Conduct and Competence Committee Substantive Hearing 8 12 July 2013 Thistle Parc Hotel, 1 Park Place, Cardiff, CF10 3UD & 2 August 2013 Nursing and Midwifery Council, 13a, Temple Court, Cathedral Road, Cardiff, CF11 9HA Name of Registrant Nurse: NMC PIN: Julie Louise Richards 85Y0006W Part(s) of the register: Registered Nurse Sub part 2 Adult Nursing December 1987 Registered Nurse Sub Part 1 Adult Nursing July 1993 Registered Midwife March 1998 Area of Registered Address: Type of Case: Case Officer: Panel Members: Legal Assessor: Panel Secretary: Representation: Nursing and Midwifery Council: Facts proved: Facts found proved by admission: Facts not proved: Fitness to practise: Sanction: Wales Misconduct Sarah Foster Richard Davies (Chair, lay member) Sheena Payne (Registrant member) Teresa Payne (Lay member) Rhys Taylor Liam Bostock Julie Richards was present and represented by Mark Whitcombe, Counsel, Thompson Solicitors on 8 & 9 July 2013. Represented by Jessica Sutherland- Mack, NMC Regulatory Legal Team (8-12 July 2013). Represented by Mohammed Ismail, NMC Regulatory Legal Team (2 August 2013) 3(h) 1(a), 1(b), 1(b)(i),(ii),(iii), 1(c), 2(a) 2(b), 3(a), 3(b), 3(c), 3(d), 3(e), 3(f) 3(g), 4(a) & 4(b) None Currently Impaired Striking Off Order Page 1 of 34
Interim Order: Suspension Order, 18 months Page 2 of 34
Details of charge: That you, whilst employed as a Band 6 Midwife by Cardiff and Vale University Health Board ( the Health Board ):- 1 When caring for Patient A on the night of 5-6 December 2008: a) Did not recognise the significance of Patient A s raised blood pressure and act appropriately in that: i) When you spoke with Dr. M you did not provide a detailed clinical history including, but not limited to, Patient A s other blood pressure readings; ii) Having been advised that Patient A should be transferred to the Consultant Led Unit if her systolic BP was more than 160 you subsequently failed to do so when the systolic BP was 170; iii) did not record that you had tested Patient A s urine; b) Did not maintain detailed records of the care that you provided; 2 On 22 August 2009 booked an induction of labour for Patient B contrary to the Health Board s Induction of Labour Protocol in that: a) Patient B was not term plus 13 days; b) Advice was not sought from medical staff; 3 When caring for Patient C on the night shift of 10-11 February 2011: a) Did not recognise and/or act on a foetal tachycardia that was present during the second stage of labour b) Did not seek a review of Patient C regarding her elevated blood pressure c) Did not transfer Patient C to the Consultant Led Unit in accordance with the Health Board s Guidance on Emergency Maternal or Neonatal Transfer from Midwifery Led Unit in relation to her elevated blood pressure d) Administered an injection of Syntocinon that had not been prescribed by a doctor e) Administered Syntocinon without Patient C s consent f) Did not ensure that Patient C was provided with an epidural for pain relief after this had been requested g) Inappropriately administered Ranitidine to Patient C at 23:45 Page 3 of 34
h) Did not communicate effectively with Patient C whilst she was in the birthing pool in that you did not recognise her discomfort i) Did not maintain accurate records in that you: j) Did not provide rationale for the decision to administer syntocinon instead of Syntometrine k) Made a retrospective entry relating to the rupture of Patient C s membranes And in light of the above, your fitness to practise is impaired by reason of your misconduct Submissions under Rule 28: Ms Sutherland-Mack, on behalf of the NMC, made an application to amend the Charge under Rule 28 of The Nursing and Midwifery Council (Fitness to Practise) Rules Order of Council 2004 (The Rules). The panel was asked to rule upon several amendments to the charge sheet which had been agreed between the parties. The parties confirmed that they were content with the amended charge and accepted the panel s modest suggestions for the consistent use of punctuation and syntax. The panel determined that the amendments could be made without injustice. Details of charge as amended: That you, whilst employed as a band 6 Midwife by Cardiff and Vale University Health Board ( the health board): 1. When caring for Patient A on the night of 5-6 December 2008: (a) did not recognise the significance of Patient A s raised blood pressure; (b) did not act appropriately given the raised blood pressure in that; (i) when you spoke with Dr. M you did not provide a detailed clinical history including, but not limited to, Patient A s other blood pressure readings; Page 4 of 34
(ii) (iii) did not transfer Patient A to the Consultant Led Unit given that her systolic BP was more than 160; did not record that you had tested Patient A s urine; (c) did not maintain detailed records of the care that you had provided. 2. On 22 August 2009 booked an induction of labour for Patient B contrary to the Health Board s induction of labour protocol in that: (a) Patient B was not term plus 13 days; (b) advice was not sought from medical staff. 3. When caring for Patient C on the night shift of 10-11 February 2011: (a) (b) (c) (d) (e) (f) did not recognise and/or act on a foetal tachycardia that was present during the second stage of labour; did not seek a review of Patient C regarding her elevated blood pressure; did not transfer Patient C to the Consultant Led Unit in accordance with the Health Board s Guidance on Emergency Maternal or Neonatal Transfer from midwifery Led Unit in relation to her elevated blood pressure; administered an injection of syntocinon that had not been prescribed by a Doctor; administered syntocinon without Patient C s consent; did not ensure that Patient C was provided with an epidural for pain relief after this had been requested and was permissible; (g) inappropriately administered Ranitidine to Patient C at 23:45; (h) did not communicate effectively with Patient C whilst she was in the birthing pool. 4. Did not maintain accurate records regarding Patient C on the nightshift on 10/11 February 2011 in that you: (a) (b) did not provide rationale for the decision to administer syntocinon instead of syntometrine; made a retrospective entry relating to the rupture of Patient C s membranes. And in light of the above, your fitness to practise is impaired by reason of your misconduct. Page 5 of 34
