Nursing and Midwifery Council Fitness to Practise Committee Substantive Order Review Hearing 19 October 2018 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of registrant: NMC PIN: Grace Arkoh-Ankrah 99J1120O Part(s) of the register: Registered Nurse Sub part 1 Adult Nursing October 1999 Mental Health Nursing February 2008 Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Mrs Arkoh-Ankrah: Nursing and Midwifery Council: Order being reviewed: Outcome: England Lack of Competence Sara Nathan (Chair, Lay member) Kim Bezzant (Registrant member) Rama Krishnan (Lay member) Robert Frazer Deepan Jaddoo Present and represented by Thomas Montford Kim Elcoate May, Case Presenter Conditions of practice order 8 months Conditions of Practice Order varied for a period of 18 months to come into effect upon the expiry of the current order, namely 25 November 2018, in accordance with Article 30 (1) 1
Decision and reasons on review of the current order The panel decided to vary the current conditions of practice order for a period of 18 months. This order will come into effect at the end of 25 November 2018 in accordance with Article 30 (1) of the Nursing and Midwifery Order 2001 (as amended) (the Order). This is the fourth review of a substantive order originally imposed by a panel of the Conduct and Competence Committee on 19 February 2015 for 12 months. That panel imposed a suspension order for 12 months, which was replaced by a 24-month conditions of practice order following a review on 18 March 2016. A further review, which concluded on 10 August 2017, took place in order to address issues with the current conditions of practice order. No new order was made at that review. The order was last reviewed on 9 February 2018, where that panel continued and extended the conditions of practice order for a period of 8 months. The current order is due to expire at the end of 25 November 2018. The panel is reviewing the order pursuant to Article 30(1) of the Order. The charges found proved which resulted in the imposition of the substantive order were as follows: That you, whilst employed by the Warrington and Halton Hospitals NHS Trust as a staff Nurse, and whilst subject to an action plan / formal capability procedure between 18 February 2011 and 4 June 2012 failed to demonstrate the standards, knowledge, skills and judgement required to practise as a Staff Nurse in that you: Whilst working on Ward A8 between 18 February 2011 and 13 November 2011: 1...: a. 2. On or around 2 March 2011: a. Failed to provide Patient 6 with a drink 2
b. c. 3. On or around 2 June 2011: a. Failed to handover Patient 10's "nil by mouth" status at the end of your shift 4. On or around 11 August 2011: a. Gave a very brief handover to Ms 1 during which you used abbreviations which you did not understand b. Failed to request clarification of abbreviations you did not understand when patients were handed over to you at the start of your shift c. Communicated with staff in a manner which appeared abrupt and/or aggressive d. Communicated with patients in a manner which appeared abrupt and/or aggressive 5. On or around 2 September 2011: a. Reported that Patient 12's mouth was "just a bit red" or words to that effect when Patient 12 had a thrush infection and swollen ulcers b. Failed to show empathy for Patient 12's condition 6. On or around 7 September 2011: a. Failed to gain the consent of Patient 13's family before transferring Patient 13 to a rehabilitation unit 7. On an unknown date between June and October 2011: a. Failed to check Patient 1's blood sugar levels b. Failed to re-dress Patient 1's leg sores c. Did not know that you should not commence suction on the chest drain for Patient 2 before the doctor had specified the correct pressure to be used d. Failed to ensure that Patient 3's pressure sores were covered 3
e. Failed to notify the doctor that the prescription in respect of Patient 5 needed to be altered 8. Between 22 and 28 September 2011 a. Failed to complete fluid balance charts for Patient 20 b. In the absence of an accurate record of urine output for patient 20, scored zero on this aspect of the Modified Early Warning Score (MEWS) Whilst working on Ward A7 between 14 November 2011 and 4 June 2012: 9. On or around 8 December 2011: 10. : a. Requested a one:one for Patient 15 without taking steps to find out the reason for the change in his condition b. Failed to request a medical review for Patient 15 for a period of around 45 minutes c. Failed to check how frequently the sedative prescribed to Patient 15 could be administered d. Did not know the steps you should take pre-administration and post-administration of Patient 15 s sedative. a. 11. On or around 1 January 2012: a. Failed to attend Patient 21 when he indicated that he was about to suffer a hypoglycaemic episode b. Failed to demonstrate an adequate understanding of diabetic care 12. On or around 9 January 2012: a. Did not know how Patient 22, who had a pneumothorax with chest drain in-situ, should be cared for 13. On or around 18 January 2012: a. Failed to administer a prescribed dose of calcium resonium to Patient 23 b. Did not know the potential consequences of raised potassium levels 4
