Conduct and Competence Committee Substantive Order Review Hearing 17 May 2017 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of Registrant Nurse: NMC PIN: Mercy Ngozi Okeke 98I6999E Part(s) of the register: Registered Nurse (Sub Part 1) Adult (September 2001) Registered Midwife (March 2005) Area of Registered Address: Panel Members: Legal Assessor: Panel Secretary: England Ian Luder (Chair, Lay member) Julie Tindale (Registrant member) Judith Alderton (Lay member) Andrew Reid Ayesha Patel Nursing & Midwifery Council: Represented by Ruth Alabaster, Case Presenter, instructed by the NMC Regulatory Legal Team Registrant: Order being reviewed: Present and represented by Manus Egan, Counsel Conditions of practice order 24 months Outcome: Extend the Conditions of Practice Order (21 months) to come into effect at the end of 19 June 2017 in accordance with Article 30 (1) 1
Decision and reasons on review of the current order: The panel is reviewing the order pursuant to Article 30(1) of the Nursing and Midwifery Order 2001 (the Order). The panel decided to extend the current conditions of practice order for a period of 21 months. This order will come into effect at the end of 19 June 2017 in accordance with Article 30 (1). On 13 January 2012 a panel of the Conduct and Competence Committee imposed a striking-off order upon your registration, having made findings in relation to both lack of competence and misconduct. Following an appeal to the High Court on 27 February 2013, that order was quashed and was remitted to a new panel. On 23 July 2013 a panel of the Conduct and Competence Committee reconsidered the sanction and made you the subject of a nine month suspension order. The suspension order was reviewed on 18 June 2014 and extended for a further 12 months. That order was reviewed on 19 June 2015 and a conditions of practice order was imposed for a period of 24 months. This is therefore the third review of the substantive order imposed in July 2013, and the current conditions of practice order is due to expire at the end of 19 June 2017. The charges found proved which resulted in the imposition of the substantive order were as follows: That you, a registered midwife, having completed a period of supported practice while working at Whipps Cross Hospital between 18 April 2005 and 10 December 2005: 1. While employed as a band 6 midwife by Queen Mary s Sidcup NHS Trust at Queen Mary s Hospital between 3 January 2006 and 24 February 2006, failed to demonstrate the standards of knowledge, skill and judgement required to practise without supervision as a band 6 midwife in that you: (a) On 12 January 2006, while working with midwife Ms 1: (i) were unable to identify the artery, the vein, and/or the anatomy of the placenta, cord and membranes; 2
(ii) injected a woman close to the sciatic nerve rather than in the upper outer quadrant of the buttock; (b) On 14 January 2006, while working with midwife Ms 1, were prepared to carry out a digital vaginal examination on a woman of 29 weeks gestation; (c) On 17 January 2006, while working with midwife Ms 2, when carrying out an admission: (i) failed to take a history; (ii) failed to perform basic maternal observations without prompting; (d) On 17 January 2006, while working with midwife Ms 2, went to give an intra-muscular injection in the wrong position; (e) On 28 January 2006, while working with midwife Ms 3, failed to perform urinary catheterisation in an aseptic manner; (f) While working with midwife Ms 4, attempted to place a baby on the mother s abdomen without unravelling the cord from around the baby s neck; (g) On various dates, while working with midwives Ms 5, Ms 2, Ms 4, Ms 1, Ms 6, Ms 7, and/or Ms 3, failed to demonstrate satisfactory communication with: (i) Women (ii) Women s family members; (iii) Other members of staff. (h) On various dates, while working with midwives Ms 5 and/or Ms 6, failed to carry out abdominal palpation correctly; 3
(i) On various dates, while working with midwives Ms 5, Ms 2, and/or Ms 6, failed to carry out vaginal examinations correctly; (j) On various dates, while working with midwives Ms 5, Ms 2, Ms 4 and/or Ms 6, failed to interpret CTGs accurately; (k) On various dates, while working with midwives Ms 2 and/or Ms 6, failed to keep adequate records, in that you: (i) Failed to keep clear records of care given; (ii) Failed to record contractions without prompting; (iii) Used incorrect terminology; (l) On various dates, while working with midwives Ms 6 and/or Ms 7, failed to carry out fetal heart rate monitoring properly; (m) On various dates while working with midwives Ms 2 and/or Ms 6, were unable to use an IVAC pump correctly. 2. While undertaking a period of supervised practise with Barking Havering and Redbridge NHS Trust at King George Hospital between 9 October 2006 and 1 December 2006, failed to demonstrate the standards of knowledge, skill and judgement required to practise without supervision as a midwife in that: (a) You failed to achieve independent practitioner level in the following skills assessments: (i) Injection technique; (ii) Vaginal examination; 4
(b) You failed to achieve independent practitioner level in the following proficiency assessments: (i) Intrapartum record keeping; (ii) Intrapartum care; (iii) Safe drug administration; (iv) Effective communication and team working. And that you, a registered nurse, while working as an agency nurse at Newham University Hospitals NHS Trust: 3. On 1 July 2006, while working on the Coronary Care Unit, failed to sign Patient A s medication chart to show that you had given medication to Patient A; 4. On 3 July 2006, while working on the Coronary Care Unit, failed to sign Patient A s medication chart to show that you had administered Metformin to her; 5. On 5 July 2006, while working in the Accident and Emergency Department, allowed Patient B to remove spinal immobilisation equipment in order to go to the lavatory: (a) Despite having been told by your colleague Ms 8 that the patient would have to use a bedpan as she had to remain immobile; (b) Without seeking any other advice from medical and/or nursing colleagues; (c) Without carrying out a clinical assessment; 5