Decision on the findings on facts and reasons: Mrs Richards, Mr Whitcombe submitted, on your behalf, that you admitted to the facts of all the Charges put to you, save for the facts of Charge 3(h). The panel found the Charges, save for Charge 3(h), proved by your own admission. In reaching its decision on the facts of the remaining Charge, the panel considered the oral evidence and written statements of Patient C, Patient C s husband and yourself, together with the submissions made by Ms Sutherland-Mack on behalf of the NMC and Mr Whitcombe on your behalf. Ms Sutherland-Mack invited the panel to find the facts of Charge 3(h) proved. Mr Whitcombe submitted that you did not fail to effectively communicate with Patient C. He invited the panel to prefer the evidence that you gave to the panel. Mr Whitcombe invited the panel to find on the balance of probabilities that the facts of Charge 3(h) were not made out. The panel heard and accepted the advice of the legal assessor. He reminded the panel of the facts of Charge 3(h), and that the burden of proof rested on the NMC. He added that the standard of proof is the civil standard, namely the balance of probabilities. This means that the facts will be proved if the panel was satisfied that it was more likely than not that the incident occurred as alleged. The legal assessor reminded the panel that you did not need to prove anything. Page 6 of 34
Background Mrs Richards, At all material times, you were employed as a band 6 midwife by Cardiff and Vale University NHS Trust, now known as Cardiff and Vale University Health Board ( the health board ). You were involved in three separate incidents in 2008, 2009 and 2011. On the night of 5-6 December 2008, you provided midwifery services and cared for Patient A at Llandough Hospital Midwifery Led Unit ( MLU ). It is alleged, and you admitted, that you did not recognise, did not act upon abnormal observations, did not provide a detailed clinical history, did not transfer Patient A from the MLU to a Consultant Led Unit ( CLU ), and did not maintain detailed records of the care that you had provided to Patient A. On 22 August 2009, it is alleged, and you admitted, that you booked an induction of labour for Patient B contrary to the health board s induction of labour protocol. The protocol stated that a woman must be full term plus 13 days before being offered an induction of labour. Patient B was not full term plus 13 days. It is alleged that you did not seek advice from other medical staff, whose role it was to consider whether or not an induction should be booked. On the night shift between 10-11 February 2011, you took over the care of Patient C at 22:10 and cared for her throughout her labour. Before you took over, Patient C had been transferred to the CLU because there had been concerns about the foetal heart rate. These had been resolved and the patient had been sent back to the MLU. Baby C was born at 05.49 in a critical condition. Baby C was later diagnosed with severe hypoxic encephalopathy. You admitted that you did not recognise or act upon a foetal tachycardia that was present during the second stage of labour. You also accepted that you did not seek a review of Patient C s elevated blood pressure. You accepted that you did not transfer Patient C to the CLU. Page 7 of 34
During the third stage of labour you administered syntocinon to Patient C without a doctor s prescription. The usual drug to be administered would have been syntometrine, the side effect of which can be to increase blood pressure. You accepted that syntocinon was given without Patient C s consent. You recorded on a Continuation Sheet for Patient C s maternity notes at 22:10 on 10 February 2011, that she had requested an epidural ASAP. Pethidine was given to Patient C following discussion. The note recorded Patient C s agreement to receive pethidine. It is alleged, and you accepted, that you administered 150mg of ranitidine to Patient C at 23:45. This is a drug that is given as a precursor to the administration of an epidural. Having taken these preparatory steps for an epidural, you then suggested the use of a birthing pool, which was in accordance with Patient C s birth plan. Patient C acquiesced in this, but alleged that you continually ignored her request for an epidural. Whilst Patient C was in the birthing pool, it is alleged, and you denied, that you did not communicate effectively with Patient C. It is alleged, and you accepted, that you did not maintain an accurate record of your rationale for administering syntocinon and that you made a retrospective entry relating to the rupture of Patient C s membranes. Having accepted your admissions, the panel considered the facts of the remaining Charge, and made the following determination. Charge 3(h) 3. When caring for Patient C on the night shift of 10-11 February 2011: (h) did not communicate effectively with Patient C whilst she was in the birthing pool. This charge is found proved. Page 8 of 34
In reaching its determination as regards the facts of Charge 3(h), the panel relied on the evidence of Patient C and Patient C s husband. The panel found both to be reliable, credible and consistent. In contrast the panel found your evidence to be inconsistent, elusive and unreliable. Wherever there is a disagreement on the relevant points at issue concerning this allegation, we have preferred the evidence of Patient C and her husband over your evidence. The panel heard detailed evidence about the discussions that took place between you and Patient C whilst she was in the birthing pool. These can be broken down into four discrete elements: 1. Patient C was unsure when she should start pushing. Upon asking for your advice, you said words to the effect that Patient C would know when to start pushing as the urge to push would be overwhelming. It should have been obvious to you that Patient C remained confused about this advice. You admitted that you were aware that Patient C had turned to her husband making it clear to him that she was unsure whether her urges to push were in fact overwhelming. Both Patient C and her husband, as first time parents, needed further explanation and did not receive it. 2. Patient C was not informed, by you, of her raised blood pressure and the increased foetal heart rate. Patient C asked on a number of occasions, when readings were being taken, whether everything was all right. Mr Whitcombe, on your behalf, stated that you had already admitted that you did not recognise the significance of the abnormal readings for blood pressure and foetal heart rate. He said that it would be unfair to make a finding in respect of poor communication arising out of something about which you were unaware at the material time. You said that you had relied on a student midwife who was in attendance, though you recognised that you carried ultimate accountability for Patient C s care. Patient C s request for confirmation that everything was all right should have acted as a prompt for you to check, and to communicate your proper assessment effectively and appropriately. 