Nursing and Midwifery Council Fitness to Practise Committee Substantive Order Review Hearing 19 December 2018 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of registrant: NMC PIN: Cristina Di Blasi 15A0520C Part of the register: Registered Nurse Sub Part 1 Adult Nursing 17 January 2015 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 Alexander Coleman (Chair Lay member) Jan Fowler (Registrant member) Geoff Baines (Lay member) Andrew Granville-Stafford Vicky Green Not present and not represented in her absence Represented by Susan Jean, Case Presenter Conditions of Practice Order (12 months) Suspension order (12 months) to come into effect at the end of 10 January 2019 in accordance with Article 30 (1) Page 1 of 18
Service of Notice of Hearing The panel was informed at the start of this hearing that Miss Di Blasi was not in attendance, nor was she represented in her absence. The panel was informed that the notice of this hearing was sent to Miss Di Blasi on 14 November 2018 by recorded delivery and first class post to her registered address. Signed for on 22 November 2018 and subsequently returned to the NMC with a note to say that she no longer resides at that address. An email was sent by the NMC to Miss Di Blasi on the 2 and 7 November 2018. Ms Jean told the panel that the NMC has not received a response from Miss Di Blasi. The panel accepted the advice of the Legal Assessor. In the light of the information available the panel was satisfied that notice had been served in accordance with Rules 11 and 34 of The Nursing and Midwifery Council (Fitness to Practise) Rules Order of Council 2004 (as amended February 2012) (the Rules). Proceeding in absence The panel then considered proceeding in the absence of Miss Di Blasi. The panel was mindful that the discretion to proceed in absence is one which must be exercised with the utmost care and caution. The panel considered all of the information before it, together with the submissions made by Ms Jean, on behalf of the Nursing and Midwifery Council (NMC). The panel accepted the advice of the Legal Assessor. Ms Jean invited the panel to proceed in the absence of Miss Di Blasi. She drew the panel s attention to two emails from the NMC to Miss Di Blasi on 2 and 7 November 2018. In the emails, an NMC Case Officer asked Miss Di Blasi if she would waive the 28 Page 2 of 18
day notice period. Ms Jean told the panel that Miss Di Blasi has not responded to either of these emails. Ms Jean submitted that it the NMC has made reasonable efforts to make Miss Di Blasi aware of today s hearing. Ms Jean told the panel that Miss Di Blasi voluntarily absented herself at the substantive hearing. She submitted that, in the circumstances, there was no reason to believe that an adjournment would secure Miss Di Blasi s attendance. Ms Jean therefore invited the panel to proceed in the absence of Miss Di Blasi. Miss Di Blasi had been sent notice of today s hearing by post and had been sent two emails by the NMC. The panel noted that the onus is on a registrant to ensure that the NMC has their correct address. The panel had no reason to believe that an adjournment would result in Miss Di Blasi s attendance; nor has she sought one. Further, given the impending expiration date of the order the panel determined that the public interest in reviewing the order before this date outweighed Miss Di Blasi s own interests. The panel therefore determined to proceed in Miss Di Blasi s absence. Page 3 of 18
Decision and reasons on review of the current order The panel decided to impose a suspension order. This order will come into effect at the end of 10 January 2019 in accordance with Article 30 (1) of the Nursing and Midwifery Order 2001 (as amended) (the Order). This is the first review of a conditions of practice order being reviewed, originally imposed by a Fitness to Practise panel on 7 December 2018 for a period of 12 months. The current order is due to expire at the end of 10 January 2019. 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, between 02 February 2015 and 30 August 2015 whilst working at Cambridge University Hospital NHS Foundation Trust, failed to demonstrate the standards, knowledge, skill, and judgement required to practise without supervision as a Band 5 nurse as follows: 2. On 08 April 2015, in respect of an unknown patient, did not scan the patient s wristband to confirm the patient electronically 3. On 05 May 2015, failed to document hourly urine output in respect of an unknown patient 5. On 03 July 2015: 5.2 When undertaking IV administration medication, did not check the monograph Page 4 of 18
7. On an unknown date in July 2015, did not administer moderate release Oxycodone to an unknown patient 11. On an unknown date in respect of an unknown patient who was pyrexial: 11.1 Failed to escalate and/or report the patient to the Junior Sister 11.2 Failed to monitor and/or take observations for at least 4.5 hours That you, between 12 September 2016 and 18 November 2016 whilst working at Peterborough and Stamford Hospitals NHS Foundation Trust, failed to demonstrate the standards, knowledge, skill, and judgement required to practise without supervision as a Band 5 nurse as follows: 12. On 17 October 2016, when admitting an unknown patient to the ward: 1.1 Obtained an MRSA sample from the patient without identification labels 1.2 Took 1 hour to complete the admission 14. On 04 November 2016 failed an action plan in respect of one or more of the following areas: 14.1 Provide personal care 14.2 Leadership/team working 14.3 Self-development/clinical competence 14.6 Documentation 15. Did not provide adequate patient care, in that you: Page 5 of 18
