Conduct and Competence Committee Substantive Hearing 20 to 22 March 2017 & Resumed 8 to 9 May 2017 NMC, 114-116 George Street, Edinburgh, EH2 4LH Name of Registrant: NMC PIN: Pamela Shaw 83B0384S Part(s) of the register: Registered Nurse Sub Part 1 Adult, Level 1 (April 1986) Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Nursing and Midwifery Council: Miss Shaw: Scotland Conduct Malcolm Davidson (Chair/Lay Member) Corinna Kershaw (Lay Member) Florence Mitchell (Registrant Member) Leighton Hughes/David McLean Julia Wanless Represented by Heather Carmichael / Bryony Dongray, instructed by Nursing and Midwifery Council Regulatory Legal Team. Not present and not represented Facts proved: 1, 2, 3, 4(a, b), 6, 8, 10(a, b), 12(a, b, c), 13, 14, 15, 16, 17 Facts not proved: 5, 7, 9, 11 Fitness to practise: Sanction: Interim Order: impaired 12 month suspension order 18 month interim suspension order 1
Charges: That you, whilst employed as a staff nurse on the Alexandra Ward at Dumfries and Galloway Royal Infirmary (the Infirmary): 1. On 15 October 2015, ordered Citalopram 20mg for stock from the Infirmary pharmacy, when Citalopram was not a stock medication on the Alexandra Ward; - found proved 2. On 29 October 2015, ordered Citalopram 20mg for stock from the Infirmary pharmacy, when Citalopram was not a stock medication on the Alexandra Ward; - found proved 3. On an unknown date in October 2015, took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation; - found proved 4. On 11 November 2015: a. ordered Citalopram 20mg either for Patient A, OR in the alternative, for stock, from the Infirmary pharmacy, when Patient A was not prescribed Citalopram, and Citalopram was not a stock medication on the Alexandra Ward; - found proved in relation to stock b. added the above order to the drug requisition form after it had been removed from the ward/unit duplicate copy, resulting in the order not being recorded on the ward/unit duplicate copy;- found proved 5. Between 11 November 2015 and 18 November 2015, took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation; - not proved 6. Between 7 and 8 December 2015 ordered Citalopram 20mg either for Patient B, OR in the alternative, for stock, from the Infirmary pharmacy, when Patient B was 2
not prescribed Citalopram, and Citalopram was not a stock medication on the Alexandra Ward; - found proved in relation to Patient B 7. Between 7 December and 15 December 2015, took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation; - not proved 8. On 5 January 2016 ordered Citalopram 20mg for stock from the Infirmary pharmacy, when Citalopram was not a stock medication on the Alexandra Ward; - found proved 9. Between 5 January and 12 January 2016, took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation; - not proved 10. On 2 February 2016: a. ordered Citalopram 20mg either for Patient C, OR in the alternative, for stock, from the Infirmary pharmacy, when Patient C was not prescribed Citalopram, and Citalopram was not a stock medication on the Alexandra Ward; - found proved in relation to Patient C b. added the above order to the drug requisition form after it had been removed from the ward/unit duplicate copy, resulting in the order not being recorded on the ward/unit duplicate copy; - found proved 11. Between 2 February and 9 February 2016 took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation; - not proved 12. On or around 19 February 2016: a. attempted to order Citalopram 20mg either for Patient D, OR in the alternative, for stock, from the Infirmary pharmacy, on drug requisition sheet 127213, when Patient D was not prescribed Citalopram, and Citalopram was not a stock medication on the Alexandra Ward; - found proved in relation to Patient D 3
b. ordered Citalopram 20mg for stock from the Infirmary pharmacy, on drug requisition sheet 127214, when Citalopram was not a stock medication on the Alexandra Ward; - found proved c. took 1 box of Citalopram 20mg from the Infirmary, without authorisation; - found proved 13. Your conduct described at charges 1, and/or 2, and/or 4(a), and/or 6, and/or 8, and/or 10(a), and/or 12(a), and/or 12(b) was dishonest, in that you were ordering medication for stock or specific patients, when it was not intended for these purposes; - found proved 14. Your conduct described at charges 3, and/or 5, and/or 7, and/or 9, and/or 11, and/or 12(c) was dishonest, in that you knew that you were not authorised to take medication from the Infirmary; - found proved 15. Your conduct described at charges 4(b) and/or 10(b) was dishonest, in that you were attempting to conceal your misconduct described at charges 4(a) and 10(a) respectively; - found proved 16. On 1 March 2016, when asked by your line manager about your conduct described at charge 12(b), stated that you had ordered Citalopram for yourself as you had run out of your prescription, when you were not prescribed Citalopram at that time; - found proved 17. Your conduct described at charge 16 was dishonest; - found proved And, in light of the above, your fitness to practise is impaired by reason of your misconduct. 4
Decision on Service of Notice of Hearing: The panel was informed at the start of this hearing that Miss Shaw was not in attendance and that written notice of this hearing had been sent to her registered address by recorded delivery and by first class post on 10 February 2016. Royal Mail Track and Trace documentation confirmed that the notice of hearing was sent to Miss Shaw s registered address by recorded delivery on that date. The panel took into account that the notice letter provided details of the allegation, the time, dates and venue of the hearing and, amongst other things, information about Miss Shaw s right to attend, be represented and call evidence, as well as the panel s power to proceed in her absence. The Track and Trace documentation also indicated that the notice was received by Miss Shaw on 11 February 2016. Ms Carmichael submitted the NMC had complied with the requirements of Rules 11 and 34 of the Nursing and Midwifery Council (Fitness to Practise) Rules 2004, as amended ( the Rules ). The panel accepted the advice of the legal assessor. In the light of all of the information available, the panel was satisfied that Miss Shaw has been served with notice of this hearing in accordance with the requirements of Rules 11 and 34. It noted that the rules do not require delivery and that it is the responsibility of any registrant to maintain an effective and up-to-date registered address. Decision on proceeding in the absence of the Registrant: The panel had regard to Rule 21 (2) (b) which states: Where the registrant fails to attend and is not represented at the hearing, the Committee...may, where the Committee is satisfied that the notice of hearing has been duly served, direct that the allegation should be heard and determined notwithstanding the absence of the registrant... 5