3. You did not heed Patient C s repeated requests for an epidural. Whilst the factual issue is confined to the time Patient C was in the birthing pool, the panel was mindful of Patient C s request at 22:10 for an epidural ASAP, and the fact that ranitidine was Page 9 of 34
given shortly before Patient C entered the birthing pool. These two pieces of evidence set the context in which the panel must consider Patient C s assertion that she repeatedly asked for an epidural whilst in your care, and in particular when in the birthing pool and when leaving it. The panel accepts that repeated requests were made for an epidural and that no clear reason was ever communicated as to why it could not be administered. 4. Patient C s position and movement within the birthing pool. Patient C and her husband told the panel that the water level in the birthing pool was such as to make it difficult for Patient C to sit comfortably. Patient C stated that the water level was such as to affect her stability within the birthing pool. Patient C was only able to ensure her stability by sitting on her clenched fists for a long period. You gave contradictory evidence. Despite having stated that Patient C was more relaxed and assisted by being in the birthing pool, you also referred to Patient C as thrashing about. You regarded this as a safety issue for her whilst in the birthing pool. Patient C and her husband referred to your abrupt and unsupportive tone when telling Patient C to try and remain still in the birthing pool. The panel did not find your account of Patient C being relaxed in the pool as being consistent with your description of her thrashing about. The panel finds that you failed to properly read Patient C s obvious distress, and to communicate with her in a way which might have alleviated this or might otherwise have reassured her. Proceeding in the absence: The panel was informed at the outset of the third day of this hearing (10 July 2013) that Mrs Richards had decided to withdraw from participating in these proceedings. Mr Whitcombe, on behalf of Mrs Richards, advised the panel that he was no longer instructed to act on her behalf. He told the panel that Mrs Richards had written a letter, dated 9 July 2013, addressed to the panel and himself. Mr Whitcombe exhibited the letter for the panel s consideration. Mr Whitcombe advised the panel that Mrs Richards understood that the hearing could proceed in her absence and without her being represented at the discretion of the Page 10 of 34
panel. He told the panel that Mrs Richards had been fully advised as to the consequences of withdrawing at this stage in proceedings, and the options available to the panel. Mr Whitcombe submitted that Mrs Richards evidence on the facts was already before the panel. Mrs Richards had confirmed her witness statement on oath at the facts stage, albeit that her live evidence, and, importantly, cross examination thereon, had been limited to the issue of communication at that stage. He invited the panel to consider documentary evidence that was to be adduced by Mrs Richards at the stage of misconduct and impairment. Furthermore, he informed the panel that Mrs Richards was to submit testimonials for the panel s consideration at the sanction stage of proceedings if that stage were to be reached. Ms Sutherland-Mack, on behalf of the NMC, did not object to the submission of Mrs Richards' documentary evidence at the appropriate stage. She told the panel that she had read it and offered no objection, subject to redactions which she proposed should be made in Mrs Richards interest. Ms Sutherland-Mack, told the panel that one of the NMC s witnesses received an email dated 9 July 2013 (time sent 22.56) from Mrs Richards about her withdrawal from the hearing. She also indicated that she understood the panel secretary to have received an email this morning from the NMC case officer who had spoken with Mrs Richards confirming that she had decided to withdraw from the hearing. The panel considered the content of Mrs Richards letter to Mr Whitcombe, which read as follows. TO WHOM IT MAY CONCERN It is with deep regret that I write inform my barrister and the panel, that I have made the difficult and painful decision to withdraw myself from my fitness to practice hearing. I no longer feel able to cope emotionally with the intense pressure and scrutiny. After a gruelling 2 ½ years of hearings, and intense media coverage it has all now become too much for me to bear. Page 11 of 34
Finding out at yesterdays hearing that it is highly likely I will not even know the outcome until possibly the end of the year has deeply affected me. I haven t taken this decision lightly and I am fully aware that the hearing will now continue in my absence. My health and mental wellbeing has to be my priority and I really have reached breaking point. To close I again wish to extend my apologies to the family of baby C and pray that they are able to finally move on at the end of my hearing. Yours Sincerely Mrs Julie Richards PIN NO 85Y0006W The panel also considered the email sent from Mrs Richards to the NMC s witness, dated 9 July 2013. Dear This is probably one of the hardest emails ive ever had to write, I have made the difficult and painful decision to pull out of my hearing. I have spent most of the day and all of this evening in tears I can no longer cope with it all. Finding out today I wont probably know the outcome until the end of the year was really the final straw. I knew the hearing wasn't going to be easy and I truly believed I could get through it but its been truly horrendous and I have crumbled big time my health and mental health has to be my priority. Thankyou so much for all your support the past 2 years its has meant so much to me Julie x Finally, the panel had regard to the email sent from the NMC case officer to the panel secretary, dated 10 July 2013 Hi Liam Just to let you know that I have spoken to Mrs Richards she said she can confirm she has withdrawn from the hearing and that she will not be attending the rest of the hearing days. She did not give a reason but I advised that I would let the panel know on her behalf Thanks, Case Officer Fitness to Practise Directorate Page 12 of 34