14. On or around 9 February 2012: a. Did not know if any of Patient 24's medications had been altered b. Did not know if Patient 24 had been administered any analgesia 15. On or around 10 February 2012: a. Failed to complete a pain score in respect of Patient 25 b. Failed to complete a bowel chart in respect of Patient 25 c. Did not know the correct steps to take on recording a Modified Early Warning Score of two for Patient 25 d. Failed to record the appearance of Patient 27 s pressure sores 16. On or around 14 February 2012: a. Inadequately completed documentation in respect of Patient 28's chest drain 17. On or around 15 February 2012: a. Caused Patient 33 to be brought up to Ward A7 when there was no bed for Patient 33 b. Failed to handover that Patient 30 was not for resuscitation c. Did not wash your hands prior to taking Patient 31 s blood sugar d. Used poor technique to take Patient 31s blood sugar, resulting in contamination of the test e. Failed to update the careplans of the patients in your care 18. On or around 16 February 2012 you failed the medication competency assessment. 19. On or around 24 February 2012: a. b. Required prompting to complete a food chart for a patient c. Required prompting to change a fluid bag for a patient 5
d. e. 20. On or around 29 February 2012: a. Required prompting to note down the necessary information at the handover of shifts b. Failed to record observations in respect of Patient 39 who had a chest drain in-situ c. Failed to speak with the relatives of Patient 40 who had attended Ward A7 for this purpose d. Gave handover to the late shift at 3.30pm when this should have been done at 1.30pm e. Failed to complete necessary documentation, including fluid balance charts during the course of the shift f. Failed to monitor Patient 43 who was on chest drain suction g. Incorrectly attempted to take blood sugars for Patient 44, who was not diabetic and did not require a blood sugar test at that time h. 21. On or around 4 March 2012: a. Failed the medication competency assessment b. Did not know that an anti-emetic could be omitted when a patient was not feeling sick c. d. 22. On or around 3 March 2012: tests a. Failed to complete the necessary blood card for Patient 45's blood 23. On or around 15 March 2012: a. Failed to handover to an oncoming member of staff that a patient had a red buttock area 6
b. Failed to handover to an oncoming member of staff that a patient had very low blood pressure and therefore required four-hourly observations c. Did not know whether or not Patient 46 had had an International Ratio (INR) to test the consistency of his blood d. e. f. Failed to check Patient 46A's feet, despite a note from the doctor mentioning that Patient 46A's feet were discoloured g. Did not know that Patient 46A had swollen and discoloured feet h. Failed to chase referrals for patients, including Patient 47 i. Failed to attend to Patient 47 who had a dry and coated mouth notes j. Required prompting to refer to Care Plans when writing up your k. Spent more than an hour writing up notes for the care given to your patients 24. On or around the weekend of 24-25 March 2012: a. Failed to offer Patient 48 alternative nutrition when he refused breakfast b. Failed to re-check Patient 48's blood sugars after his refusal to take breakfast c. Did not know the correct treatment for a patient with low blood sugar levels d. Required prompting to re-check Patient 48's blood sugar levels after they had been recorded as below a normal level e. Required prompting to re-check Patient 49's blood sugar after they had been recorded as low. f. Failed to administer a second dose of colyamicin to Patient 50 g. Failed to carry out risk assessments for Patient 50 25. On or around 7 April 2012: 7
a. Failed to complete observations of any patients for the first three and a half hours of your shift 26. On or around 12 April 2012: a. Failed to complete patient care plans b. Failed to document wound care given to Patient 52 who had a Grade 2 sacral sore c. Failed to carry out an assessment of Patient 52's sacral sore 27. On or around 16 April 2012 a. Gave an inadequate handover of information to oncoming staff b. Recorded Patient 53's respiration rate as 17, when it was in fact 22 28. On or around 18 April 2012: a. Failed to hand over information which was required to enable to the transfer of Patient 54 from Ward A7 29. On or around 19 April 2012: a. Ordered blood for a non-urgent transfusion for Patient 55 for a time when you would not be able to administer it b. Asked a carer to give the blood to Ms 3 to deal with as you did not have time to do so yourself c. Asked a carer to put the blood in a fridge on Ward A7 when this was not correct procedure d. Failed to handover to Ms 4 that Patient 56 had a broken hip e. Had to be asked three times by Patient 57 before you took down the empty blood bag following Patient 57's transfusion 30. On or around 24 April 2012: a. Used the incorrect nebuliser for Patient 59 31. On or around 26 April 2012: a. Recorded in a patient's notes that the Medical Team had "no idea" about the Home Oxygen Therapy required for the patient on discharge, even though they had previously documented the requirement in his notes. 8