15.2 On an unknown date in September 2016, having identified an unknown patient to have a NEWS of 7; 15.2.1 Failed to escalate the NEWS to the Nurse in Charge and/or your mentor and/or the ward medical team 15.2.2 Did not carry out an assessment of the patient 15.2.3 Did not carry out any additional observations on the patient and/or review the patient following identity of the NEWS 15.4 On 20 October 2016, did not correctly position ECG electrodes on a patient 17. Did not ensure documentation was complete and/or correct, in that you: 17.1 On 22 September 2016: 17.1.1 Did not complete an unknown patient s admission documentation 17.1.2 Signed to say risk assessments had been completed when they had not 17.2 On 20 September 2016, did not complete the fluid balance charts correctly 17.3 On 22 September 2016, incorrectly completed one or more fluid balance charts fluid input/output 17.4 On 27 September 2016, incorrectly calculated the fluid input and output and/or plotted this in the wrong place on one or more unknown patient s fluid balance charts 17.5 On an unknown date in September 2016: Page 6 of 18
17.5.1 for one or more patients did not complete the fluid balance charts 17.5.2 Incorrectly calculated one or more fluid balance charts 17.7 On 31 October 2016: 17.7.1 Did not fully complete an unknown patient s admission paperwork 17.7.2 Did not handover that the admission paperwork in respect of charge 17.7.1 was not complete AND in light of the above, your fitness to practise is impaired by reason of your lack of competence. The original panel determined the following with regard to impairment: The panel next went on to decide if as a result of Miss Di Blasi s lack of competence, her fitness to practise is currently impaired. The panel was mindful of the need to consider not only whether Miss Di Blasi continues to present a risk to members of the public, but also whether the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the particular circumstances of this case. The panel had regard to the guidance given in the judgment of Mrs Justice Cox in the case of Grant. At paragraph 76 of that judgment, she said: Do our findings of fact in respect of the doctor s misconduct, deficient professional performance, adverse health, Page 7 of 18
conviction, caution or determination show that his/her fitness to practise is impaired in the sense that s/he: a. has in the past acted and/or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and/or b. has in the past brought and/or is liable in the future to bring the medical profession into disrepute; and/or c. has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the medical profession; and/or d. [ ] In light of its findings of fact, the panel determined that Miss Di Blasi s actions had engaged the first three questions of the guidance in Grant. The panel concluded that Miss Di Blasi has in the past acted so as to put patients at unwarranted risk of harm. Furthermore, that Miss Di Blasi s clinical failings related to basic and fundamental tenets of nursing practice and demonstrated a pattern of lack of competence which was liable to bring the nursing profession into disrepute. The panel was mindful that the issue it had to determine was that of current impairment as of today. It therefore had to consider whether Miss Di Blasi is liable in future to act in such a way as to put patients at unwarranted risk of harm, breach fundamental tenets or bring the profession into disrepute. The decision about the risk of repetition in this case would be informed by consideration of the level of insight Miss Di Blasi has demonstrated and by whether her lack of competence is capable of being remedied and, if so, whether it has been remedied. The panel considered Miss Di Blasi s insight into her clinical shortcomings but concluded that it had very little evidence of insight apart from Miss Di Blasi s admission that she did not know how the fluid balance chart worked. When shortcomings were discussed at the time of the incidents, Miss Di Blasi at times Page 8 of 18
made light of the errors rather than accepting the deficiencies in her practice. Due to Miss Di Blasi s limited engagement no meaningful evidence of insight was available to the panel other that evidence from the witnesses that she was making some progress and was eager to learn. With regard to remediation, the panel formed the view that clinical failings relating to a lack of competence are remediable. However, it had not been presented with any evidence of remediation that Miss Di Blasi had practised as a nurse since November 2016. The panel also considered that despite the significant support provided, Miss Di Blasi had been unable to remediate her clinical shortcomings whilst employed by two different Trusts. The panel noted Miss Di Blasi had previously stated an intention not to return to nursing practice. The panel concluded that Miss Di Blasi s lack of competence has not been remedied and, consequently, there is a real risk of repetition. Therefore, the panel concluded that a finding of impairment on the grounds of public protection is necessary. The panel bore in mind the overarching objective of the NMC: to protect, promote and maintain the health safety and well-being of the public and patients and the wider public interest which includes promoting and maintaining public confidence in the nursing and midwifery professions and upholding the proper professional standards for members of those professions. In the judgement of the panel public confidence in the profession and the regulator would be undermined if a finding of impairment was not made in the particular circumstances of Miss Di Blasi s case. Having regard to all of the above, the panel was satisfied that Miss Di Blasi s fitness to practise is currently impaired by reason of her lack of competence. The original panel determined the following with regard to sanction: Page 9 of 18