Ms Sutherland-Mack made an application for the panel to proceed in the absence of Mrs Richards under Rule 21 of The Nursing and Midwifery Council (Fitness to Practise) Rules Order of Council 2004 (The Rules). She referred the panel to Rule 32 and invited the panel to consider the public interest in the expeditious disposal of cases, inconvenience to the parties in attendance and fairness to Mrs Richards in determining whether or not to proceed. Ms Sutherland-Mack referred the panel to the case of R. v Jones (Anthony William), R. v Purvis (Paul Nigel), R. v Hayward (John Victor) (No.2) [2002] UKHL 5. Ms Sutherland-Mack submitted that it was evident that Mrs Richards had voluntarily absented herself. She had not requested an adjournment. Ms Sutherland-Mack informed the panel that 12 witnesses remained to give live evidence and that an adjournment could disadvantage those in attendance. She drew attention, in particular, to the interests of Patient C and her husband, who are present at the hearing. She submitted that it was in the public interest to dispose of this case expeditiously given the seriousness of the facts found proved. In her submission, it was necessary to proceed in Mrs Richards absence in order to protect the public, uphold public confidence in the profession and to declare and uphold proper standards of conduct and behaviour. The panel heard and accepted the advice of the legal assessor. He to referred the panel to Rule 21 of The Nursing and Midwifery Council (Fitness to Practise) Rules Order of Council 2004 (The Rules). He advised the panel that a decision to proceed must be taken with the utmost care and caution. He referred the panel to the case of R. v Jones (Anthony William), R. v Purvis (Paul Nigel), R. v Hayward (John Victor) (No.2) [2002] UKHL 5. The legal assessor also referred the panel to the checklist in the case of Tait v Royal College of Veterinary Surgeons [2003] UKPC 34 and Raheem v Nursing and Midwifery Council [2010] EWHC 2549 (Admin). He again reminded the panel of the care and caution which must be taken when exercising a discretion as to proceeding in absence. He reminded the panel that there were potentially very serious outcomes to the proceedings which it should bare in mind when exercising its discretion. Page 13 of 34
The panel accepted the advice of the legal assessor and was mindful that proceeding in the absence of Mrs Richards was a decision which must be handled with the utmost care and caution. The panel bore in mind that Mrs Richards had attended the hearing, and had been represented by Mr Whitcombe on 8 and 9 July 2013. Mrs Richards had also given evidence. The panel was in no doubt that Mrs Richards had clearly articulated her decision to withdraw from this hearing. Moreover, her email and letter did not request an adjournment generally, or for a short period, to obtain any medical note. The panel did not understand Mrs Richards to be saying that she was currently medically unfit to attend, but that the pressure of the proceedings was something that was weighing seriously upon her and that a continuation of the proceedings had the potentially to affect her future health and mental wellbeing. In exercising its discretion the panel reminded itself that Mrs Richards had, in general, a right to be present at this hearing and a right to be legally represented. However, Mrs Richards was also free not to avail herself of that right, or otherwise to waive it. The panel retained its discretion to proceed notwithstanding the absence of Mrs Richards and her legal representative. The fact that Mr Whitcombe had also withdrawn, on account of his instructions having been withdrawn, heightened the care and concern with which it determined to exercise its discretion. The panel had in mind that fairness to Mrs Richards was of prime importance in relation to this decision. However, it also recognised the importance of fairness to the NMC and its witnesses, including Patient C and her husband. Mrs Richards had expressed herself clearly. Mr Whitcombe had had some two hours in order to take further instructions and advise Mrs Richards. The panel was satisfied that Mrs Richards had freely chosen to absent herself from proceedings which were stressful. The panel considered that there was no immediate medical reason why she could not be present. The panel acknowledged that Patient C and her husband would have found the proceedings stressful themselves. Despite the clarity implicit in Mrs Page 14 of 34
Richards letter, she had made no application to adjourn. She had had the opportunity to seek an adjournment through Mr Whitcombe this morning. Mr Whitcombe confirmed that Mrs Richards had been advised as to the possible outcomes from these proceedings. The panel noted the risk of its reaching an improper conclusion in the absence of Mrs Richards. However, it further noted that she had engaged in the proceedings to a large extent thus far. She had provided a statement, confirmed on oath, together with supporting testimonials. There had been a limited opportunity for cross examination on the statement (limited to the issue of communication). None of Mrs Richards testimonial evidence would be supported by oral statements. However, the panel would be in a position to give such weight to the evidence as it thought fit in due course. The panel considered that there was a general public interest in the hearing taking place within a reasonable time. An adjournment would serve no purpose. There was no material before the panel which would suggest that Mrs Richards would engage at a later date. Further delay would be detrimental to the recollection of witnesses. The panel reminded itself that Mrs Richards absence did not represent an admission of misconduct or impairment, and added nothing to the NMC case which it must prove. In all the circumstances, the panel decided to proceed in Mrs Richards absence. Determination on misconduct and impairment: Having determined its findings of fact, the panel went on to consider whether the facts admitted and found proved amount to misconduct and, if so, whether Mrs Richards fitness to practise is currently impaired. The panel heard oral evidence from eight witnesses called by the NMC. Ms 1, Senior Midwife at the Midwifery Led Unit, Cardiff and The Vale Health Board. Page 15 of 34
