Nursing and Midwifery Council Fitness to Practise Committee Substantive Order Review Hearing 28 November 2018 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of registrant: NMC PIN: Mrs Zainab Hussain Zaidi 05I1572E Part(s) of the register: Registered Nurse Sub part 1 Adult Nursing 21 September 2005 Registered Midwife Midwifery 15 April 2008 Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Registrant: Nursing and Midwifery Council: Order being reviewed: Outcome: England Lack of Competence Adrian Ward (Chair, Lay member) Sarah Fleming (Registrant member) Sue Davie (Lay member) Nigel Mitchell Tereka Bowes Attended by telephone Represented by Karen Tarling, counsel, instructed by NMC Regulatory Legal Team. Conditions of Practice Order 12 months Conditions of Practice Order 12 months to come into effect at the end of 5 January 2019 in accordance with Article 30 (1) 1
Decision and reasons on review of the current order: The panel decided to impose a conditions of practice order. This order will come into effect at the end of 5 January 2019 in accordance with Article 30 (1) of the Nursing and Midwifery Order 2001 (as amended) (the Order). This is the third review of the order. On 4 March 2016 a panel of the Conduct and Competence Committee made you the subject of a suspension order for 9 months. This order was reviewed on 8 December 2016 and changed to a 12 month conditions of practice order. The order was reviewed again on 24 November 2017 and this time the panel varied the conditions of practice and extended them for a further 12 months. The committee is required to review this order under article 30(1) of the Nursing and Midwifery Order 2001 before its expiry. The current order is due to expire at the end of 5 January 2019. The panel is reviewing the order pursuant to Article 30 (1) of the Order. The charges found proved by way of admission which resulted in the imposition of the substantive order were as follows: That you, a Registered Midwife and Registered Nurse, whilst employed by Central Manchester University Hospitals NHS Foundation Trust as a Band 6 Midwife at St Mary s Hospital between 8 June 2013 and 20 February 2014 failed to demonstrate the standard of knowledge, sill and judgment required for practise without supervision as a Registered Midwife in that you: 1. On 8 June 2013 in relation to Patient A and Baby A: 1.1. Failed to record in Patient A s patient records: 1.1.1. The temperature of Baby A at birth; 2
1.1.2. The time that you took over the care of Patient A; 1.1.3. The care that you provided to Patient A and/or Baby A between approximately 07:30 and 09:00; 1.2. Having realised that Baby A s temperature at birth was lower than 36.6 degrees Celsius you failed to respond appropriately in that you did not: 1.2.1. Escalate Baby A s condition to a neonatal doctor/paediatrician and/or the shift coordinator; 1.2.2. Repeat observations of Baby A s temperature; 1.3. Did not adequately monitor Baby A s blood sugar levels; 2. On about 10/11 June 2013 in relation to Patient B who had been diagnosed with Type 1 diabetes failed to provide an adequate standard of care in that you did not: 2.1. At approximately 23:00 on 10 June 2013 administer the correct dose of 10% dextrose; 2.2. Between approximately 22:26 on 10 June 2013 and approximately 06:48 on 11 June 2013: 2.2.1. Ensure a second midwife reviewed Patient B s cardiotocograph (CTG) trace on an hourly basis; 2.2.2. Record assessments of Patient B s contractions on a half hourly basis; 2.2.3. Record a review of Patient B s CTG trace every 15 minutes; 3
2.3. Record the maternal pulse on an hourly basis between approximately 21:40 on 10 June 2013 and 01:33 on 11 June 2013; 2.4. Escalate Patient B s condition to the medical team and/or the shift coordinator as soon as practicable having noted that Patient B: 2.4.1. Had a blood glucose level of: a) 13.9mmol/I at approximately 04:15 on 11 June 2013; b) 14mmol/l at approximately 04:46 on 11 June 2013; c) 12.8mmol/l at approximately 05:05 on 11 June 2013; 2.4.2. Had a suspicious CTG trace 2.5. Record the insertion of the catheter bag at around 01:00 on 11 June 2013 in Patient B s K2 notes; 2.6. Stop the intravenous administration of oxytocin to Patient B at around 06:07 on 11 June 2013 upon a decision having been made to deliver Patient B s baby by caesarean section; 3. On 4 July 2013 in relation to Patient C failed to provide an adequate standard of care in that you: 3.1. Between 08:00 and 09:10 did not escalate to the medical team or the shift coordinator Patient C s condition when there was evidence of hyperstimulation and/or high blood pressure and/or the loss of contact on the CTG; 4
3.2. Between 08:35 and 09:10 did not make a record of observations taken of Patient C s condition; 3.3. Incorrectly recorded in Patient C s handwritten clinical notes that Patient C s perineum was intact; 4. While undergoing an LSA Supervised Practice Programme ( the Programme ) between around 7 October 2013 and 20 February 2014 failed to demonstrate the required skills in: 4.1. The management of the fetal heart rate, on one or more of the occasions set out in Schedule A; 4.2. The management of the condition of patients, on one of more of the occasions set out in Schedule B; 4.3. Communication, on one or more of the occasions set out in Schedule C; 4.4. The recording of treatment given to patients on one or more of the occasions set out in Schedule D. AND in light of the above, your fitness to practise is impaired by reason of your lack of competence. Schedule A 1 In a date between 14 and 21 October 2013 wanted to change the classification of a CTG for an unknown patient s baby before allowing a sufficient time to pass 5
