Conduct and Competence Committee Substantive Order Review Hearing 11 December 2015 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of registrant: PIN: Veronique Mettle 06I0231E Part(s) of the register: Registered Nurse Sub part 1 Children s Nursing January 2007 Area of registered address: Panel Members: Legal Assessor: Panel Secretary: Nursing & Midwifery Council: Mrs Mettle: Order being reviewed: Outcome: England Anne Asher (Chair/ Registrant member) Gillian Frame (Registrant member) Judith Alderton (Lay member) Oliver Wise Steven King Represented by Mary-Teresa Deignan, Case Presenter, instructed by the NMC Regulatory Legal Team Attended NMC premises but did not attend the hearing. Represented by Ben Rich, RCN Suspension Order (9 months) Conditions of Practice Order (18 months) to take effect upon the expiry of the existing order namely 17 January 2016 1
Service of Notice of Hearing The panel was informed at the start of this hearing that you were in attendance but did not wish to enter the hearing room. In your absence you are represented by Mr Rich from the RCN. Decision and reasons on review of the current order: The panel decided to impose a conditions of practice order for 18 months. This is the first review of a Suspension Order, originally imposed by a panel of the Conduct and Competence Committee on 17 March 2015 for nine months. The current order is due to expire on 17 January 2016. The panel is reviewing the order pursuant to Article 30(1) of the Nursing and Midwifery Order 2001( the Order ). The sanctions available to the panel that made the substantive order, and accordingly that are available to this panel, are contained within Article 29 of the Order. This panel may allow the present order to lapse upon expiry, extend the present order, make a caution order, make a conditions of practice order or impose a striking-off order. The charges found proved which resulted in the imposition of the substantive order were as follows: Charges read: That you, a registered nurse, whilst working as a Band 5 staff nurse at the Royal London Hospital on the Grosvenor A Ward ('the Ward') between 1 June 2010 and 20 July 2012, 2. On 18 April 2011, a. demonstrated poor time management during your shift. 2
b. did not recognise that a patient's nasal cannula was attached to the emergency wall oxygen when it should not have been c. had to be prompted during the beginning of your shift to carry out checks on patient i. wound sites ii. cannula sites d. failed to demonstrate an understanding of commonly used drugs on the Ward, more specifically, i. domperidone ii. lansoprazole 3. On 26 September 2011, a. failed to demonstrate an understanding of commonly used drugs on the Ward, more specifically, i. domperidone ii. omprezole 4. On 18 October 2011, prior to administering antibiotics to a patient, failed to carry out the required steps in that you a. failed to carry out a patient identification check b. failed to carry out an allergy check 3
5. On 5 November 2011, did not ensure emergency equipment was available for use in that you failed to notice that a facial oxygen mask was missing from the emergency oxygen beside a patient's bed. 6. On 28 November 2011, a. failed to carry out adequate safety checks on the oxygen and suction for one or more patients in your care b. behaved aggressively towards Ms 1 and/or called her a liar or words to that effect. 7. On 5 December 2011, a. acted unprofessionally in that you refused to communicate with Ms 1 8. Failed to comply with management requests, more specifically you, a. failed to complete your intravenous workbook b. did not write a set of SMART objectives AND, in light of the above, your fitness to practise is impaired by reason of your misconduct. The substantive hearing panel said with regard to impairment: The panel determined that your actions met the threshold for misconduct. The charges found proved do not relate to an isolated incident and occurred over a period of a year. In the panel s view there appears to have been a pattern of failures. It concluded that there were wide ranging failures of basic nursing skills which took place over a 4
considerable period of time which involved care of vulnerable patients and attitudinal problems with your work colleagues. In particular you have behaved aggressively towards another remember of staff and acted unprofessionally in refusing to communicate with her. By exposing vulnerable patients to a risk of serious harm, your conduct fell well below the standard expected of a registered nurse and brought the profession into disrepute. The panel concluded that your actions amounted to a significant departure from the code, and that you had failed to take responsibility or show the necessary commitment to meet your tasks as would be expected of a registered nurse. Accordingly, the panel determined that the charges proved against you cumulatively amounted to serious misconduct. The substantive hearing panel said with regard to sanction: The panel identified the following aggravating features of the case: - Your failure to take personal accountability for your actions and omissions as a nurse. - Vulnerable patients were put at potential risk of serious harm. - No evidence of reflection or remorse. - Limited evidence of remediation. - Some evidence of poor attitude towards your colleagues. This is demonstrated through your inability and unwillingness to take instructions and your inability to accept constructive criticism and support as part of your learning and development as a nurse. - Your aggressive and unprofessional behaviour towards your colleagues in a sensitive working environment. - You have shown limited insight into your failings. - Wide ranging and repeated failings over a long period of time. - Your inability to modify or address your failings over a period of one year despite professional development support. 5
The panel identified the following mitigating features of the case: - Your engagement with the NMC. - You have undertaken some relevant training particularly in relation to the administration of intravenous and oral medications, although this has been mainly theoretical. - Your motivation to stay in the nursing profession. - The positive reference you provided from your volunteering job. - The panel accepted that your nursing career has been relatively short; however this does not validate the lack of personal accountability you demonstrated and your ability to seek advice and guidance when you needed it. Accordingly, the panel concluded that the public interest would be served by imposing a suspension order for a period of 9 months. In all the circumstances this period of suspension will demonstrate to the public, the profession and you the unacceptability of your misconduct and the seriousness of these matters. This will also give you sufficient time to reflect on your practice and devise strategies as to how you can improve your practice and demonstrate that you have the determination to do so. The panel considered that a suspension order for any time longer would be punitive. Decision on current fitness to practise The panel has considered carefully whether your fitness to practise remains impaired. Whilst there is no statutory definition of the 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 the light of the current circumstances. It has noted the decision of the previous substantive panel. However, it has exercised its own judgment as to current impairment. 6
