Nursing and Midwifery Council Fitness to Practise Committee Substantive Order Review Meeting 16 October 2017 Nursing and Midwifery Council, 2 Stratford Place, Montfichet Road, London, E20 1EJ Name of registrant: NMC PIN: Anne Rosemarie Hotten 72I2161E Part(s) of the register: Registered Nurse Sub Part 1 Adult Nursing March 1976 Children s Nursing March 1976 Registered Midwife Midwifery May 1981 Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Order being reviewed: Outcome: England Misconduct and Lack of Competence Mary Monnington (Chair, Registrant member) Michael Duque (Registrant member) Gregory Hammond (Lay member) Nigel Pascoe Rebekah Isaacs Suspension Order 6 months Striking off order to take effect on the expiry of the current order at the end of 28 November 2017 Page 1 of 12
Decision on Service of Notice of Meeting: The panel was informed that a letter had been sent by recorded delivery and first class post to Miss Hotten s registered address on 11 September 2017 informing her that this matter would be considered at a meeting on or after 16 October 2017. In light of the above information, and having heard and accepted the advice of the legal assessor, the panel concluded that service had been effected in accordance with the Rules. Decision and Reasons: The panel decided to replace the current suspension order with a striking off order. This order will take effect on the expiry of the current order at the end of 28 November 2017. This hearing was the third review of an order imposed on Miss Hotten s registration by a panel of the Conduct and Competence Committee on 24 April 2015. The substantive panel reviewing the order in April 2016 imposed a suspension order for twelve months. Subsequently, a substantive panel reviewing the order in May 2017 imposed a suspension order for six months. The panel is reviewing the order pursuant to Article 30(1) of the Order. Decision and reasons of previous panels Substantive hearing 21-24 April 2015 At the substantive hearing in April 2015 the following charges were found proved: That you, while employed as a registered nurse on Newick Ward, Sussex Orthopaedic Treatment Centre between 1 August 2012 and 24 January 2014, Page 2 of 12
failed to demonstrate the standards of knowledge, skill and judgment required to practise without supervision as a registered nurse, in that you: 1. Failed to safely administer medication during a medication round on any or all of the following dates: 1.1. 3 January 2013 1.2. 6 January 2013 1.3. 4 August 2013 1.4. 18 September 2013 2. On one or more occasion, failed to correctly put on a pair of gloves following the aseptic touch technique; 3. On 22 February 2013, failed to take any or any adequate steps to escalate Patient B's deterioration; 4. On 16 February 2013, when you were under supervision disconnected a Patient Controlled Analgesia pump from a patient without any supervision; 5. On 24 September 2013, in relation to Patient X, 5.1. did not check Patient X's post-operative notes prior to suggesting treatment for Patient X 5.2. informed Witness 1 that you had seen Patient X's drain vacuumed when you had not 6. Your actions in charge 5.2 above were dishonest in that you informed Witness 1 that you had seen Patient X's drain vacuumed when you knew you had not; And in light of the above, your fitness to practise is impaired by reason of your lack of competence in respect of charges 1-3, and/or by reason of your misconduct in respect of charges 4-6. Page 3 of 12
Background: Miss Hotten worked as a bank nurse for Brighton and Sussex University Hospitals NHS Trust ( the Trust ) for at least six years before she began her full time role on the Ward on 2 July 2012 as a senior Band 5 nurse. Miss Hotten had worked for the NHS since 19 April 2001 and been a registered nurse since 1976. The Ward is an elective orthopaedic ward which has capacity for 31 beds including four level 1 beds, which are for patients requiring level 1 care following surgery. The layout comprises 11 side rooms and another four four-bedded bays. Patients on the Ward are a mix of total hip or knee replacement through to minor ligament surgery on wrists or feet. The Ward also covers spinal surgery. Initial concerns regarding Miss Hotten s performance were raised in August 2012, at which time she was working towards being signed off on the Trust s Band 5 competencies. As a result, Miss Hotten was put under supervision for all clinical tasks. At a meeting on 27 September 2012, Miss Hotten requested she be given the Band 5 competencies for newly qualified nurses, rather than those for established nurses. A number of these competencies were highlighted by the management as ones she must complete. Regular progress meetings were held with the management and Miss Hotten. By 30 November 2012, it was deemed that Miss Hotten had made insufficient progress with achieving the required competencies. She was informed that she was required to have fifteen of the competencies that had already been identified, signed off by 22 January 2013. Miss Hotten continued to work under supervision; however, she was unable to pass the required competencies despite working on the Ward for over a year. The competencies would normally be expected to have been completed within six months. On 3 January 2013, during a drug round supervised by a Band 6 nurse, Miss Hotten is alleged to have failed to check the allergies and medical notes of a patient, before administering medication (Charge 1.1). Page 4 of 12