Ms 2, Clinical Lead at the Midwifery Led Unit, Cardiff and The Vale Health Board. Ms 3, Midwife at the Midwifery Led Unit, Cardiff and The Vale Health Board. Ms 4, Band 6 Midwife, University Hospital of Wales, Cardiff and The Vale Health Board. Ms 5, the Head of Midwifery and Directorate Lead Nurse, Cardiff and The Vale Health Board. Ms 6, Band 7 Midwife, University Hospital of Wales, Cardiff and The Vale Health Board. Ms 7, Consultant Midwife, University Hospital of Wales, Cardiff and The Vale Health Board. Ms 8, Local Supervising Authority Midwifery Officer. In making its determination the panel also had regard to all the evidence previously considered, the documentary evidence of witnesses for the NMC, the documentation submitted on behalf of Mrs Richards, and the submissions made by Ms Sutherland- Mack on behalf of the NMC. The panel bore in mind that for a finding of impairment to be made, it must consider whether the facts found proved amounted to misconduct and then, if that misconduct was found, whether, by reason of that misconduct, Mrs Richards fitness to practise is currently impaired. The panel reminded itself of its duty to protect the public, to maintain public confidence in the profession and the regulatory process, which includes the declaring and upholding of proper standards of behaviour and conduct. Page 16 of 34
Ms Sutherland-Mack submitted that there had been misconduct and that there is current impairment. She invited the panel to consider this when considering the charges individually and particularly when pulling all the strands together and considering the action relating to each patient as a whole. Ms Sutherland-Mack referred the panel to the case of Roylance v GMC (no. 2) [2000] 1 AC 311 which defines misconduct as, a word of general effect, involving some act or omission which falls short of what would be proper in the circumstances. Ms Sutherland-Mack invited the panel to take the view that Mrs Richards actions did amount to breaches of relevant parts of The code: Standards of conduct, performance and ethics for nurses and midwives (2008) and the Midwives rules and standards (2004). In relation impairment she referred the panel to the case of CHRE v Nursing and Midwifery Council and Grant, [2011] EWHC 927 (Admin) and Cohen v General Medical Council [2008] EWHC 581 (Admin). The panel heard and accepted the advice of the legal assessor. Amongst other things he reminded the panel that there is no statutory definition of misconduct. He advised that misconduct is a wide concept comprising a serious departure from good professional practice whether or not it was covered by the NMC standards. He reminded the panel that not all breaches of the relevant parts of the code and midwives rules and standards necessarily constitute misconduct. The legal assessor reminded there panel that there was no statutory definition of impairment. He advised that case law establishes that it is a present day test. The issue to be considered is whether Mrs Richards fitness to practise is currently impaired as of today. Decision on whether the facts found proved amount to misconduct: The panel found misconduct in respect of Mrs Richards acts and omissions in all three cases. Page 17 of 34
As regards Patient A it was evident to the panel that Mrs Richards failed to understand the significance of Patient A s raised blood pressure, and that she failed to act upon observations showing a deviation from the normal parameters. The panel noted the National Institute for Health and Clinical Excellence ( NICE ) guideline on Intrapartum Care (September 2007). This includes a requirement for assessment and observation of women following the birth of a baby. Further, the panel was mindful of the local protocol on maternal transfer from the MLU to CLU. When blood pressure readings exceed stated levels then transfer is required. Having heard the oral evidence of the NMC s witnesses, the panel was satisfied that the blood pressure readings for Patient A did call for a transfer from the MLU to the CLU. Ms 5 exhibited to her witness statement the post operative pain and assessment chart for Patient A. Patient A s blood pressure observations at 01:50, 03:00 and 03:30 were all above the normal parameters. The panel noted that Mrs Richards, in her statement to the panel, sought to challenge the observation at 03:00 on the basis that a document which she should have completed was in fact completed retrospectively by another midwife later in the shift. Mrs Richards contention, in her statement signed and dated June 2013, was that the 03:00 reading was no more that 150 systolic. The panel found this evidence to be inconsistent on two grounds. The first is that the document produced following the root cause analysis investigation meeting on 22 December 2008, at which Mrs Richards was present, records the blood pressure as 160 systolic over 90 diastolic. Second, the primary responsibility, and therefore accountability, for plotting Patient A s observations rested squarely with Mrs Richards. By her own admission, Mrs Richards accepted that she did not provide the doctor with a detailed clinical history of Patient A s condition. The doctor was based at another hospital and relied on information given to her by Mrs Richards. The panel determined that not providing the doctor with a detailed history could have adversely impacted on the care that the doctor was able to provide to Patient A. Without providing a full and proper clinical history as regards Patient A, the doctor could not ensure that the advice she provided to Mrs Richards was appropriate. Mrs Richards accepted that she did not complete records appropriately. Page 18 of 34