And in light of the above, your fitness to practise is impaired by reason of your lack of competence in respect of 1 and/or 2 above, and/or by reason of your misconduct in respect of 3, 4 and/or 5 above. Your fitness to practise was found to be impaired in relation to charges 1, 2 and 5. The previous reviewing panel determined the following with regard to impairment: The panel noted that since the last review in June 2014 you have: offered some reflection in your written witness statement and your oral evidence which acknowledges your failings; provided positive professional and character references; and attended and completed some training in relation to your failings. You have also obtained employment as a healthcare assistant since February 2015 and have submitted positive references from your current employer. The panel is encouraged by your willingness, at your own expense, to undergo short course training and remediate your previous failings. Further, the panel is of the view that you are now beginning to demonstrate insight into your failings. The panel noted that you are now admitting all the charges and that your fitness to practise is impaired. In your reflective piece you apologise for your actions and were able to explain to some extent to the panel what you would do differently if faced with a similar situation again. However, the panel is of the view that, although you have begun the process of remediating your failings and developing your insight, you have not fully demonstrated that you would not repeat your failings. The panel noted that your failings were serious and covered a wide range of core nursing practice. The panel considers, given further training and time to reflect, that your failings are remediable. The panel noted that you concede that your fitness to practise is impaired. 6
In all the circumstances, and for the reasons set out above, the panel finds that your current fitness to practise remains impaired. The previous reviewing panel determined the following with regard to sanction: The panel considered whether imposing a conditions of practice order would provide the necessary degree of public protection and protect the public interest. The panel has evidence that you are willing to undertake retraining and that you would respond positively to conditions, particularly in the light of your recent developing insight and the training courses you have undertaken at your own expense. The panel therefore decided that it was appropriate to impose a conditions of practice order. The panel next considered imposing a suspension order. There is no evidence before the panel to demonstrate that you would benefit from being suspended from the register. The panel noted that some of the incidents referred to in the charges are approximately 10 years ago. You are engaging with the NMC and have taken steps to remediate your misconduct and lack of competence, such as attending training sessions and acknowledging that you need further training before returning to practice. Given your engagement with the process and willingness to retrain, the panel is of the view that a suspension order would be disproportionate in the circumstances of this case. In particular it would prevent you from retraining as a nurse or midwife and progress the process of remediation. Balancing all of these factors and after having taken into account both the aggravating and mitigating features of this case the panel determined that that the appropriate and proportionate sanction is that of a conditions of practice order. Having regard to the matters it has identified, the panel has concluded that a conditions of practice order will mark the importance of maintaining public confidence in the profession, and will send to the public and the profession a 7
clear message about the standard of practice required of a registered nurse and midwife. The panel determined that [a conditions of practice order is] appropriate and proportionate in this case. The period of this order is for 24 months and will take effect at the expiry of the current order. This period should allow ample time to undertake the training set out above. Before the end of the period of the order, a panel will hold a review hearing to see how you have complied with the order. 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 with another order. 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 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. The panel has had regard to all of the documentation before it, including your witness statement dated 17 May 2017, email correspondence between you and various universities regarding a Return to Practice course, and completed training certificates. The panel has taken account of the submissions made by Ms Alabaster on behalf of the NMC and those made by Mr Egan, on your behalf, and your own oral evidence. Ms Alabaster outlined the background of the case and the findings of the substantive hearing panel and the previous review hearing panels. Ms Alabaster drew the panel s attention to the documents provided by you today and referred to your application to Greenwich University to enrol on a Return to Practice course. She submitted that this application constitutes an attempt to address the conditions set out in condition 4, and 8