Ms Carmichael invited the panel to continue in the absence of Miss Shaw on the basis that she had voluntarily absented herself. She referred the panel to Miss Shaw s response dated 24 February 2017 in which she indicated, amongst other matters, that she would like the hearing to proceed in her absence. Ms Carmichael highlighted the public interest in dealing with matters expeditiously and submitted that there was no reason to believe that an adjournment would secure Miss Shaw s attendance on some future occasion. The panel accepted the advice of the legal assessor. The panel noted that its discretionary power to proceed in the absence of a registrant under the provisions of Rule 21 is one that should be exercised with the utmost care and caution as referred to in the case of R. v Jones (Anthony William), (No.2) [2002] UKHL 5. The panel further noted the case of R (on the application of Raheem) v Nursing and Midwifery Council [2010] EWHC 2549 (Admin) and the ruling of Mr Justice Holman that:...reference by committees or tribunals such as this, or indeed judges, to exercising the discretion to proceed in the person's absence "with the utmost caution" is much more than mere lip service to a phrase used by Lord Bingham of Cornhill. If it is the law that in this sort of situation a committee or tribunal should exercise its discretion "with the utmost care and caution", it is extremely important that the committee or tribunal in question demonstrates by its language (even though, of course, it need not use those precise words) that it appreciates that the discretion which it is exercising is one that requires to be exercised with that degree of care and caution. The panel noted the correspondence, dated 24 February 2017, from Miss Shaw in which she indicated that she wanted the hearing to proceed in her absence and did not request a postponement to another date. She stated her reason for not coming to the hearing as I am very upset and couldn t cope. Her last correspondence before the panel, dated 10 March 2016, stated that she would send details of what she had been through. The panel has decided to proceed in the absence of Miss Shaw. In reaching this decision, the panel has considered the submissions of the case presenter, and the 6
advice of the legal assessor. It has had particular regard to the factors set out in the decision of Jones. It has had regard to the overall interests of justice and fairness to all parties. It noted that: Miss Shaw indicated that she wanted the hearing to proceed in her absence; no application for an adjournment has been made by Miss Shaw; there is no reason to suppose that adjourning would secure her attendance at some future date; a number of witnesses are due to attended to give live evidence; not proceeding may inconvenience the witnesses, their employer(s) and, for those involved in clinical practice, the clients who need their professional services; the charges relate to events that occurred between October 2015 and February 2016; further delay may have an adverse effect on the ability of witnesses accurately to recall events; there is a strong public interest in the expeditious disposal of the case. There is some disadvantage to Miss Shaw in proceeding in her absence. Although the evidence upon which the NMC relies will have been sent to her at her registered address, she will not be able to challenge the evidence relied upon by the NMC and will not be able to give evidence on her own behalf. However, in the panel s judgment, this can be mitigated. The panel can make allowance for the fact that the NMC s evidence will not be tested by cross examination and, of its own volition, can explore any inconsistencies in the evidence which it identifies. Furthermore, the limited disadvantage is the consequence of Miss Shaw s decision to voluntarily absent herself from the hearing, waive her rights to attend and/or be represented and to not provide evidence on her own behalf. In reaching this decision the panel also noted that in her response of 24 February 2017 Miss Shaw provided some written submissions to be considered by this panel. In these circumstances, the panel has decided that it is fair, appropriate and proportionate to proceed in the absence of Miss Shaw. The panel will draw no adverse inference from Miss Shaw s absence in its findings of fact. 7
Background The allegations arose from Miss Shaw s employment as a registered nurse on Alexandra Ward (the Ward), Dumfries and Galloway Royal Infirmary (the Hospital). The Ward is an 8 bedded inpatient unit offering specialist palliative care for complex symptom control, complex psychological support and end of life care. At the time of the concerns coming to light Miss Shaw had been employed on the Ward for about 20 years. Concerns first came to light as a result of the deputy charge nurse noticing an order for Patient D for 20 mg Citalopram in the drug requisition book on the night shift of 18 February 2016. However, she also noted that Patient D did not have this mediation prescribed. She scored out the entry (which had reportedly been made by Miss Shaw) and spoke with a nurse colleague. The next day, the same nurse colleague was on the early shift with Miss Shaw. She noted that Miss Shaw had apparently re-ordered the 20mg Citalopram, but this time for the stock in the ward. The nurse colleague checked and was unable to find any prescriptions indicating that this was required. She also checked all admissions and discharges and found that none of the patients were prescribed 20 mg Citalopram. The matter was reported to the senior charge nurse, Ms 1, who carried out an initial investigation. As part of her investigation she spoke with Miss Shaw on 1 and 2 March 2016. Miss Shaw reportedly admitted that she had run out of her own prescription and so had ordered the Citalopram for her own use. She said that this was the first occasion she had done so and she subsequently returned the pack of Citalopram minus one tablet. Miss Shaw was referred to Occupational Health (OH) and investigations were continued by Ms 3, senior workforce business partner. As part of her investigation Ms 3 looked at all the drug requisition forms for the period October 2015 to February 2016. She compared the duplicate drug requisition sheets held in the drug requisition book on the Ward, with the top copies held by the Pharmacy store. She found that Miss Shaw had, apparently on a further three occasions, added orders for medication to the top copy drug requisition sheets after they had been removed from the duplicate pad on the Ward. This meant that the orders 8