2 On or around 18 November 2013 did not appropriately prioritise the care of an unknown patient who had a CTG trace classified as suspicious 3 On 19 November 2013 for an unknown patient did not 3.1. Identify and/or categorise the CTG 3.2. Ensure a second midwife reviewed the CTG trace on an hourly basis 4 On 25 November 2013 discontinued the CTG trace for an unknown patient 5 On 30 December 2013 for an unknown patient did not: 5.1. Use the correct terminology to classify the CTG 5.2. Incorrectly identified the CTG trace as one that could be discontinued 6 On an unknown date between 7 October 2013 and 20 February 2014 for an unknown patient who had a pathological CTG trace that was deteriorating did not ensure an urgent medical review was conducted by a doctor of the patient s condition 7 On 11 January 2014 in respect of an unknown patient was unable to identify 7.1. That a patient concerned about reduced fetal movements required CTG monitoring 7.2. The features and/or category of the CTG subsequently commenced 8 On or around 13 January 2014 in respect of an unknown patient was unable to identify: 8.1. That a patient concerned about reduced fetal movements required CTG monitoring 8.2. The features and/or category of the CTG subsequently commenced Schedule B 1 On 30 December 2013 did not identify that, in order to effectively manage the condition of an unknown patient a: 1.1. Vaginal examination was required 1.2. Place on an obstetric led unit was required 2 On 1 January 2014 did not use a Maternity Early Warning Score (MEWS) correctly to assess an unknown patient s condition 6
3 On 7 January 2014 did not identify the fact that an unknown patient had delivered a baby with congenital abnormalities as a risk factor affecting the management of the patient s condition 4 On 21 January 2014 did not identify that the fact that an unknown patient had delivered a baby by caesarean section was a risk factor requiring the patient to be managed on an obstetric led unit 5 On 21 January 2014 incorrectly identified an unknown patient as one that could be discharged from the Hospital 6 On 3 February 2014 in order to ensure that an unknown patient s condition was managed appropriately did not identify whether the patient had suffered a per vaginal bleed or a heavy blood stained show 7 On 3 February 2014 incorrectly identified the risk factors for an unknown patient when assessing how to manage their condition in that: 7.1. A previous surgical termination was incorrectly identified as a risk factor 7.2. You did not identify the existence of a fibroid on the uterus as a risk factor 8 On 5 February 2014 did not appropriately prioritise patient care in that you transferred one unknown patient to the delivery suite without first commencing the CTG for another unknown patient Schedule C 1 On or around 18 November 2013 did not appropriately communicate to an unknown patient the process to be followed following the administration of prostaglandin 2 On 11 January 2014 did not use simple language when explaining to an unknown patient her condition 3 On or around 13 January 2014 questioned your own ability to provide safe care in the presence of an unknown patient 4 On a date between 17 and 19 February 2014 did not use simple language when explaining to an unknown patient her condition 7
Schedule D 1 On 19 November 2013 did not use the customised growth chart to record the fundal height 2 On 10 December 2013 for an unknown patient did not, until prompted to do, make a record of: 2.1. Concerns about the patient s baby s withdrawal symptoms 2.2. Observations taken of the patient s baby s concerns 2.3. The request made for a senior house officer to review the patient s baby s condition 3 On 5 February 2014 made a contradictory record of an unknown patient s MEWS by recording MEWS of zero in the patient s notes and a MEWS of three in the patient s MEWS chart 4 On 11 February 2014, until prompted to do so, did not record the cumulative urine output over three hours for an unknown patient The second reviewing panel determined the following with regard to impairment: Regarding insight, the panel noted that Ms Zaidi provided the panel with a reflective piece demonstrating understanding, remorse, and developed insight into the acts and omissions in her practice. It noted her submissions in today s hearing via telephone during which she stated that she expressed remorse and a desire to return to practice. She is currently seeking to apply for a return to practice course and has an interview for this in one weeks time. The panel took into account Ms Zaidi s numerous certificates of training which she has completed since the last review hearing, and a number of positive testimonials. However, Ms Zaidi has not practised since the previous review and has therefore not had the opportunity to make significant progress in remediation or demonstrate that she is able to practise safely without any restrictions. In light of this the panel determined that there remains a risk of repetition. The panel 8