subsequently condition 5, of the current conditions of practice order. She acknowledged that you are willing, motivated and making significant efforts to address the risks identified in your practice as a registered nurse and/or midwife. Ms Alabaster submitted that it is a matter for the panel to determine whether your fitness to practice is currently impaired. She submitted that the current conditions of practice order manages the risk presented by your unrestricted practice. She further submitted that extending the current order will allow you to continue the efforts that you are making to remedy your failings with regard to both competence and conduct. Mr Egan invited you to give evidence on oath. You confirmed that the contents of the witness statement dated 18 June 2015 are correct to the best of your knowledge and that you relied upon this at the previous substantive hearing. You also confirmed that an additional witness statement dated 17 May 2017 is correct to the best of your knowledge. You informed the panel that you applied to Kingston University in 2016 for a place on a Return to Practice course. However, you were told that the university did not accept nurses who are subject to conditions of practice. You told the panel that you understand that that policy may have changed. You submitted a new application to the same university on 10 April 2017 with the letter from the NMC outlining the current conditions of practice order but you have not yet received a decision. You have not been practising as a registered nurse or midwife for a decade and have been working as a health care assistant since (HCA) since February 2015. You are still motivated to return to practising as a registered nurse and/or midwife. You accept that the current conditions of practice order is necessary as you are not yet safe to practise as a registered nurse or midwife and that you are willing to continue searching for a Return to Practice course for nursing upon which you can enrol. You have had considerable difficulty in doing so and you have also looked outside of your local area but have been referred back to your catchment area, which limits your options to two universities. 9
You told the panel that you are currently working as an agency HCA at St George s and Ealing Hospitals, as well as in the community visiting clients in their own homes. Your role includes clinical observations, general patient care, and dressing wounds. You have undertaken study days on topics such as tissue viability, ECG, and communication skills. However, as you are an agency nurse, you have not been given certificates as evidence of these studies. In your role as HCA, you have learned to work with other multidisciplinary team members, take instructions from doctors, and to ask questions when you are unsure of your role or the task before you. You told the panel that you love caring for people, for the sick, and that you also love bringing babies into the world. You said that, with regard to your university applications, Canterbury University invited you for an interview but you do not live in the catchment area so your application was transferred to Greenwich University. You continue to communicate with Greenwich University and are yet to get a definitive answer as to whether you have been given a place on the October 2017 intake. Ms Alabaster drew the panel s attention to your witness statement dated 18 June 2015 in which, she submitted, you had addressed each of your failings and had accepted the deficiencies identified in your practice. She submitted that there is no information to suggest that the risk presented by your unrestricted practice has lessened since the imposition of the current conditions of practice order but acknowledged that you have made significant efforts to comply with the current order. Mr Egan informed the panel that the NMC proceedings, since 2006, have had a detrimental impact on your finances and health. He drew the panel s attention to the previous panel s findings and told the panel that you endeavour to secure a place on a Return to Practice course despite the difficulties you have faced. Mr Egan invited the panel to extend the current conditions of practice order for a further 24 months in order for you to complete a Return to Practice course. The panel heard and accepted the advice of the legal assessor. 10
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. The panel had regard to the following documents provided by you: your witness statement dated 17 May 2017 email correspondence between you and universities dated March to April 2017 your Workforce Development Application to Kingston University certificates of mandatory training that you have completed documents provided to the previous reviewing panel, including your witness statement dated 18 June 2015 In its consideration of insight, this panel noted that the last panel found that you had begun to demonstrate insight into your actions. At this hearing, the panel heard your oral evidence and it considered that you have demonstrated some further insight into your failings. The panel was also of the view that you show commitment to learning in your role as a HCA and to returning to practice as a registered nurse and/or midwife. You recognise that you are not yet safe to practise as a registered nurse. The panel was mindful that your deficiencies, which are serious and wide-ranging, have not yet been addressed. The panel considered that, in your role as an HCA, you will have observed the practice of registered nurses, but there is insufficient evidence before the panel to demonstrate that you have been able to keep your knowledge up to date. The panel was satisfied that you have made attempts to secure a place on a Return to Practice course and that, while you have faced difficulties, you continue to make efforts. The previous panel concluded that you were likely to repeat matters of the kind found proved, but that your failings were remediable. This panel considered that you have not yet been able to remediate your deficiencies in clinical practice. In light of this the panel determined that there remains a significant risk of repetition of your previous 11