were not recorded as part of the audit trail on the Ward. Ms 3 also spoke with Mr 2, the chief pharmacist, and ascertained that nursing staff do not need to order medication for stock. He also confirmed that Citalopram is not a stock item on the Ward. Ms 3 compared the duty roster with the relevant drug requisition sheets and found that Miss Shaw was on duty on each occasion. She identified that a number of orders of 20mg Citalopram had been made by other members of staff during the relevant period, but that these were legitimate orders for specific patients. In total Ms 3 identified that 3 packs of 28 tablets, plus a further 24 tablets were unaccounted for. In total there were six drug requisition sheet discrepancies. Ms 3 spoke with Miss Shaw on 5 April 2016. She readily confirmed that it was her handwriting and signature on the relevant drug requisition forms. She stated that she had taken medication home from the hospital on one occasion in October 2015, but that she did not use any of them. She also admitted having taken one box of Citalopram, on 19 February 2016, that she had returned with one tablet missing. She informed Ms 3 that she did not take the amount of Citalopram alleged, she could only remember taking one or two boxes. She stated she didn t take any more than that. The medical information before the panel [PRIVATE] confirmed that Miss Shaw was not prescribed 20mg Citalopram between the period October 2015 and 2 March 2016, when concerns were first raised with her by Ms 1. [PRIVATE]. A disciplinary hearing was held on 31 March 2016, and the outcome was that Miss Shaw was dismissed for gross misconduct. In her response to the hearing dated 24 February 2017, Miss Shaw stated that she could not remember the alleged incidents due to medical and personal circumstances. She stated I am ashamed of what has happened I am not and never have been a dishonest person. Reasons and decisions on finding of facts: 9
In her response to the notice of hearing dated 24 February 2017, Miss Shaw did not address whether she accepted or denied charges 1 to 12. However she indicated a clear denial in relation to the remaining charges 13 to 17 alleging dishonesty. Accordingly, in reaching its decisions on all of the facts, the panel has taken into account the oral and written evidence adduced by the NMC. It has considered the submissions made by the case presenter, Ms Carmichael on behalf of the NMC that all the charges are capable of proof to the required standard. Throughout its considerations the panel was conscious of Miss Shaw s health issues. It reminded itself of Rule 14 of the Rules, which enables a panel to refer allegations to a Health Committee and suspend its consideration of the allegation, if it appears that the allegation would be better dealt with by the Health Committee. It bore in mind that a panel shall not transfer an allegation unless it is satisfied that, if the registrant s fitness to practise were found to be impaired, it would not make a striking-off order. The panel heard and accepted the advice of the legal assessor. The legal assessor reminded the panel that the burden of proof rests on the NMC, and that the standard is the civil standard, namely the balance of probabilities. This means that the facts would be proved if the panel was satisfied that it was more likely than not that the incidents occurred as alleged. He advised that the panel must assess the evidence presented. It was entitled to draw reasonable inferences but must not speculate. In relation to considerations of dishonesty, he advised the panel that dishonesty is a serious allegation and the panel must be satisfied that there is cogent evidence of it. In this regard he referred the panel to the cases of Sharma v GMC [2014] EWHC 1471 (Admin) and Lawrance v GMC [2015] EWHHC 586 (Admin). He referred the panel to the appropriate test to apply to its consideration of dishonesty as that outlined in the judgement in the case of R v Ghosh [1982] Q.B. 1053. This case outlines a two part test in determining dishonesty. Firstly whether according to the ordinary standards of reasonable and honest people what was done was dishonest. If it was dishonest by those standards then secondly, the panel have to consider whether Miss Shaw must have known that what she did was, by those standards, dishonest. The panel heard from the following witnesses on behalf of the NMC: 10
Ms 1, senior charge nurse on the Ward. Mr 2, chief pharmacist for Dumfries and Galloway Royal Infirmary. Ms 3, senior workforce business partner. The panel found each of them to be credible and reliable. They gave their evidence in a straightforward and fair manner. In relation to the charges, That you, whilst employed as a staff nurse on the Alexandra Ward at Dumfries and Galloway Royal Infirmary (the Infirmary): 1. On 15 October 2015, ordered Citalopram 20mg for stock from the Infirmary pharmacy, when Citalopram was not a stock medication on the Alexandra Ward; Mr 2 s evidence was that at the Hospital a pharmacy technician checked the medicine stock in each ward on a regular basis. The Ward s stock would have been checked at least weekly. During these stock checks any items that were in short supply would be ordered by the pharmacy technician, and any surplus removed. The only circumstance in which a member of the Ward staff would require to order a stock drug would be when the allocated stock had been used up between the stock top up days. He was clear that Citalopram was not a stock medication on the Ward and produced a copy of the Stock Control Sheet for the Ward in support of this. The panel was satisfied, on the basis of Mr 2 s evidence that Citalopram was not a stock medication on the ward. It noted that this was confirmed by both Ms 1 and Ms 3. The panel next considered whether Miss Shaw ordered the medication as alleged. It had sight of the Pharmacy copy and corresponding Ward duplicate drug requisition form 123884 dated 15 October 2015. A number of drugs were ordered for a named a patient on the first four lines, including a bonafide entry for 40 mg Citalopram prescribed by a named consultant. Near the bottom of the form Miss Shaw had recorded a number of entries for medication for stock. This included citalopram 20mg stock orally. The evidence of Mr 2, from the pharmacy s stock adjustment list, was that the pharmacy was 11