On 7 January 2009 and following the incident concerning Patient A, Mrs Richards was placed on a period of supervised practice for 300 hours. Mrs Richards was initially reluctant to undertake supervision, regarding it as a punitive measure. There were a number of objectives which Mrs Richards was required to meet. Ms 5 told the panel that the supervised practice objectives appeared to have been met, but that in retrospect, Mrs Richards had actually lacked sufficient insight to apply her learning to her midwifery practice. In finding misconduct in respect of Patient A, the panel considered that Mrs Richards had breached the following parts of The code: The preamble: The people in your care must be able to trust you with their health and wellbeing To justify that trust, you must: work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community provide a high standard of practice and care at all times The paragraphs: 21. You must keep your colleagues informed when you are sharing the care of others. 26. You must consult and take advice from colleagues when appropriate. 28. You must make a referral to another practitioner when it is in the best interests of someone in your care. 35. You must deliver care based on the best available evidence or best practice. 38. You must have the knowledge and skills for safe and effective practice when working without direct supervision. 42. You must keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give, and how effective these have been. Page 19 of 34
The panel also determined that there had been clear breaches of the Midwives rules and standards, in particular: Rule 6.3 In an emergency, or where a deviation from the norm which is outside her current sphere of practice becomes apparent in a woman or baby during the antenatal, intranatal or postnatal periods, a practising midwife shall call such qualified health professional as may reasonably be expected to have the necessary skills and experience to assist her in the provision of care. The panel then considered the incident concerning Patient B. It was evident that in this instance Mrs Richards had breached the local Induction of Labour ( IOL ) protocol. Patient B was not full term plus 13 days. Her pregnancy was not complicated, and she did not meet the requirements of the protocol to qualify for an IOL. On the basis of the evidence before it, the panel determined that there was no clinical justification for Mrs Richards to breach the protocol. It was not acceptable for her to have done so. Mrs Richards breach of the IOL protocol was compounded by her failure to consult and seek advice from other staff. The panel determined that the incident concerning Patient B was not sufficiently serious, when considered in isolation, as to amount to misconduct. However, when taken together with the facts in relation to Patients A and C, and that the incident involving Patient B followed shortly after a period of supervised practice, the panel determined that Mrs Richards acts and omissions had amounted to misconduct. Following the incident concerning Patient B, Mrs Richards was placed on 3 months of supervised practice and 3 months of supported developmental practice. The panel regarded this incident as serious given that it took place after a first period of supervised practice during which Mrs Richards had had an opportunity to reflect upon her duties under The code. The panel found that the following provisions were breached: The paragraphs: Page 20 of 34
26, 28, 35 as above; and 24. You must work cooperatively within teams and respect the skills, expertise and contributions of your colleagues. 39. You must recognise and work within the limits of your competence. The panel then considered the matter of Patient C. Mrs Richards did not properly interpret and/or act upon the significance of observations relating to foetal tachycardia and Patient C s elevated blood pressure. This was in breach of the NICE guideline and of the local Emergency Maternal or Neonatal Transfer from MLU protocol. Ms 2 told the panel that when considering Patient C s partogram, she was astounded that the combination of maternal blood pressure and foetal tachycardia observations had not resulted in action, and in particular a transfer to the CLU. The panel shared this view. The panel found this failure to act to be deplorable. This failure to act was further aggravated given the facts of Patient A s case, and subsequent episodes of supervised practice. The panel considered Mrs Richards failure to act in the context of her administering syntocinon without a prescription and without Patient C s consent. The usual drug to be administered to assist third stage of labour is syntometrine, a side effect of which is to raise maternal blood pressure. The local drug administration protocol for midwives provided that syntocinon may only be administered without a prescription in particular circumstances which did not pertain here. Mrs Richards was seen by Ms 4 collecting syntocinon from the drug fridge, and she challenged her as to her rationale. The panel accepted that the only logical inference that could be drawn from Mrs Richards using syntocinon was that she was well aware of Patient C s elevated blood pressure. This failure to follow local protocol must be seen as even more serious in light of the facts surrounding Patient B, and the subsequent second period of supervised practice. Patient C s medical records disclosed that Ranitidine was administered at 23:45. The panel was informed that Ranitidine was only given to patients on the MLU prior to transfer to the CLU. The inference that the panel drew was that this was a precursor to Page 21 of 34