On 6 January 2013, during a supervised drug round with Witness 3, Miss Hotten is alleged to have left a box of tablet medication on a patient s bedside table. Also on this date, Miss Hotten is alleged to have failed to administer medication to a patient who, at the time Miss Hotten attempted to administer medication, was behind a curtain. Miss Hotten had to be reminded to do so by Witness 3 (Charge 1.2). On 4 August 2014, Miss Hotten took two hours to complete a drug round, which was only expected to take thirty minutes. This caused some patients to be left in pain for longer than they should have been, as controlled drugs for pain relief were administered at the end of each round. Miss Hotten is alleged to have failed to give a tablet of Metformin to one patient, until she was reminded. Also on this date, during a second drug round, it is alleged that Miss Hotten failed to administer Paracetamol and Tinzapain to a patient, until she was reminded (Charge 1.3). On 18 September 2013, it is alleged that Miss Hotten had to be reminded to sign for each drug administration that she provided. Further, when administering a 10ml dose of Lactulose, she failed to measure out the dosage. Miss Hotten is alleged to have squirted the medication into a pot without actually measuring it. When questioned about this method, she stated that she could ascertain this was the correct amount, by relying upon her years of experience as a nurse. The amount squirted into the pot was then checked, and was not the prescribed 10ml (Charge 1.4). On an unknown date prior to December 2012, Miss Hotten was seen to have been unable to follow the aseptic touch technique when putting on sterile gloves without contaminating the sterile field. It is alleged that on 6 January 2013, when preparing for a patient dressing, the same error occurred. Further, on 16 February 2013, while changing a patient s dressing, it is alleged that Miss Hotten again contaminated the sterility of her gloves. She did not recognise her error, and when it was highlighted to her, suggested that as she had used alcohol-gel on her hands, this did not present an infection risk (Charge 2). Page 5 of 12
On 22 February 2013, a health care assistant (HCA) reported to Witness 1 her concerns regarding Patient B, who appeared confused and whose oxygen saturation levels had dropped. As the HCA felt that Miss Hotten was not listening to her concern, Witness 1 attended the patient. Miss Hotten was found with Patient B, writing in the doctor s book. By this time, Patient B was unresponsive. When asked to call the doctor urgently by Witness 1, Miss Hotten is alleged to have replied that she was leaving a note for the doctor, so as not to disturb him whilst he was on his round. It is alleged that Miss Hotten had not recognised and/or acted on the urgent need for escalation to a doctor. Witness 1 pressed the emergency call button and the patient was transferred to the Intensive Care Unit (ICU) for 26 days (Charge 3). In addition to concerns regarding Miss Hotten s competence, there were specific instances of alleged misconduct during Miss Hotten s employment with the Trust. On 16 February 2013, Miss Hotten was caring for a patient with a Patient Controlled Analgesia pump ( PCA pump ), which is used to allow patients to selfadminister morphine. Miss Hotten is alleged to have removed the PCA pump from the patient so that she could wash her. At the time Miss Hotten was not PCA or IV competent, so was not permitted to interfere in any way with the PCA pump and was also not permitted to carry out any clinical activity without supervision. This PCA pump, which still contained the controlled drug morphine, was then left on the side in the room with the patient (Charge 4). On 24 September 2013, Miss Hotten is alleged to have stated to Witness 1 that Patient X, who was recovering from spinal surgery and had a dural tear, needed his drain vacuumed and dressing changed. It is alleged that when asked by Witness 1 if she had looked at Patient X s notes, Miss Hotten confirmed she had not (Charge 5.1). Miss Hotten stated, when asked whether she had seen the drain vacuumed earlier that day, that she had (Charge 5.2). Witness 1 looked at the notes while Miss Hotten prepared the trolley in order to vacuum the drain as she had suggested. Upon doing so, Witness 1 realised the drain was in fact a gravity drain which did not require vacuuming (indeed vacuuming would be dangerous as it could cause nerve damage or paralysis to Page 6 of 12