only able to supply 15 tablets of 20mg Citalopram on 15 October 2015, to fulfil only the prescription for the patient. Ms 3 s evidence was that Miss Shaw admitted having made the entry on the drug requisition form. She also informed Ms 3 that she thought that Citalopram was a stock medication on the Ward. This was confirmed by the record of Ms 3 s investigatory interview with Miss Shaw on 5 April 2016. Taking all of the above into account the panel was persuaded to the requisite standard that on 15 October 2015 Miss Shaw ordered Citalopram 20mg for stock from the Infirmary pharmacy, when Citalopram was not a stock medication on the Alexandra Ward. Accordingly this charge is found proved. 2. On 29 October 2015, ordered Citalopram 20mg for stock from the Infirmary pharmacy, when Citalopram was not a stock medication on the Alexandra Ward; The panel had sight of the Pharmacy copy and the Ward duplicate drug requisition form 125955 dated 29 October 2015. Miss Shaw had recorded on both forms citalopram 20mg stock orally. The evidence of Mr 2 was that although pharmacy have written 1 ward pack 1 WP next to the entry, there was no associated dispatch sticker stuck to the form. Further there was no entry in the pharmacy s stock adjustment list, therefore this medication did not appear to have been issued by the pharmacy. Ms 3 s evidence was that Miss Shaw also admitted having made this entry on the drug requisition form. This was confirmed by the record of Ms 3 s investigatory interview with Miss Shaw on 5 April 2016. Taking all of the above into account, including Mr 2 s evidence as narrated at charge 1, the panel was persuaded to the requisite standard that on 29 October 2015, Miss Shaw 12
ordered Citalopram 20mg for stock from the Infirmary pharmacy, when Citalopram was not a stock medication on the Alexandra Ward. Accordingly this charge is found proved. 3. On an unknown date in October 2015, took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation; The panel accepted the credible and reliable oral evidence of Ms 1 that, in accordance with the NMC code of conduct, it is unacceptable to take medication from the workplace for one s own use. It noted in particular Ms 1 s evidence that it was wrong and that Miss Shaw would have known that it is not acceptable to order medications from the pharmacy for her own use. The panel next considered whether Miss Shaw took Citalopram from the ward as alleged. Ms 3 informed the panel that from her investigation in relation to the number of 20 mg Citalopram tablets supplied to the ward and returned to the pharmacy she found the following: 15 October 2015, 15 tablets supplied from pharmacy for a named patient 16-20 October 2015, 2 tablets per day to be administered (10 in total), therefore a minimum of 5 tablets should have been left. 20 October 2015, a further 28 tablets supplied from pharmacy for the named patient (as evidenced by the relevant drug requisition form), therefore a minimum of 33 tablets should have been left. 21 October 2015, the patient passed away. Therefore a minimum off 33 tablets should have been left and returned to pharmacy. Pharmacy stock adjustment records show that only 16 units were returned, therefore 17 tablets were missing. 13
The panel noted that these calculations were based on a number of assumptions made by Ms 3. It bore in mind Mr 2 s evidence that it was difficult, from the pharmacy s stock adjustment list, to associate the issued medications with those that had been returned. The panel therefore formed the view that in the interests of justice it could not accept Ms 3 s evidence on this point without other supporting information. The panel noted that Ms 3 also provided evidence that Miss Shaw admitted having taken a box of Citalopram tablets from the Ward in October 2015, albeit she did not accept that she used them. This was confirmed by the record of Ms 3 s investigatory interview with Miss Shaw on 5 April 2016. Taking all of the above into account the panel was persuaded to the requisite standard that on an unknown date in October 2015, Miss Shaw took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation. Accordingly this charge is found proved. 4. On 11 November 2015: a. ordered Citalopram 20mg either for Patient A, OR in the alternative, for stock, from the Infirmary pharmacy, when Patient A was not prescribed Citalopram, and Citalopram was not a stock medication on the Alexandra Ward; The panel had sight of the Pharmacy copy and the Ward duplicate drug requisition form 125978 dated 11 November 2015. This form had a drug requested for Patient A by a named consultant on the first line and a second drug requested on the third line. Miss Shaw had recorded on the second line of only the Pharmacy form Citalopram 20mg orally. In addition, the corresponding box for the consultant s name was blank. Ms 3 s evidence was that Patient A did not have this medication prescribed. The panel noted that Miss Shaw admitted having made the entry on the drug requisition form. This was confirmed by the record of Ms 3 s investigatory interview with Miss Shaw on 5 April 2016. 14