32. On or around 8 May 2012: a. Required prompting to give assistance to Patient 62 who was unwell and short of breath b. Failed to provide an adequate handover Patient 62's condition to the nurse who took over the care of Patient 62 at the time the nurse took over care c. Failed to handover information relating to Patient 62's planned transfer to the High dependency Unit d. Failed to chase up test results for patients allocated to you 33. On or around 10 May 2012: a. Failed to carry out instructions given to you by Ms 2 in respect of Patient 63 and instead handed this patient over to another member of staff 34. On or around 18 May 2012: a. Requested that the ward clerk send a fax referring Patient 64 to the district nursing team, when that fax did not contain: i. Information as to medication dosages ii. iii. The time for the patient's discharge The weight of the patient upon discharge b. Failed to provide Patient 64 with a sharps bin on discharge AND in light of the above, your fitness to practise is impaired by reason of your lack of competence. The reviewing panel on 9 February 2018 determined the following with regard to impairment: The panel considered whether Ms Arkoh-Ankrah s fitness to practise remains impaired. It noted that, to date, she has not been able to complete a return to practice course. There has therefore been no change as far as her remediation and she remains a risk. 9
The panel noted that the charges found proved related to a number of wide-ranging issues, and that she has not worked as a registered nurse since 2012. It had no information before it to show that Ms Arkoh-Ankrah had made any progress towards addressing these, apart from applying to undertake a return to practice course. There was also no new information before the panel in respect of any developments in Ms Arkoh-Ankrah s insight. The panel again acknowledged Ms Arkoh-Ankrah s continued engagement in these proceedings and her continued efforts to gain a place on a return to practice course. The outcome of these efforts will be of interest to a future reviewing panel. The last panel determined that Ms Arkoh-Ankrah was liable to repeat matters of the kind found proved. This panel has received no new information that would indicate otherwise. In light of this, the panel determined that Ms Arkoh-Ankrah is liable to repeat matters of the kind found proved, and that a finding of current impairment is necessary on the grounds of public protection. The panel bore in mind that its primary function was to protect patients and the wider public interest which includes maintaining confidence in the nursing 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 required. For these reasons, the panel finds that Ms Arkoh-Ankrah s fitness to practise remains currently impaired. The reviewing panel on 9 February 2018 determined the following with regard to sanction: The panel first considered whether to take no action, or to impose a caution order, but concluded that either outcome would be inappropriate in view of the risk of repetition identified by this panel and the consequent risk to the public if she were allowed to practice unrestricted. The panel decided that these outcomes would be neither proportionate, nor in the public interest. 10
The panel next considered the imposition of a conditions of practice order. The panel was of the view that a conditions of practice order is sufficient to protect patients and the wider public interest, noting that appropriate and proportionate conditions could be formulated which would protect patients during the period they are in force. It further took into account Ms Arkoh-Ankrah s continued attempts to comply with the current conditions of practice order, and the fact that she appears to be in the process of undertaking a return to practice course in the near future. Accordingly, the panel determined, pursuant to Article 30(1) of the Nursing and Midwifery Order 2001, to extend the current conditions of practice order for a period of 8 months, in order to give Ms Arkoh-Ankrah the opportunity to complete the return to practice course and possibly gain employment as a registered nurse. This order will come into effect on the expiry of the current order. The conditions remain as follows: 1. You must tell the NMC within 14 days of any nursing appointment (whether paid or unpaid) you accept within the UK or elsewhere, and provide the NMC with contact details of your employer. 2. You must tell the NMC about any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 14 days of you receiving notice of them. 3. a) You must within 14 days of accepting any post or employment requiring registration with the NMC, or any course of study connected with nursing 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 14 days of entering into any arrangements required by these conditions of practice provide the NMC with the name and contact details of the individual/organisation with whom you have entered into the arrangement. 11
4. Before returning to practice you must successfully complete and pass an NMCapproved return to practice programme. The course should address the following areas of competency and you must be assessed as competent in those areas; a) Communication b) Record Keeping c) The assessment, planning, implementation and evaluation of care d) Time management e) Prioritisation of tasks f) Compliance with procedures and policies g) The ability to assess your own performance and limitations in performance. 5. You must immediately inform 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 (4) above, to them: a. Any organisation or person employing, contracting with, or using you to undertake nursing work; b. Any agency you are registered with or apply to be registered with (at the time of application); c. Any prospective employer (at the time of application); and d. 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 such a course (at the time of application). A future reviewing panel may be assisted by the following: - Ms Arkoh-Ankrah s attendance at the review hearing - A reflective piece focusing on the return to practice course outcomes and relating to the problem areas identified at the substantive hearing. - Any up-to-date testimonials from registered nursing colleagues who have worked with Ms Arkoh-Ankrah during her return to practice course. 12