the patient). She questioned Miss Hotten as to whether she had really seen the drain vacuumed that morning and Miss Hotten is alleged to have admitted she had lied and she had not seen the drain vacuumed (Charge 6). The last reviewing panel on 2 May 2017 determined the following with regard to impairment: The panel considered whether your fitness to practise remains impaired. The panel found that you have demonstrated significant insight, and that you have addressed the impact of your misconduct on your colleagues, patients and on your profession. It took into account that you recognised and acknowledged, even before the substantive hearing, that your clinical practice had been flagging. It noted your engagement with the proceedings and also noted your attendance at today s hearing by way of telephone. Regarding dishonesty, the panel appreciates that dishonesty is hard to remediate. The panel however was satisfied in noting your insight, reflective piece and references that this had been remediated. Whilst the panel was of the view that you had demonstrated significant insight, it took into account that you have not fully remediated as you have not been practising as a registered nurse. You were unable therefore to comply with all of the recommendations of the last panel. It also considered your own comments, where you stated that you are not fit to practise. Therefore, the panel concluded that you are still liable in the future to put patients at unwarranted risk of harm, bring the profession into disrepute and breach fundamental tenets of the profession. 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. The panel determined that, in this Page 7 of 12
case, a finding of continuing impairment is required on public protection grounds. The last reviewing panel on 2 May 2017 determined the following with regard to sanction: The panel first considered whether to take no action but concluded that this would be inappropriate in view of the ongoing risk to patients and the public. The panel also 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 for the same reasons as set out above. The panel next considered whether a conditions of practice order would be sufficient and appropriate. It concluded that a conditions of practice order would not be workable nor appropriate in the circumstances. It also considered that conditions would not be sufficient to protect patients and the wider public interest. It noted that you yourself have said that a conditions of practice order would not assist your fitness to practise. The panel considered the imposition of a further period of suspension. It noted that the charges proved were very serious and demonstrated a lack of competence on your behalf. The panel bore in mind the references it had received which refer to your capacity as a Health Care Assistant. It noted evidence of some training and was encouraged by your written reflective piece which talks about your current and future plans. The panel noted however that you have not complied with all of the panel s recommendations. You have not provided the panel with any evidence in relation to keeping your nursing skills up to date by way of further training, particularly medicines management. The panel concluded that there was an absence of remediation in relation to medicines administration and supervision. In all the circumstances, the panel determined that it is appropriate and proportionate to impose a suspension order. It determined that despite your Page 8 of 12
repeated intentions to no longer work as a registered nurse, a suspension period of 6 months would afford you adequate time to further develop your remediation. The panel next considered a striking-off order. The panel concluded that a striking off-order would not be appropriate or proportionate as the panel did not believe that it was the only sanction which would be sufficient to protect the public interest. It concluded that public confidence in the profession and the NMC would be sustained by a sanction other than a striking-off order. Substantive order review meeting 16 October 2017 Determination on impairment The panel heard and accepted the advice of the legal assessor. The panel first considered whether Miss Hotten s fitness to practice remains impaired. In reaching its decision, the panel took into account the need to protect the public, maintain public confidence in the profession, and the need to declare and uphold proper standards of conduct and behaviour. The panel considered the recent correspondence from Miss Hotten dated 12 October 2017. It noted that Miss Hotten had not provided any evidence of having addressed the deficiencies in her practice, neither has she demonstrated that she has kept her skills and knowledge up to date. The panel noted that Miss Hotten has not been working as a registered nurse since the original suspension order was imposed in April 2015 and therefore she has not remediated her failings. The panel considered that from her representations it appears that Miss Hotten has no intention of remediating her practice. Further it considered the decision of the last panel to afford Miss Hotten a further period of suspension for six months, which gave her an opportunity to take steps to remediate her misconduct and Page 9 of 12