The pharmacy s stock adjustment list demonstrated that the pharmacy supplied 1 box of 28 tablets on 11 November 2015. This was supported by a copy of the relevant pharmacy sticker which indicated that the Citalopram was supplied by the pharmacy as stock. The panel inferred that the pharmacy had therefore treated Miss Shaw s entry as being for stock medication. Accordingly the panel formed the view that it was more likely that Miss Shaw ordered the medication for stock. Taking all of the above into account, the panel was persuaded to the requisite standard that Miss Shaw ordered Citalopram 20mg for stock, from the Infirmary pharmacy and Citalopram was not a stock medication on the Alexandra Ward. In any event, the panel was satisfied that the substance of this charge related to the inappropriate ordering of the Citalopram, rather than the specific intended recipient(s). Accordingly this charge is found proved. b. added the above order to the drug requisition form after it had been removed from the ward/unit duplicate copy, resulting in the order not being recorded on the ward/unit duplicate copy; The panel carefully considered the Pharmacy and Ward drug requisition forms 125978 dated 11 November 2015. Miss Shaw s entry for 20 mg Citalopram was recorded on the second line of only the Pharmacy form. This entry could only have been made after the pharmacy copy had been removed from the Ward s duplicate book. Taking all of the above into account the panel was persuaded that Miss Shaw added the above order to the drug requisition form after it had been removed from the ward/unit duplicate copy, resulting in the order not being recorded on the ward/unit duplicate copy. Accordingly this charge is found proved. 15
5. Between 11 November 2015 and 18 November 2015, took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation; The pharmacy s stock adjustment list demonstrated that the pharmacy supplied 1 box of 28 tablets on 11 November 2015 to the Ward, this was immediately returned and then reissued. Mr 2 was unable to clarify what had occurred. It bore in mind Mr 2 s evidence that it was difficult, from the pharmacy s stock adjustment list, to associate the issued medications with those that had been returned. The panel formed the view that in the interests of justice it could not solely accept the evidence of the pharmacy s stock adjustment list on this point without other supporting information. Although the evidence suggests that it is possible that the 28 tablets that were issued were not returned, there was insufficient evidence to suggest that Miss Shaw taking them from the ward was the only inference that could be drawn. Accordingly, the panel was not persuaded to the required standard that between 11 November 2015 and 18 November 2015, Miss Shaw took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation. Therefore, this charge is not proved. 6. Between 7 and 8 December 2015 ordered Citalopram 20mg either for Patient B, OR in the alternative, for stock, from the Infirmary pharmacy, when Patient B was not prescribed Citalopram, and Citalopram was not a stock medication on the Alexandra Ward; The panel had sight of the Pharmacy copy and the Ward duplicate drug requisition form 126022 dated 8 December 2015 by the ward and 7 December 2015 by the dispensing pharmacist. This form had three drugs requested for Patient B with the corresponding prescribing consultant s name, on the first three lines. Underneath, on line 4, Miss Shaw had recorded (on both copies), citalopram 20mg. However, the corresponding box for the consultant s name was blank. Ms 3 s evidence was that Patient B did not have this medication prescribed. 16
The pharmacy s stock adjustment list, demonstrated that the pharmacy supplied 25 tablets on 7 December 2015. This was supported by a copy of the relevant pharmacy sticker which indicated that the Citalopram was supplied by the pharmacy for Patient B on 7 December 2015. The panel inferred that the pharmacy had therefore treated Miss Shaw s entry as being for Patient B. Accordingly the panel formed the view that it was more likely than not that Miss Shaw ordered the medication for Patient B. The panel noted that Miss Shaw admitted having made the entry on the drug requisition form. This was confirmed by the record of Ms 3 s investigatory interview with Miss Shaw on 5 April 2016. Taking all of the above into account, the panel was persuaded to the requisite standard that Miss Shaw ordered Citalopram 20mg for Patient B, when Patient B was not prescribed Citalopram. In any event, the panel was satisfied that the substance of this charge related to the inappropriate ordering of the Citalopram, rather than the specific intended recipient(s). Accordingly this charge is found proved. 7. Between 7 December and 15 December 2015, took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation; The pharmacy s stock adjustment list demonstrated that the pharmacy supplied 25 tablets on 7 December 2015. Ms 3 s evidence was that the pharmacy s stock adjustment list show that no 20 mg Citalopram was returned to the pharmacy as a patient return or from being found in the stock cupboard circa this date. The panel bore in mind Mr 2 s evidence that it was difficult, from the pharmacy s stock adjustment list, to associate issued medications with those that had been returned. The panel formed the view that in the interests of justice it could not solely accept the evidence of the pharmacy s stock adjustment list on this point without other supporting information. Although the evidence suggests that it is possible that the 25 tablets that 17
were issued were not returned, there was insufficient evidence to suggest that Miss Shaw taking them from the ward was the only inference that could be drawn. Accordingly, the panel was not persuaded to the required standard that between 7 December and 15 December 2015, Miss Shaw took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation. Therefore, this charge is not proved. 8. On 5 January 2016 ordered Citalopram 20mg for stock from the Infirmary pharmacy, when Citalopram was not a stock medication on the Alexandra Ward; The panel had sight of the Pharmacy copy and the Ward duplicate drug requisition form 127158 dated 5 January 2016. Miss Shaw had recorded on both forms stock citalopram 20mg. The corresponding pharmacy sticker indicated that 1 box of 28 tablets of Citalopram was supplied by the pharmacy for stock on 5 January 2016. Ms 3 s evidence was that Miss Shaw admitted having made the entry on the drug requisition form. She also informed Ms 3 that she thought that Citalopram was a stock medication on the Ward. This was confirmed by the record of Ms 3 s investigatory interview with Miss Shaw on 5 April 2016. Taking all of the above into account, including Mr 2 s evidence as narrated at charge 1, the panel was persuaded to the requisite standard that on 5 January 2016, Miss Shaw ordered Citalopram 20mg for stock from the Infirmary pharmacy, when Citalopram was not a stock medication on the Alexandra Ward. Accordingly this charge is found proved. 9. Between 5 January and 12 January 2016, took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation; 18