immediate transfer for Patient C. The panel bore in mind its findings in relation to a lack of communication between Mrs Richards and Patient C whilst she was in the birthing pool. In all the circumstances, Mrs Richards acts and omissions in respect of Patient C s midwifery care breached the following parts of The code: The paragraphs: 3. You must treat people kindly and considerately. 8. You must listen to the people in your care and respond to their concerns and preferences. 12. You must share with people, in a way they can understand, the information they want or need to know about their health. 13. You must ensure that you gain consent before you begin any treatment or care. 43. You must complete records as soon as possible after an event has occurred. As well as paragraphs 26, 28, 35 and 42 as set out above. Further, the panel determined that Mrs Richards breached the following parts of the Midwives rules and standards: Rule 6.3 as set out above; Rule 7. A practising midwife shall only supply and administer those medicines, including analgesics, in respect of which she has received the appropriate training as to use, dosage and methods of administration. The panel noted that there were certain core similarities in Mrs Richards approach to the care of Patients A, B and C. In Patient A s case there was a failure to recognise and act upon deviations from normality in basic observations. The panel heard and accepted that the practice of midwifery is confined to the management of normality, and that it is the duty of a midwife to recognise and act upon a situation which deviates from normality. Page 22 of 34
Mrs Richards failed to transfer Patient A when the indications were such that this was required. This was a breach of the local protocol. Mrs Richards failed to maintain detailed records and to communicate adequate information to other health professionals. In respect of Patient B, the panel found a failure to follow local protocol and a failure to communicate with other health professionals. The panel considered that this was of particular concern given that it followed shortly after a period of supervised practice. Patient C s case involved a serious failure to recognise and act upon deviations from normal observation. There was a failure to transfer to the CLU, in breach of protocol; a failure to communicate properly or at all with appropriate health practitioners; and poor record keeping. Patient A, and C s cases individually involved serious misconduct. Taking the cases of Patients A, B and C together, Mrs Richards care fell very considerably below the standards that may be reasonably expected of a Registered Midwife. Decision on Impairment: The panel next went on to decide whether, as a result of this misconduct, Ms Richards fitness to practise is currently impaired. The panel reminded itself that it should consider not only the risk that a registrant poses to members of the public, but also the public interest in upholding proper professional standards and public confidence in the NMC as a regulator, and whether that confidence would be undermined if a finding of impairment were not made in the circumstances. The panel noted Mrs Richards own statement in which she said at the time of the incident [Patient C] I now have no doubt that my fitness to practise was impaired. The panel shared Mrs Richards own view and bore in mind the common features arising in the cases of Patients A, B and C. Page 23 of 34
The panel did not accept Mrs Richards case, that two and a half years on with acceptance, insight, education and support I no longer believe it [her fitness to practise] is [currently impaired]. Ms 9, Mrs Richards supervisor of midwives, in a note dated 17 June 2013 recorded the work which Mrs Richards had undertaken to address her shortcomings. Despite some measure of insight, Ms 9 referred to Mrs Richards as working towards addressing identified issues The panel was not satisfied that she had in fact addressed these successfully. Ms 7, who was involved in Mrs Richards initial period of supervised practice, told the panel that she originally thought Mrs Richards had learnt from experience, but that it was obvious to her now that Mrs Richards had not. Ms 7 s evidence was that Mrs Richards had been unable to convert apparent insight and learning into practice. Ms 5 also referred to having likewise initially been assured, but that in retrospect, she considered that Mrs Richards lacked insight. The panel was concerned by Mrs Richards apparent satisfaction with her two periods of supervised practice and her later complaint about its delivery (which was largely not upheld). The complaint appeared to have arisen only after the incident concerning Patient C had arisen. The panel is bound to observe that at points Mrs Richards attempted to suggest that she was not solely responsible for the incidents concerning Patient C and Baby C. The panel was not satisfied on the evidence before it that Mrs Richards had remedied the failings which lay at the root of her misconduct. Overall the panel determined that Mrs Richards has in the past acted in a way so as to place patents at risk of unwarranted and actual harm. The panel had no confidence that her failings would not be repeated in the future, and determined that there remained a real and continuing risk to the public. Mrs Richards fundamental acts and omissions were also damaging to the reputation of the profession. Given the likelihood of repetition, combined with the profound Page 24 of 34
consequences which have affected patients, the panel finds that Mrs Richards fitness to practise is currently impaired. In all the circumstances, a finding of current impairment of fitness to practise is the only finding available to the panel to uphold public confidence in the profession and the NMC as its regulator. Page 25 of 34
Determination on Interim Order (upon adjournment): Pursuant to Rule 32 (5) of the Nursing and Midwifery Council Fitness to Practise Rules 2004 the panel is required to consider the imposition of an interim order upon adjourning the hearing. Ms Sutherland-Mack, on behalf of the NMC, did not make an application for an interim order. She confirmed that Mrs Richards is already subject to an interim order. She invited the panel to confirm the existing interim suspension order. The panel heard and accepted the advice of the legal assessor. The panel determined that it would confirm the existing interim suspension order on the grounds that it was necessary for the protection of the public and that it was otherwise in the public interest. This case will resume on 2 August 2013 (subject to scheduling). Page 26 of 34