The panel has considered this case very carefully and has decided to make a conditions of practice order for a period of 12 months. In reaching this decision, the panel has had regard to all the evidence that has been adduced in this case, together with the submissions of Ms Guest on behalf of the NMC. Ms Guest referred to the Sanctions Guidance (SG) and submitted that ultimately sanction is a matter for the panel s independent judgment. The panel heard and accepted the advice of the legal assessor. The panel has borne in mind that any sanction imposed must be appropriate and proportionate and, although not intended to be punitive in its effect, may have such consequences. The panel had careful regard to the SG published by the NMC. It recognised that the decision on sanction is a matter for the panel, exercising its own independent judgement. The panel first considered the aggravating and mitigating factors in this case. The panel identified the following as aggravating factors in this case: Miss Di Blasi s lack of competence related to a number of failings over a prolonged period of time in two hospitals, over several wards; Miss Di Blasi made repeated errors of the same kind. The panel identified the following as mitigating factors in this case: There have been no other previous referrals to the NMC in relation to Miss Di Blasi s practice; Miss Di Blasi is new on the NMC Register and new to working in the UK; Some lack of support given by hospitals and wards. Page 10 of 18
The panel then turned to the question of which sanction, if any, to impose. It considered each available sanction in turn, starting with the least restrictive sanction. The panel first considered whether to take no action. The panel bore in mind that it had identified at the impairment stage that these were serious failings and that there remained a risk of repetition in this case. Any repetition would bring with it a risk of harm to patients. To take no action would not protect the public. In addition, the panel considered that to take no further action would be inadequate to mark the seriousness of the lack of competence in this case. It would not be in the public interest in declaring and upholding standards and maintaining public confidence in the profession. Next, in considering whether a caution order would be appropriate, the panel took into account the SG, which states that a caution order may be appropriate where the case is at the lower end of the spectrum of impaired fitness to practise and the panel wishes to mark that the behaviour was unacceptable and must not happen again. The panel considered that Miss Di Blasi s lack of competence was not at the lower end of the spectrum and that a caution order would be inappropriate in view of the clinical shortcomings identified. A caution order would offer no protection to the public and the panel decided that it would be neither proportionate nor in the public interest to impose a caution order. The panel next considered whether placing conditions of practice on Miss Di Blasi s registration would be a sufficient and appropriate response. The panel is mindful that any conditions imposed must be relevant, proportionate, measurable and workable. The panel was mindful that the purpose of a conditions of practice order is to address the concerns which led to the finding of impairment of fitness to practise. The panel also noted that the aim of the order must be to protect the public and maintain public confidence in the nursing profession and to uphold proper professional standards and conduct. The panel decided that in all of the Page 11 of 18
circumstances of Miss Di Blasi s case, a conditions of practice order would be workable and appropriate and safely address the protection of the public and the wider public interest. Balancing all of these factors, and after having taken into account both the aggravating and mitigating features of this case, the panel determined that the most appropriate and proportionate sanction is that of a conditions of practice order. The effect of this order is that Miss Di Blasi s name on the NMC register will show that she is subject to a conditions of practice order, and anyone who requires to know about her registration is informed of the order. The panel considered that there were identifiable areas of practice in need of assessment. In light of the SG the panel then considered the next sanction upwards. The panel was of the view that imposing a suspension order would be disproportionate and would not be a reasonable response in the circumstances of Miss Di Blasi s case as there are factors which the panel have considered that would mitigate against a suspension. These include: There was no evidence of harmful deep-seated personality or attitudinal problems; The panel was satisfied that Miss Di Blasi has some developing insight. The panel determined that the following conditions are appropriate and proportionate in this case: 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 who is physically present in or on the same ward, unit, floor, or home that you are working in or on. Page 12 of 18
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 practise: a) Assessing and escalating deteriorating patients; b) Monitoring of patient including NEWS; c) Documentation: (i) Patient admission; (ii) Patient monitoring; (iii) Fluid balance. 3. You must meet with your line manager, mentor or supervisor (or their nominated deputy) at least every 14 days to discuss the standard of your performance and your progress towards achieving the aims set out in your personal development plan. 4. You must not administer medication unsupervised until deemed competent by another registered nurse. 5. You must forward to the NMC a copy of your personal development plan within 28 days of the date on which these conditions become effective or the date on which you take up an appointment, whichever is sooner. 6. You must send a report from your line manager mentor or supervisor (or their nominated deputy) setting out the standard of your performance and your progress towards achieving the aims set out in your personal development plan to the NMC every 6 months and before any NMC review hearing or meeting. 7. 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 Page 13 of 18