The pharmacy s stock adjustment list, demonstrated that the pharmacy supplied 1 box of 28 tablets on 5 January 2016. Ms 3 s evidence was that the pharmacy s stock adjustment list show that no 20 mg Citalopram was returned to the pharmacy. The panel bore in mind Mr 2 s evidence that it was difficult, from the pharmacy s stock adjustment list, to associate the issued medications with those that had been returned. The panel formed the view that in the interests of justice it could not solely accept the evidence of the pharmacy s stock adjustment list on this point without other supporting information. Although the evidence suggests that it is possible that the 28 tablets that were issued were not returned, there was insufficient evidence to suggest that Miss Shaw taking them from the ward was the only inference that could be drawn. Accordingly, the panel was not persuaded to the required standard that between 5 January and 12 January 2016, Miss Shaw took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation. Therefore, this charge is not proved. 10. On 2 February 2016: a. ordered Citalopram 20mg either for Patient C, OR in the alternative, for stock, from the Infirmary pharmacy, when Patient C was not prescribed Citalopram, and Citalopram was not a stock medication on the Alexandra Ward; Ms 3 s evidence was that this form was not put to Miss Shaw at the time of her investigatory interview. She told the panel that Miss Shaw was on duty during the relevant shift and the entry was similar handwriting to all the other entries that Miss Shaw had accepted were hers. The panel was therefore satisfied that it was more likely than not that the entry was made by Miss Shaw. The panel had sight of the Pharmacy copy and the Ward duplicate drug requisition form 127208 dated 2 February 2016. This form had two drugs requested for Patient C by a named consultant, on the first and second lines. Miss Shaw had recorded on the third 19
line of only the Pharmacy form citalopram 20mg. In addition, the box for the consultant s name was blank. The corresponding pharmacy sticker indicated that 1 box of 28 tablets of Citalopram was supplied by the pharmacy for Patient C on 2 February 2016. The panel inferred that the pharmacy had therefore treated Miss Shaw s entry as being for Patient C. Accordingly the panel formed the view that it was more likely than not that Miss Shaw ordered the medication for Patient C. Ms 3 s evidence was that Patient C did not have this medication prescribed. Taking all of the above into account, the panel was persuaded to the requisite standard that Miss Shaw ordered Citalopram 20mg for stock, for Patient C when Patient C was not prescribed Citalopram. In any event, the panel was satisfied that the substance of this charge related to the inappropriate ordering of the Citalopram, rather than the specific intended recipient(s). Accordingly this charge is found proved. b. added the above order to the drug requisition form after it had been removed from the ward/unit duplicate copy, resulting in the order not being recorded on the ward/unit duplicate copy; The panel carefully considered the Pharmacy and Ward drug requisition forms 127208 dated 2 February 2016. Miss Shaw s entry for 20 mg Citalopram was recorded on the third line of only the Pharmacy form. This entry could only have been made after the pharmacy copy had been removed from the Ward s duplicate book. Taking all of the above into account the panel was persuaded that Miss Shaw added the above order to the drug requisition form after it had been removed from the ward/unit duplicate copy, resulting in the order not being recorded on the ward/unit duplicate copy. Accordingly this charge is found proved. 20
11. Between 2 February and 9 February 2016 took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation; Mr 2 s evidence, from the pharmacy s stock adjustment list, was that the pharmacy supplied 1 box of 28 tablets on 2 February 2016. Ms 3 s evidence was that the pharmacy s stock adjustment list shows that 21 tablets of 20 mg Citalopram were returned to the pharmacy on 2 February 2016. The panel bore in mind Mr 2 s evidence that it was difficult, from the pharmacy s stock adjustment list, to associate the issued medications with those that had been returned. The panel formed the view that in the interests of justice it could not solely accept the evidence of the pharmacy s stock adjustment list on this point without other supporting information. Although the evidence suggests that it is possible that seven of the tablets that had been issued were not returned, there was insufficient evidence to suggest that Miss Shaw taking them from the ward was the only inference that could be drawn. Accordingly, the panel was not persuaded to the required standard that between 2 February and 9 February 2016, Miss Shaw took an unknown number of Citalopram 20mg tablets from the Infirmary, without authorisation. Therefore, this charge is not proved. 12. On or around 19 February 2016: a. attempted to order Citalopram 20mg either for Patient D, OR in the alternative, for stock, from the Infirmary pharmacy, on drug requisition sheet 127213, when Patient D was not prescribed Citalopram, and Citalopram was not a stock medication on the Alexandra Ward; The panel had sight of the Ward duplicate drug requisition form 127213 dated 19 February 2016. The evidence of Ms 1 and Ms 3 is that this was the form the deputy charge nurse identified, on 19 February 2016, as being an erroneous entry. The panel had sight of the contemporaneous statement made by the deputy charge nurse regarding her concern. She set out that she had not been informed that Patient D had 21