the deficiencies in her practice. The panel was of the view that Miss Hotten could have applied for a place on a Return to Nursing programme and accessed relevant online training in medications administration, aseptic technique and surgical wounds and procedures. It further considered that Miss Hotten could have maintained her knowledge and provided evidence of reading and reviewing peer review journals. Given the serious charges that were found proved against Miss Hotten by a previous panel; disregard shown by Miss Hotten in relation to the provision of information to the panel; failure to demonstrate remediation, and information from Miss Hotten as to her current and future intentions not to return to nursing practice the panel has concluded that her fitness to practise remains impaired. Determination on sanction The panel next considered the issue of sanction and took into account the provisions in the NMC publication The Sanctions Guidance ( SG ). The panel considered sanctions in ascending order of severity. Given that Miss Hotten s fitness to practise remains impaired, that the matters of concern were serious, and that she has not remediated the shortcomings in her practice which relate to clinical matters, the panel considered that taking no further action or imposing a caution order was not appropriate in this case. To do so would be insufficient to protect patients or to maintain public confidence in the profession and in the regulator. Page 10 of 12
The panel next considered whether a conditions of practice order would be appropriate. The panel had regard to the NMC s Sanctions Guidance, in particular, the following paragraphs: no evidence of general incompetence potential and willingness to respond positively to retraining The panel determined that there was evidence of general incompetence present in this case for which it would be difficult to frame workable conditions of practice. It further considered that whilst there are clinical issues in this case which could theoretically be addressed by a conditions of practice order, given Miss Hotten s representations that she is not willing to retrain, the panel had no reason to suppose that Miss Hotten would be willing to comply with a conditions of practice order. In such circumstances the panel concluded that a conditions of practice order was not the appropriate sanction. The panel next considered a suspension order. The panel determined that Miss Hotten had not demonstrated that she has used her periods of suspension to rectify the concerns relating to her practice, save for addressing the dishonesty by way of reflection. The panel concluded that Miss Hotten s failure to take steps to remediate the deficiencies in her practice over the last two and a half years, was indicative of an unwillingness to return to safe and effective unrestricted practice. The panel considered that this indicated an attitudinal problem that would not be rectified. The panel considered that there would be no purpose in imposing a further period of suspension as it concluded there was no reason to expect that Miss Hotten would change her behaviour in relation to her misconduct and lack of competence. The panel then considered a striking off order. The panel noted that in a recent letter sent to Miss Hotten on 11 September 2017, she was informed of the possibility of a striking off order being imposed at a substantive order review hearing/meeting. Page 11 of 12
The panel noted that Miss Hotten had had three suspension orders. The final suspension order was for a six month period and was specifically targeted at remediation. The panel noted from the previous panel s decision that, a suspension period of six months would afford you adequate time to further develop your remediation. The panel determined that the only sanction that would both protect the public and satisfy the public interest is a striking off order. Miss Hotten has not addressed the deficiencies in her practice to date despite being given several opportunities to do so. It would not be in the public interest to prolong the case with a further suspension order, nor would such action maintain confidence in the profession or the regulator. Miss Hotten continues to pose a significant risk to the public were she to return to unrestricted nursing practice. In considering all the circumstances, the panel determined that Miss Hotten s behaviour can be described as fundamentally incompatible with being a registered nurse. The panel concluded that public confidence in the profession and in the NMC as regulator could not be sustained if Miss Hotten was allowed to remain on the register. The panel concluded that a striking off order was the only appropriate and proportionate response. This decision will be communicated to Miss Hotten in writing. That concludes this determination. Page 12 of 12