decision, the panel took into account the need to protect the public, maintain public confidence in the profession, and the need to declare and uphold proper standards of conduct and behaviour. In reaching its decision the panel considered all of the documentation before it. This consisted of the findings of the substantive panel in May 2017, correspondence between Ms Kett and her case officer, and a reflective piece submitted by Ms Kett on 13 May

24 In her reflective piece Ms Kett has acknowledged her responsibility for the errors she made and has considered how she could have better managed the situation which led to the medication errors. She has also considered the impact that her errors had on her patients, her colleagues and the wider profession. The panel concluded that the reflective piece indicated that Ms Kett has used her period of suspension to develop her insight and remorse. It also gave some details of mitigating factors that the substantive panel was not aware of. In reaching its decision the panel took into account that it is over a year since Ms Kett last practised. She has not provided any current references or testimonials. Further, because she has been suspended, she has been unable to provide any information as to how she has remedied her errors. Nor has she demonstrated how she has kept her knowledge and skills up to date. The panel concluded that Ms Kett has not yet had the opportunity to embed her reflection into her practice. In these circumstances the panel concluded that the risk of repetition of similar incidents remains. The panel therefore concluded that Ms Kett s fitness to practise remains impaired. Sanction Having found Ms Kett s fitness to practise is currently impaired, the panel then considered what, if any, sanction it should impose in this case. The panel took into account the aggravating and mitigating features summarised by the substantive panel, and noted that Ms Kett had supplied more information about mitigating factors. The panel considered the NMC s Sanctions Guidance (SG.) It bore in mind that the purpose of a sanction is to protect the public and the public interest and not to be punitive, though it recognised that any sanction imposed may have a punitive effect. 24

25 The panel first considered whether to take no action or impose a caution order, but concluded that neither option would be appropriate. The effect of both of these actions is that Ms Kett would be allowed to practise without any restriction. This would not be appropriate in a situation where Ms Kett has yet to remediate the deficiencies identified in her practice, and where there remains a risk of repetition. The panel next considered imposing a conditions of practice order. The panel took into account that Ms Kett has had a change of heart during her period of suspension. She explained in her written documents that in 2017 a combination of factors had left her feeling that she no longer wished to practise as a nurse at the time of the substantive hearing. The substantive panel took this factor, and the lack of any evidence of insight and remorse, into account and decided that in those circumstances a conditions of practice order was not appropriate. The situation is quite different today. Ms Kett in her written reflection has demonstrated insight and remorse and she has stated that she wishes to return to practice. The panel noted that the incidents which led to a finding of impaired fitness to practise occurred on a single shift in an otherwise long and unblemished career, and relate only to the administration of medication on that shift. In those circumstances the panel considered it would be possible to formulate workable and practical conditions. The panel concluded that Ms Kett has now demonstrated a willingness to comply with conditions of practice including undertaking medication training modules. The panel did consider imposing a further suspension order but concluded such a sanction would be disproportionate in current circumstances. 25

26 The panel concluded that it would be appropriate and proportionate in these new circumstances to impose a conditions of practice order on Ms Kett s registration. The panel therefore imposes the following conditions of practice: 1. You must tell the NMC within 7 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. 2. You must tell the NMC about any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 7 days of you receiving notice of them. 3. a) You must within 7 days of accepting any post or employment requiring registration with the NMC, or any course of study connected with nursing or midwifery, provide the NMC with the name/contact details of the individual or organisation offering the post, employment or course of study. b) You must within 7 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. 4. You must complete a course in medication administration, preferably face to face, before returning to nursing practice. 5. You must not carry out administration of medication unless directly supervised by a registered nurse of at least Band 6 or equivalent until you have been assessed as competent by that nurse; you must provide written evidence of any such assessment at least 14 days before any review hearing. 6. You must keep a personal development log recording every shift on which you have undertaken medicines administration which must be signed by the nurse who supervised you and contain that person s comments at to how you carried out the procedures, until such time as you have been assessed as competent in accordance with condition 5 above. 7. You must meet with your line manager, mentor or supervisor (or their nominated deputy) at least every month to discuss the standard of your clinical performance, including the administration of medication. 8. You must send a report from your line manager, mentor or supervisor (or their nominated deputy) setting out the standard of your clinical performance including the administration of medication at least 14 days before any review hearing. 26

27 9. You must immediately tell the following parties 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 (8) above, to them 1. Any organisation or person employing, contracting with or using you to undertake nursing work 2. Any agency you are registered with or apply to be registered with (at the time of application) to provide nursing or midwifery 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 midwifery, or any such establishment to which you apply to take a course (at the time of application). The duration of this order is 8 months to afford you sufficient time to re-register with the NMC, find suitable employment and to demonstrate compliance with these conditions. This order will be reviewed before its expiry. That concludes this determination. This decision will be confirmed to in writing. 27