been prescribed this medication and on checking the patient s records was unable to locate such a prescription. She therefore crossed it out on the form. The panel noted that the form had drugs requested for Patient D by a named consultant on the first line and a second drug requested on the third line. In addition Miss Shaw had recorded on the second line of the form citalopram 20mg orally, but this had been scored out so that the entry was almost illegible. Further, the corresponding box for the consultant s name was blank. The panel noted that on the fourth line, another drug had been requested, but that this was clearly labelled as for stock. Ms 3 s evidence was that Patient D did not have Citalopram prescribed and that Miss Shaw admitted having made the entry on the drug requisition form. At the interview she accepted that the order was written in such a way that it looked like it was being ordered for the patient. This was confirmed by the record of Ms 3 s investigatory interview with Miss Shaw on 5 April 2016. Taking all of the above into account, including Miss Shaw s own admission at the investigatory interview, the panel was satisfied that Miss Shaw attempted to order Citalopram 20mg for Patient D, from the Infirmary pharmacy, on drug requisition sheet 127213, when Patient D was not prescribed Citalopram. Accordingly this charge is found proved only on the limbs in relation to Patient D, rather than the specific intended recipient(s). b. ordered Citalopram 20mg for stock from the Infirmary pharmacy, on drug requisition sheet 127214, when Citalopram was not a stock medication on the Alexandra Ward; The panel had sight of the Pharmacy copy and Ward duplicate drug requisition form 127214 dated 19 February 2016. Miss Shaw had written stock citalopram 20mg. The corresponding pharmacy sticker indicated that 1 box of 28 tablets of Citalopram was supplied by the pharmacy for stock on 19 February 2016. 22
Ms 3 s evidence was that Miss Shaw admitted having made the entry on the drug requisition form. She also informed Ms 3 that she thought that Citalopram was a stock medication on the Ward. This was confirmed by the record of Ms 3 s investigatory interview with Miss Shaw on 5 April 2016. Ms 3 s evidence was also supported by the evidence of Ms 1 that when she spoke with Miss Shaw on 1 March 2016, Miss Shaw admitted that she knew about this order and that she had ordered it for herself. Taking all of the above into account, including Mr 2 s evidence as narrated at charge 1, the panel was persuaded to the requisite standard that on 19 February 2016, Miss Shaw ordered Citalopram 20mg for stock from the Infirmary pharmacy, when Citalopram was not a stock medication on the Alexandra Ward. Accordingly this charge is found proved. c. took 1 box of Citalopram 20mg from the Infirmary, without authorisation; The pharmacy s stock adjustment list, demonstrated that the pharmacy supplied 1 box of 28 tablets on 19 February 2016. Ms 1 s evidence was that when she spoke with Miss Shaw on 1 March 2016 her immediate response when asked if she knew about the Citalopram order was that she did know about it and that she had run out of her GP prescription and ordered it for herself. She told Ms 1 she had not done it before. Ms 1 told the panel that Miss Shaw initially did not appear to think there was anything wrong with what she had done. However, when Ms 1 spoke with her again on 2 March 2017, Miss Shaw appeared to have more understanding of the severity of what she had done. Ms 1 s evidence was supported by the evidence of Ms 3. Miss Shaw admitted to Ms 3 at the investigatory interview that she had taken this box of Citalopram tablets from the Ward on 19 February 2016 and had removed one of them before returning the box as requested by Ms 1. This was confirmed by the record of Ms 3 s investigatory interview with Miss Shaw on 5 April 2016: 23
In response to the question what did you with the stock you ordered on 19 February you took the unit or the one packet home and it appears you took one tablet although you don t remember and you were asked to bring the remainder of the tablets back in. Is that correct?, Miss Shaw answered yes. In response to the follow up question is there any other explanation as to why [colleagues] couldn t find the box, are you saying that yes you did take them home on the 19 th February?, Miss Shaw replied, I must have done, yes. Taking Miss Shaw s admission into account the panel was satisfied that on or around 19 February 2016, Miss Shaw took 1 box of Citalopram 20mg from the Infirmary, without authorisation. Accordingly this charge is found proved. 13. Your conduct described at charges 1, and/or 2, and/or 4(a), and/or 6, and/or 8, and/or 10(a), and/or 12(a), and/or 12(b) was dishonest, in that you were ordering medication for stock or specific patients, when it was not intended for these purposes; Each of the charges as narrated above have been found proved. The panel therefore next considered whether it was not intended for these purposes. The only legitimate reasons to order the medication would be for stock or for the patient concerned. The evidence is that this was not a stock medication and that none of the intended patients had the medication prescribed. The panel was therefore satisfied that it was being ordered for stock or specific patients when it was not intended for these purposes. The panel did not need to go on to determine what, in fact, was Miss Shaw s intended purpose for the medication. The panel was satisfied that by the ordinary standards of reasonable and honest people ordering medication for stock or specific patients, when it was not intended for these purposes was clearly dishonest. The panel next considered whether Miss Shaw must have known that what she did was, by those standards, dishonest. 24