Decision on current fitness to practise This 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 it 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. The panel has had regard to all of the documentation before it, including a bundle of documents from the NMC and documents which you provided which, amongst other things, containing evidence of your Return to Practice Course (RTPC) assessments and a written reflective piece. It has taken account of the submissions made by Ms Elcoate May on behalf of the NMC, and those made by Mr Montford on your behalf. Ms Elcoate May outlined the background of this case to the panel. Ms Elcoate May reminded the panel that the matters found proved (some 86 failings) relate to serious and wide ranging deficiencies involving fundamental aspects of nursing, concerning your clinical practice. Ms Elcoate May referred the panel to a bundle of documentation you had provided, and noted that you have twice failed the practical modules of your RTPC. Ms Elcoate May submitted that whilst you have made attempts to undertake the RTPC, as you have not remedied the concerns identified or yet passed the RTPC, you remain a risk to the public, such that public confidence in the profession would be undermined if you were to return to unrestricted practice at this time. Accordingly, Ms Elcoate May invited the panel to find that you remain currently impaired on both public protection and public interest grounds. Ms Elcoate May invited the panel to consider the recent change of approach by the NMC sanction guidance to panels, specifically in relation to RTPCs, which advises panels to no longer direct that a RTPC be successfully completed as a requirement under a conditions of practice order. Ms Elcoate May invited it to consider amending the 13
current order, to address this particular issue, but that ultimately this was a matter for the panel. Mr Montford told the panel that at the time of taking your RTPC, you had suffered a bereavement of a close family member. [PRIVATE]. Mr Montford explained that you failed the majority of the practical modules. Mr Montford invited the panel to take into account the difficult circumstances you faced at the time and the fact that you have appealed the outcome of your RTPC. Mr Montford explained that whilst you accept the outcome and decision of the course, the main reason for your appeal was due to your belief that you were not supported at a difficult time for you. Mr Montford explained that you are currently working as a Health Care Assistant on an agency basis in various places and invited the panel to consider imposing conditions which would allow you to return to supervised nursing practice, despite you not having completed a RTPC. The panel heard and accepted the advice of the legal assessor. Panel s Decision The panel exercised its independent judgement and applied the principles of fairness, reasonableness and proportionality, and weighed the public interest against your own interests. The panel reminded itself that the public interest includes protection of members of the public including patients, the maintenance of public confidence in the profession and its regulator and the declaring and upholding of proper standards of conduct and performance. The panel considered whether your fitness to practise remains impaired. The panel has had regard to all of the documentation before it and it has taken account of the submissions made by Ms Elcoate May on behalf of the NMC and by Mr Montford on your behalf. 14
The panel considered that since the last finding of current impairment of fitness to practise on 9 February 2018, no further information had been received sufficient to enable this panel to conclude that your fitness to practise is no longer impaired. The panel took into account that you have made attempts to undertake and pass the RTPC. However, it noted with concern that you have failed the majority of the practical aspects of the course on two separate occasions, specifically concerning matters raised as problems identified by previous panels. As you have not successfully completed the RTPC, you have been unable to practise as a nurse, nor have you provided any evidence of remediation with regard to the particular areas of concern previously identified. As such, the panel decided that there remains a risk of repetition and that you therefore still pose a risk to patient safety. To allow you to return to unrestricted practice would undermine public confidence in the profession and bring the nursing profession into disrepute. The panel decided that a finding of impairment was therefore necessary on both public protection grounds and public interest grounds. The panel therefore concluded that your fitness to practise remains impaired and went on to consider, what, if any, sanction is now appropriate. Determination on sanction: The panel has taken account of the Sanctions Guidance, bearing in mind that the decision on sanction is one for its own independent judgement. The panel has considered the sanctions available to it in ascending order of restrictiveness. The panel has borne in mind that the purpose of a sanction is to protect the public. It is not intended to be punitive. The panel first considered taking no further action and allowing the current order to lapse upon its expiry. Given the finding that your fitness to practise remains impaired, the panel decided that taking no further action would neither be in the public interest nor would it protect the public against the risks identified. 15