The panel has had regard to all of the documentation before it, including the bundle and your written reflection. It has taken account of the submissions made by Ms Deignan on behalf of the NMC and those made by Mr Rich, on your behalf. Ms Deignan explained the background to the case and guided the panel to the relevant elements of the previous panel s decision. She said that the incidents were not isolated, they showed a pattern of failure which exposed vulnerable patients to the risk of serious harm. The previous panel had found you had showed limited insight as at March 2015 and there was no evidence of remediation in your written reflection. You failed to accept the facts proved. With your limited insight and remediation there was a risk of repetition. The previous panel had noted aggravating features and pointed out some mitigating factors. Your present representations in your reflection did not attest to your remediation and, as such, your fitness to practise remains impaired. Mr Rich explained that you had not worked as a nurse since 2012. He provided on table papers which included the references which were placed before the substantive hearing and a reflective piece. He informed the panel that you have attempted by reading and attendance at a training course to keep your nursing skills up to date. Mr Rich conceded that your fitness to practise remained impaired. He referred the panel to the case of Amao v Nursing and Midwifery Council [2014] EWHC 147 (Admin). In that case Mr Justice Walker criticised the panel s approach in taking a strongly adverse line to the registrant because she had not accepted its findings. By analogy Mr Rich submitted that it would not be right for the panel to stand in the way of your possible rehabilitation into the profession because you continue to maintain that you had been unfairly treated. He asked the panel to consider appropriate steps to break the impasse. He submitted that the case could properly be dealt with by the panel making a conditions of practice order which required you to complete and pass a return to practice course; after which there would be a report and a review before you could continue to work as a nurse. 7
The panel accepted the advice of the legal assessor, who referred to the case of Grant, the Indicative Sanctions Guidance and the Guidance to Panels on Conditions of Practice Orders. In reaching its decision, the panel was mindful of 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 whether your fitness to practise remains currently impaired. It agreed with your concession that your fitness to practise is currently impaired and therefore there remain concerns about you returning to practise. The panel is of the view that there is a risk of repetition based on your failure to adequately address the issues that had been previously highlighted. You have not addressed how you might improve your practice. You have not demonstrated an understanding of how your actions put patients at a risk of harm and affected colleagues. The panel therefore decided that a finding of current impairment was 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 profession and upholding the proper standards and behaviour. The panel determined that, in this case, a finding of impairment on public interest grounds was 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 noted that its powers in relation to sanction are set out in Article 29 of the Order. 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. 8
The panel first considered whether to take no action but concluded that this would be inappropriate in view of the seriousness of the case. The panel decided that it would be neither proportionate nor in the public interest to take no further action. For the same reason it decided not to impose a caution. The panel considered replacing the current suspension order with a conditions of practice order. Your misconduct was serious. However, there has been evidence produced to show that you have limited insight and some attempts at keeping your practice up-to-date. You wish to return to nursing. Further the panel considered that it would be possible to formulate practicable and workable conditions, that if complied with, may lead to your unrestricted return to practice and would serve to protect the public and the reputation of the profession in the meantime. The panel decided that the public would be suitably protected as would the reputation of the profession by the implementation of the following conditions of practice, to take effect at the expiry of the nine months suspension order: 1. Before you return to practice you must successfully complete and pass an NMCapproved return to practice programme complying with the requirements set out below. a) The length of the return to practice programme shall be a minimum of 12 weeks. b) The length of the practice element of the programme shall be a minimum of 150 hours. c) The areas that the programme must include are: i. Administration of Medicines to include Intravenous Therapy; ii. Management of medical emergencies including the correct use of equipment; iii. Team working. d) The specific outcomes expected from the programme are: i. successful completion of the course and 9
ii sign off by a mentor who is a registered nurse indicating that you are a safe practitioner and competent to : (i) undertake the safe administration of medicines to include Intravenous therapy; (ii) undertake safe management of medical emergencies; (iii) work as part of a healthcare team. 2. You must within 7 days of accepting a place on a course of study connected with nursing provide the NMC with the name/contact details of the individual or organisation offering the course of study. 3. You must immediately tell 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 and 2 above, to them: a) Any educational establishment at which you are undertaking a course of study connected with nursing, or any such establishment to which you apply to take such a course (at the time of application). 4. On successful completion of the Return to Practise programme before you accept any Registered Nurse post you must: a) inform the NMC of this successful completion; b) request a review of this order. 5. You must tell the NMC about any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 7 days of you receiving notice of them. In determining this sanction, the panel consider that the public are adequately protected whilst you are learning and treated as a student as there will be a substantial amount of supervision. The conditions of practice are designed to address your shortcomings and the fact that there should be a report and a review before you can go into ordinary practice is designed to ensure the protection of the public in the light of the continuing impairment of your fitness to practise. The panel 10
recognises that you have made scant progress since the substantive panel imposed the suspension order; however, in the panel s judgement it would be wrong simply to make a further suspension order which would be likely to have the effect of preventing you from ever returning to practice. The public interest has previously been met by the imposition of the nine months suspension order and the public protection aspect has now been provided for by limiting your nursing to a return to practice course. Either you or the NMC may apply for an early review of this order. You are encouraged to do so on the successful completion of a return to practice course. This decision will be confirmed to you in writing. That concludes this determination. 11