The panel noted that Miss Shaw has been a registered nurse for 30 years and had been on that ward for 20 years. As an experienced nurse it was inconceivable that Miss Shaw did not know that the Hospital s drug requisition forms need to be completed accurately and medication only ordered for its intended purpose. During the investigatory interview of April 2016 Miss Shaw s response to the question can I just ask, would you consider it common sense that you cannot order drugs at work for your own use?, was yes. In response to the question how would you have known this?, Miss Shaw stated yes I know it is just bad practice to do so. Taking all of the above into account the panel was satisfied Miss Shaw s conduct described at charges 1, and/or 2, and/or 4(a), and/or 6, and/or 8, and/or 10(a), and/or 12(a), and/or 12(b) was dishonest, in that she was ordering medication for stock or specific patients, when it was not intended for these purposes. Accordingly this charge is found proved. 14. Your conduct described at charges 3, and/or 5, and/or 7, and/or 9, and/or 11, and/or 12(c) was dishonest, in that you knew that you were not authorised to take medication from the Infirmary; Only charges 3 and 12 (c) as narrated above have been found proved. The panel therefore next considered whether Miss Shaw knew that she was not authorised to take medication from the Infirmary. The panel was satisfied that by the ordinary standards of reasonable and honest people taking medication from the workplace without authorisation is dishonest. The panel next considered whether Miss Shaw must have known that what she did was, by those standards, dishonest. The panel considered it inconceivable, given her responses as narrated at charge 13 above, that as an experienced nurse she did not know that she was not authorised to take medication from the ward. The panel has found, and Miss Shaw has accepted, that she had taken something from her workplace that did not belong to her. 25
Taking all of the above into account the panel was satisfied that Miss Shaw s conduct described at charges 3 and 12(c) was dishonest, in that she knew that she was not authorised to take medication from the Infirmary. Accordingly this charge is found proved. 15. Your conduct described at charges 4(b) and/or 10(b) was dishonest, in that you were attempting to conceal your misconduct described at charges 4(a) and 10(a) respectively; Each of the charges as narrated above have been found proved. The panel therefore next considered whether Miss Shaw was attempting to conceal her misconduct in that in relation to charges 4(a) and 10(a) the panel has found that Miss Shaw dishonestly ordered medication for stock or specific patients, when it was not intended for these purposes. The panel noted Ms 1 s evidence was that nothing should be added to the drug requisition form after it had been removed from the ward s duplicate copy. The panel was satisfied that by the ordinary standards of reasonable and honest people attempting to conceal ordering medication in this manner is dishonest. The panel next considered whether Miss Shaw must have known that what she did was, by those standards, dishonest. The panel was satisfied that Miss Shaw s actions were a deliberate attempt to conceal her unauthorised ordering of drugs. It considered it inconceivable that as an experienced nurse she would not realise that to act in that way was dishonest. Accordingly this charge is found proved. 16. On 1 March 2016, when asked by your line manager about your conduct described at charge 12(b), stated that you had ordered Citalopram for yourself as 26
you had run out of your prescription, when you were not prescribed Citalopram at that time; The panel reflected on Ms 1 s direct evidence that when she spoke with Miss Shaw on 1 March 2016, Miss Shaw told her that she had ordered the medication for herself on 19 February 2016 as she had run out of her GP s prescription. However, the medical evidence before the panel showed that Miss Shaw was not prescribed Citalopram during the period relevant to the charges. [PRIVATE]. [PRIVATE]. The panel placed reliance on the evidence of Ms 1 and the medical documentation available. It was therefore persuaded that on 1 March 2016, when asked by Ms 1 about her conduct described at charge 12(b), Miss Shaw stated that she had ordered Citalopram for herself as she had run out of her prescription, when she was not prescribed Citalopram at that time. Accordingly this charge is found proved. 17. Your conduct described at charge 16 was dishonest; The medical evidence before the panel showed that at the time of Miss Shaw s interview with Ms 1 on 1 March 2016, Miss Shaw was not prescribed Citalopram. [PRIVATE]. It considered it was inconceivable that Miss Shaw did not know what medication she may have been prescribed at the time of the interview. The panel therefore formed the view that it was more likely than not that Miss Shaw s comment was an attempt to mislead Ms 1 to justify her actions in ordering the Citalopram when she was not authorised to do so. The panel was satisfied that by the ordinary standards of reasonable and honest people this would be considered dishonest and that Miss Shaw must have known that what she said was, by those standards, dishonest. 27
Accordingly this charge is found proved. Determination on impaired fitness to practise Having determined the facts the panel has now considered whether on the basis of the facts found proved, Miss Shaw s fitness to practise is currently impaired. This is a two stage process. The panel must first determine if Miss Shaw s actions amounted to misconduct. If misconduct is found, the panel must consider whether that misconduct amounts to current impairment of her fitness to practise. When coming to its decision the panel has taken into account all of the facts found proved. It has taken account of all the evidence before it and considered Ms Carmichael s submissions on behalf of the NMC. Ms Carmichael highlighted the dishonesty found in this case and invited the panel to find that Miss Shaw s actions were so serious as to amount to misconduct. In relation to the standards required to be followed by a registered nurse she referred the panel to aspects of the Code: Professional standards of practice and behaviour for nurses and midwives (the Code) which were, in the NMC s view, breached. She emphasised the potential damage to the reputation of the profession and the potential risk to patients. She also referred the panel to the limited up to date information available on Miss Shaw s behalf and invited the panel to find that her fitness to practise is currently impaired. The panel heard and accepted the advice of the legal assessor. He advised that the panel must determine whether Miss Shaw s fitness to practise is currently impaired by reason of misconduct. He advised that the panel must exercise its own professional judgement as there is no standard or burden of proof that is applied at this stage in the process. He advised the panel to adopt the approach set out in the case of Cheatle vs GMC [2009] EWHC 645 Admin. 28