competency failing. The panel therefore decided that a finding of continuing impairment is necessary on the grounds of public protection. The panel had borne in mind that its primary function is to protect patients and the wider public interest which includes maintaining confidence in the nursing and midwifery professions and upholding proper standards of conduct and performance. The panel determined that, in this case, a finding of continuing impairment on public interest grounds is required. For these reasons, the panel finds 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 has also taken into account the NMC s Indicative Sanctions Guidance (ISG) 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 the 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 the 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 extending the current 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 as the previous panel did that your failings are remediable. The panel was of the view that the current conditions are necessary and would sufficiently protect patients during the period that they are in force, while giving you the opportunity to remedy your failings. Accordingly, the panel determined, pursuant to 12
Article 30(1) (a) of the Nursing and Midwifery Order 2001, to extend the current conditions of practice order for a period of 21 months, which will come into effect on the expiry of the current order. The panel decided to continue the following conditions which it considered are appropriate and proportionate in this case: 1. You must notify the NMC within 14 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. 2. You must inform the NMC of 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 you return to nursing practice you must successfully complete and pass an NMC-approved return to practice nursing programme complying with the requirements set out below: a. You must disclose this requirement to the provider of the programme. b. The length of the practice element of the programme shall be a minimum of 450 clinical hours. c. The areas that the programme should focus on are: i. Communication skills with patients; 13
ii. Communication and escalation of clinical concerns to the multidisciplinary team; iii. NMC standards of record keeping; iv. Medication administration both practical and theoretical; v. Infection prevention control and aseptic techniques; and vi. The use of infusion pumps. d. The specific outcome expected from the programme is to gain accreditation from an academic provider that your clinical skills and knowledge reach the current required standards of a registered nurse. 5. Before you return to midwifery practice you must successfully complete and pass an NMC-approved return to practice midwifery programme complying with the requirements set out below: a. You must disclose this requirement to the provider of the programme. b. The length of the practice element of the programme shall be a minimum of 900 clinical hours. c. The areas that the programme should focus on are: i. Communication skills with patients; ii. Communication and escalation of clinical concerns to the multidisciplinary team; iii. NMC standards of record keeping; iv. Medication administration both practical and theoretical; v. Infection prevention control and aseptic techniques; vi. The use of infusion pumps; vii. Placenta anatomy; viii. Abdominal palpation; ix. Competency in vaginal examinations; x. CTG interpretation; and xi. Competence in intrapartum care. d. The specific outcome expected from the programme is to gain accreditation from an academic provider that your clinical skills and 14
knowledge reach the current required standards of a registered midwife. 6. Once you have commenced a Return to Practice ( RTP ) programme you must forward to the NMC at least 14 days before any review of your case a copy of a personal development plan developed by you. This should cover all the elements listed in the recommendations for your RTP programme(s). Against each element you should show: a. The recording of the actions you have taken to remedy your deficiencies in practice; b. Your reflection upon them; and c. Evidencing that your practice meets the required standards. 7. You must send a report from your line manager, mentor or tutor, setting out your performance on your RTP course and your progress in achieving the aims in your Personal Development Plan at least 14 days before any review of your case. 8. You must immediately inform the following parties that 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 (7) above, to them: 1 Any organisation or person employing, contracting with, or using you to undertake nursing or midwifery work 2 Any agency you are registered with or apply to be registered with (at the time of application) 3 Any prospective employer (at the time of application) 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 such a course (at the time of application) 15
The panel considered the imposition of a suspension order but determined that this would be a disproportionate response at this time. The panel was conscious that by the time the order expires, you will not have practised as a registered nurse or midwife for almost 13 years and, after that, enrolment on a Return to Practice Course may have become an unrealistic goal. The panel took the view that a future reviewing panel would benefit from: an ongoing reflective diary of what you learn in your role as HCA up-to-date written references, on letter headed paper, from the organisations to whom you have provided services This decision will be confirmed to you in writing. That concludes this determination. 16