therefore decided that a finding of current impairment is necessary on the grounds of public protection. The panel had borne in mind that its primary function was to protect patients and the wider public interest which includes maintaining confidence in the nursing and midwifery profession and upholding proper standards of conduct and performance. The panel determined that, in this case, a finding of current impairment on public interest grounds is also required. For these reasons, the panel is satisfied that Ms Zaidi s fitness to practise remains impaired. The second reviewing panel determined the following with regard to sanction: The panel next considered the imposition of a further conditions of practice order. It noted that Ms Zaidi has engaged with this review process. She has provided the panel with a reflective piece which demonstrates insight and genuine remorse and has expressed a willingness to retrain and address the deficiencies in her practice. Ms Zaidi has expressed her wish to return to midwifery and has acknowledged that she will require further training. The panel concluded that a variation of the current conditions of practice order would be the appropriate and proportionate response. The panel considered that such an order would offer Ms Zaidi the opportunity to remedy the deficiencies in her practice and return to safe midwifery practice. The panel considered that given her further developed insight and genuine remorse, which Ms Zaidi has demonstrated, a suspension order would be disproportionate. Further, it found that a period of suspension would serve no useful purpose beyond the short term protection of the public, as it would not allow Ms Zaidi to remedy her failings through supported practice. The panel noted that Ms Zaidi stated in her reflective piece that she hoped this panel would allow her midwifery registration to lapse, giving her the chance to 9
return to practice following an approved return to practice in the future. However, the panel noted that once Ms Zaidi has been out of practice for more than 3 years, she will have to do a return to practice course for both nursing and midwifery as appropriate. The panel considered that, despite this, conditions of practice remained appropriate until such time that Ms Zaidi has been able to demonstrate that she can safely return to practice whether in general nursing and/or midwifery. The panel therefore decided that the public would be suitably protected, as would the reputation of the profession, by the implementation of the following conditions of practice: 1. At any time that you are employed or otherwise providing nursing or midwifery services, you must place yourself and remain under the supervision of a workplace line manager, mentor or supervisor nominated by your employer, such supervision to consist of working at all times on the same shift as, but not necessarily under the direct observation of, a registered nurse and/or midwife of band 6 or above who is physically present in or on the same ward, unit, floor, or home that you are working in or on. 2. You must work with your line manager, mentor or supervisor (or their nominated deputy) to create a personal development plan designed to address the concerns about the following areas of your general practice: Record-keeping Monitoring vital signs and responding appropriately And in respect of your midwifery practice: Monitoring of babies and mother s vital signs during labour Management of the fetal heart during labour Interpretation of cardiotocography (CTG) 10
3. You must meet with your line manager, mentor or supervisor (or their nominated deputy) at least once a month to discuss the standard of your performance and your progress towards achieving the aims set out in your personal development plan. 4. You must forward to the NMC a copy of your personal development plan within 28 days of the date on which these conditions become effective or the date on which you take up an appointment, whichever is sooner. 5. You must send a report from your, line manager mentor, or their nominated deputy, setting out the standard of your performance and your progress towards achieving the aims set out in your personal development plan to the NMC at least 14 days before any NMC review hearing or meeting. 6. You must allow the NMC to exchange, as necessary, information about the standard of your performance and your progress towards achieving the aims set out in your personal development plan with your line manager mentor, or their nominated deputy, and any other person who is or will be involved in your retraining and supervision with any employer, prospective employer, and at any educational establishment. 7. You must disclose a report not more than 28 days old from your line manager, mentor or supervisor (or their nominated deputy) setting out the standard of your performance and your progress towards achieving the aims set out in your personal development plan to any current and prospective employers (at the time of application) and any other person who is or will be involved in your retraining and supervision with any employer, prospective employer, and at any educational establishment. 8. 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. 11
9. a) You must within 7 days of accepting any post of 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 practise provide the NMC with the name and contact details of the individual/organisation with whom you have entered into the arrangement. 10. You must tell the NMC within 7 days of any nursing or midwifery appointment (whether paid or unpaid) you accept within the UK or elsewhere, and provide the NMC with contact details of your employer. 11. 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 (10) above, to them Any organisation or person employing, contracting with or using you to undertake nursing or midwifery work Any agency you are registered with or apply to be registered with (at the time of application) to provide nursing or midwifery services Any prospective employer (at the time of application) where you are applying for any nursing or midwifery appointment 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). Decision on current fitness to practise The panel has considered carefully whether your fitness to practise remains impaired. Whilst there is no statutory definition of fitness to practise, the NMC has defined fitness to practise as a registrant s suitability to remain on the register without restriction. In considering this case, the panel has carried out a comprehensive review of the order in light of the current circumstances. It has noted the decision of the last panel. However, it has exercised its own judgment as to current impairment. 12