The panel next considered a caution order. Given the panel s finding regarding impairment, the panel decided that a caution order would be insufficient to protect the public and maintain the public s confidence in the nursing profession and its regulatory function. A caution order would not provide the monitoring or restriction of your practice, which is necessary given the risks identified. The panel had regard to the conditions of practice order currently in place and considered whether such an order remained an appropriate and proportionate response to the risks it has identified. The panel took into account your recent difficult personal circumstances, and that you are appealing the outcome of your RTPC failure. However, the panel set this against the fact that you have now been subject to a conditions of practice order for over 3 years, that this was your fourth substantive review hearing, and that you have still not successfully completed your RTPC. The panel considered that you have had sufficient opportunity to address the gaps in your clinical competence and next considered imposing a suspension order. In the panel s view a suspension order at this time would not serve any useful purpose, and would be disproportionate given that you still wish to complete a RTPC and return to nursing. The panel next considered a striking off order. In the panel s view, it is not in the public interest to allow countless reviews where there has been no marked improvement since the original concerns had been identified. The panel carefully considered whether this case merited such an order, and identified a number of criteria which satisfied this. However, given that you continue to engage with the NMC and are in the process of appealing your RTPC outcome, the panel decided to provide you with a further opportunity to successfully complete a RTPC and fulfil the other conditions imposed. However, the panel strongly wished to make clear that a future reviewing panel may consider a striking off order more appropriate if there has been no positive change of 16
circumstance since this hearing, or if you have not been able to successfully complete your RTPC. In all the circumstances, the panel took the view that a conditions of practice order remained the appropriate and proportionate sanction at this time. It therefore decided to extend the current set of conditions, albeit an amendment to condition (4). It therefore decided to impose the following varied conditions: 1. You must tell the NMC within 14 days of any nursing appointment (whether paid or unpaid) you accept within the UK or elsewhere, and provide the NMC with contact details of your employer. 2. You must tell the NMC about any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 14 days of you receiving notice of them. 3. a) You must within 14 days of accepting any post or employment requiring registration with the NMC, or any course of study connected with nursing 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 14 days of entering into any arrangements required by these conditions of practice provide the NMC with the name and contact details of the individual/organisation with whom you have entered into the arrangement. 4. Before returning to unrestricted practice you must undergo training and be assessed as competent by a registered nurse in the following areas; a) Communication b) Record Keeping 17
c) The assessment, planning, implementation and evaluation of care d) Time management e) Prioritisation of tasks f) Compliance with procedures and policies g) The ability to assess your own performance and limitations in performance. 5. You must immediately inform 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 (4) above, to them: a. Any organisation or person employing, contracting with, or using you to undertake nursing work; b. Any agency you are registered with or apply to be registered with (at the time of application); c. Any prospective employer (at the time of application); and d. 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 such a course (at the time of application). A future reviewing panel will be assisted by the following: - Evidence of your successful completion of a NMC approved RTPC (both theoretical and practical) - Your attendance at the review hearing - A reflective piece focusing on the return to practice course outcomes and relating to the areas of concern identified at your substantive hearing. The reflection should use a recognised reflective model (for example GIBBS or JOHNS ) - Any up-to-date testimonials from colleagues who have worked alongside you in a health care setting (for example as a HCA) The panel decided that the length of this order should be for 18 months from the date of expiry at the end of 25 November. It considered that 18 months would be a sufficient 18
period of time in which you can provide a future panel evidence to demonstrate your compliance with and fulfilment of the conditions of practice order. This order will come into effect upon the expiry of the original order at the end of 25 November 2018. 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