manager, mentor or supervisor (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 8. 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. 9. 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. 10. 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. 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: 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 services; Page 14 of 18
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 period of this order is for 12 months. Before the end of the period of the order, a panel will hold a review hearing. At the review hearing the panel may revoke the order or any condition of it, it may confirm the order or vary any condition of it, or it may replace the order for another order. Any future panel reviewing this case would be greatly assisted by Miss Di Blasi s attendance and evidence of: Professional development including documentary evidence of completion of the above mentioned competencies; Up to date reference and testimonials from any work, paid or voluntary, that Miss Di Blasi undertakes. Decision on current fitness to practise The panel today has considered carefully whether Miss Di Blasi s 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. Page 15 of 18
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 Jean on behalf of the NMC. Ms Jean outlined the background of the case to the panel along with the outcome of the substantive hearing which took place in December 2017. She invited the panel to find that due to Miss Di Blasi s non engagement since the substantive hearing, her fitness to practice remains impaired, as she has not remediated her practice. The panel heard and accepted the advice of the Legal Assessor. 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 was of the view that the areas of practice where Miss Di Blasi fell short were capable of remediation The panel had regard to the conditions of practice order that was imposed by the substantive panel and considered whether Miss Di Blasi has complied with each of the conditions, so as to demonstrate insight and remediation. The panel considered whether Miss Di Blasi s fitness to practise remains impaired. The panel noted that Miss Di Blasi has not engaged with the NMC since the substantive hearing. The panel noted the original panel s determination, in particular: The panel concluded that Miss Di Blasi s lack of competence has not been remedied and, consequently, there is a real risk of repetition. The panel has received no new information from Miss Di Blasi to be considered at this hearing. The panel considered that in the absence of any further information or compliance with the conditions of practice order, that there remains a real risk of repetition. Page 16 of 18
The panel noted the original panel s determination in relation to Miss Di Blasi s insight: The panel considered Miss Di Blasi s insight into her clinical shortcomings but concluded that it had very little evidence of insight This panel found that as a result of her non engagement, Miss Di Blasi s level of insight has not developed. The panel determined that Miss Di Blasi is liable to repeat matters of the kind proved. The panel therefore decided that a finding of continuing impairment is necessary on the grounds of public protection and in the public interest which includes maintaining confidence in the nursing profession and upholding proper standards of conduct and performance. For these reasons, the panel finds that Miss Di Blasi s fitness to practise remains impaired. Determination on sanction Having found Miss Di Blasi s fitness to practise is 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 30 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. 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 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. Page 17 of 18
The panel next considered the continuation of the conditions of practice order. Miss Di Blasi has not engaged with the NMC or complied with the conditions of practice order. On this basis the panel concluded that a conditions of practice order is no longer practicable. The panel concluded that no workable conditions of practice could be formulated which would protect the public or satisfy the wider public interest given the total lack of constructive engagement by Miss Di Blasi at this time. The panel determined therefore that a suspension order is the only appropriate sanction which would both protect the public and satisfy the wider public interest. Accordingly, the panel determined to impose a suspension order for the period of 12 months. The panel was of the view that 12 months would give Miss Di Blasi the opportunity to reengage with the NMC and to state her intentions as regards to her nursing career. It considered this to be the most appropriate and proportionate sanction available. This suspension order will take effect upon the expiry of the current conditions of practice order, namely at the end of 10 January 2019 in accordance with Article 30 (1) of the Nursing and Midwifery Order 2001. The panel noted that at this stage a striking off order was not available to it. This decision will be confirmed to Miss Di Blasi in writing. That concludes this determination. Page 18 of 18