The panel has had regard to all of the documentation before it, including the NMC bundle. It has taken account of the submissions made by Ms Tarling on behalf of the NMC and those made by you. Ms Tarling submitted impairment is a matter for the panel to consider. She also submitted that you have not worked as a registered nurse/midwife since February 2014. The panel heard your evidence by affirmation over the telephone. You told the panel that over the past year you have attempted to apply for a Return to Nursing Practice Course at a university. You had an interview at that university, however you told the panel that they were unable to accommodate you in view of your conditions of practice. You said that they advised you to gain employment in a care home as this would assist in your pursuit of returning to practicing as a registered nurse. You informed the panel that you worked part-time (one night per week) in a care home as a care assistant for six months. You also informed the panel that the head nurse at that care home was aware of the conditions imposed on your practice and you have supplied his name and email address to the NMC for them to take up any reference if they so wish. You told the panel that you have completed some online training relevant to nursing. You also told the panel that your commitment to your family is greater than it was at the time of the last review hearing and this has impacted on your ability to progress your career. You said that the conditions of practice have restricted your ability to return to practise and that you want to return to nursing. You also said that you felt that you have made errors and mistakes in the past and that you know that you could have done better. 13
You told the panel that you are keen to retrain, you want to improve your knowledge and you are keen to demonstrate that you can work towards meeting the NMC s standards. You told the panel that you are currently not employed and that you are minded to reapply for the Return to Nursing Practice Course for the September 2019 intake at your local universities. In reaching its decision, the panel was mindful of the need to protect the public, maintain public confidence in the profession and to declare and uphold proper standards of conduct and performance. The panel considered whether your fitness to practise remains impaired. Regarding insight, the panel noted your submissions in today s hearing via telephone during which you stated that you expressed remorse and a strong desire to return to practice. The panel took into account your certificate of training completed since the last review hearing. The panel took into account that you stated that feedback from your interview for the return to practice course suggested that the conditions were not workable. However, the panel determined that the conditions imposed on your practice are not onerous. The panel noted that indirect supervision of clinical practice is towards the lower end of public protection. However, you have not practised since the previous review and have therefore not had the opportunity to make significant progress in remediation or demonstrate that you are able to practise safely without any restrictions. In light of this the panel determined that there remains a risk of repetition. The panel therefore decided that a finding of current impairment is necessary on the grounds of public protection. 14
The panel had borne in mind that its primary function was to protect patients and the wider public interest which includes maintaining confidence in the nursing and midwifery profession and upholding proper standards of conduct and performance. The panel determined that, in this case, a finding of current impairment on public interest grounds is also required. For these reasons, the panel is satisfied that your fitness to practise remains impaired. Determination on sanction Having found your fitness to practise currently impaired, the panel then considered what, if any, sanction it should impose in this case. The panel noted that its powers are set out in Article 29 of the Order. The panel has also taken into account the NMC s Sanctions Guidance (SG) and has borne in mind that the purpose of a sanction is not to be punitive, though any sanction imposed may have a punitive effect. Ms Tarling submitted if the panel has found that your fitness to practise is impaired, then sanction is a matter for the panel to decide. The panel first considered whether to take no action but concluded that this would be inappropriate in view of the risk of repetition identified and seriousness of the case. The panel decided that it would be neither proportionate nor in the public interest to take no further action. The panel then considered whether to impose a caution order but concluded that this would be inappropriate in view of the risk of repetition identified and seriousness of the case. The panel decided that it would be neither proportionate nor in the public interest to impose a caution order. The panel next considered the imposition of a conditions of practice order. It noted that you have engaged with this review process. You have demonstrated insight and genuine remorse and have expressed a willingness to retrain and address the deficiencies in your practice. You have expressed your wish to return to nursing 15
and you have acknowledged that you require further training. The panel concluded that a continuation of the current conditions of practice order would be the appropriate and proportionate response. The panel considered that such an order would offer you the opportunity to remedy the deficiencies in your practice and return to safe nursing practice. The panel therefore decided that the public would be suitably protected, as would the reputation of the profession, by the implementation of the following conditions of practice: 1. At any time that you are employed or otherwise providing nursing or midwifery services, you must place yourself and remain under the supervision of a workplace line manager, mentor or supervisor nominated by your employer, such supervision to consist of working at all times on the same shift as, but not necessarily under the direct observation of, a registered nurse and/or midwife of band 6 or above who is physically present in or on the same ward, unit, floor, or home that you are working in or on. 2. You must work with your line manager, mentor or supervisor (or their nominated deputy) to create a personal development plan designed to address the concerns about the following areas of your general practice: Record-keeping Monitoring vital signs and responding appropriately And in respect of your midwifery practice: Monitoring of babies and mother s vital signs during labour Management of the fetal heart during labour Interpretation of cardiotocography (CTG) 3. You must meet with your line manager, mentor or supervisor (or their nominated deputy) at least once a month to discuss the standard of your 16
performance and your progress towards achieving the aims set out in your personal development plan. 4. You must forward to the NMC a copy of your personal development plan within 28 days of the date on which these conditions become effective or the date on which you take up an appointment, whichever is sooner. 5. You must send a report from your, line manager mentor, or their nominated deputy, setting out the standard of your performance and your progress towards achieving the aims set out in your personal development plan to the NMC at least 14 days before any NMC review hearing or meeting. 6. You must allow the NMC to exchange, as necessary, information about the standard of your performance and your progress towards achieving the aims set out in your personal development plan with your line manager mentor, or their nominated deputy, and any other person who is or will be involved in your retraining and supervision with any employer, prospective employer, and at any educational establishment. 7. You must disclose a report not more than 28 days old from your line manager, mentor or supervisor (or their nominated deputy) setting out the standard of your performance and your progress towards achieving the aims set out in your personal development plan to any current and prospective employers (at the time of application) and any other person who is or will be involved in your retraining and supervision with any employer, prospective employer, and at any educational establishment. 8. 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. 9. a. You must within 7 days of accepting any post of employment requiring registration with the NMC, or any course of study connected with nursing or 17
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 practise provide the NMC with the name and contact details of the individual/organisation with whom you have entered into the arrangement. 10. You must tell the NMC within 7 days of any nursing or midwifery appointment (whether paid or unpaid) you accept within the UK or elsewhere, and provide the NMC with contact details of your employer. 11. 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 (10) above, to them Any organisation or person employing, contracting with or using you to undertake nursing or midwifery work Any agency you are registered with or apply to be registered with (at the time of application) to provide nursing or midwifery services Any prospective employer (at the time of application) where you are applying for any nursing or midwifery appointment 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 panel decided that a duration of 12 months for the order would be both appropriate and proportionate to allow you time to find and enrol upon a Return to Nursing Practice Course. In accordance with Article 30 (1) this order will come into effect upon the expiry of the existing conditions of practice order at the end of 5 January 2019. 18
This panel considered that a future panel would be assisted by your attendance (in person or by telephone) at a future review hearing. A future reviewing panel would also be assisted by a detailed account of how you have, or have not, been able to meet each of the conditions and any up to date references and/or testimonials. This order will be reviewed shortly before its expiry but can be reviewed earlier by either party if requested. This decision will be confirmed to you in writing. That concludes this determination. 19