Determination on Sanction: The panel has considered this case very carefully and has decided to make a Striking Off Order. The purpose of the Order is to remove Mrs Richards name from the NMC s register. Having determined that Mrs Richards fitness to practise is currently impaired, the panel considered what sanction, if any, it should impose in relation to her registration. In reaching its decision on sanction, the panel has considered all the evidence that has been placed before it. It also had regard to three testimonials submitted by Mrs Richards prior to her absenting herself on 10 July 2013. On behalf of the NMC, Mr Ismail reminded the panel that the imposition of a sanction is entirely a matter for its own professional judgement. He also reminded the panel of its earlier determination and the findings it had made in respect of Mrs Richards serious misconduct and impairment. He told the panel that Mrs Richards allegations were of the highest order and that her misconduct was exceedingly serious. Under Article 29 of the Nursing and Midwifery Order (2001) the panel considered the following sanctions in ascending order: take no action; make a caution order for one to five years; make a conditions of practice order for no more than three years; make a suspension order for a maximum of one year; or make a striking off order. The panel recognised that the purpose of sanctions is not to be punitive, although a legitimate sanction may have a punitive effect. The panel accepted the advice of the legal assessor. It also had due regard to the NMC s Indicative Sanctions Guidance ( ISG ). The panel acknowledged that it should consider the matter of sanction beginning with the least severe and working upwards, in so far as that might be necessary. The panel recognised specifically that it must attend to the public interest. The public interest includes the protection of the public including patients, the maintenance of public confidence in the profession, and in the NMC as regulator, and the declaring and upholding of proper standards of conduct and behaviour within the professions. Page 27 of 34
The panel further acknowledged that it must apply the principles of proportionality and fairness. It is no part of its function to satisfy whatever public appetite there might be for retribution. Rather it must act as regards sanction with proper regard to what is necessary, appropriate and proportionate weighing all the evidence in the round, considering Mrs Richards own interests, and upholding the public interest. This is a case in which serious failings of professional standards occurred on three occasions. It involves three patients and two deaths, one of a mother post childbirth and the other of a child some months after birth. No evidence has been put before the panel as to direct causation. It was impossible for the panel to reach any findings as to whether the outcomes in both cases would have been different, if Mrs Richards care for the patients for whom she had charge had itself been different. The panel has approached the issues with due regard to risk, and to what might reasonably be expected of an experienced nurse and midwife in the application of professional standards of conduct. It accepted that circumstances can arise in which nurses and midwives will be faced with extremely difficult decisions and very great pressure. It did not assume that an experienced nurse and midwife could never make a mistake, notwithstanding the best of intentions. The panel duly recognised the mitigating and aggravating factors. At the relevant times Mrs Richards had practised successfully as a registered midwife. There was no evidence before the panel that her conduct had been deficient at any point prior to 2008. She admitted all but one of the charges she faced before this panel. She attended the hearing and was represented until her voluntary withdrawal on the third day. She had engaged with the NMC Conduct and Competence Committee process fully to that point and had given evidence under oath. There was no charge relating to her personal integrity, nor any evidence to the effect that she was not motivated by anything other than a general desire to act in the interests of patients. Mrs Richards attributed her withdrawal from these proceedings to her inability to cope with the pressures that attended them, including those associated with publicity. In a written statement to the panel she stressed that she remained committed to nursing. Page 28 of 34
She expressed a desire to return to practice as a Registered Nurse. Furthermore, she also expressed some remorse. The panel had due regard to the three testimonials submitted in evidence by Mrs Richards. Whilst commendable features were highlighted within these testimonials, they nevertheless related to Mrs Richards current employment for which registration with the NMC is not a requirement. The panel also bore in mind that Mrs Richards was an experienced midwife at the time of the relevant incidents affecting Patients A, B and C. She had a period of supervised practice after failings has been identified in relation to Patient A. She had another period of supervised practice, followed by supported developmental practice lasting six months, after her failings had been identified as regards Patient B. For all three patients Mrs Richards failed to follow established protocols, for two of them she failed to apply the most elementary standards expected of a midwife for the protection of patients. In particular, the panel found that Mrs Richards failed to attend to basic observations appropriate to monitoring women in childbirth, and failed to recognise obvious abnormalities. Further, she did not act upon them so as to refer both Patients A and C for medical attention in line with established protocols. She failed them both, gravely and deplorably. Despite significant periods of supervised practice, plus a period of supported developmental practice, Mrs Richards exhibited standards of conduct and care which fell far below those that may reasonably be expected of a professional nurse and midwife. Her misconduct was neither isolated nor wholly explicable. Rather it featured a pattern of failings related to: communication with colleagues and patients; record keeping; applying necessary practical protocols in the interests of patient protection; attending to the most basic of observations; practicing within her own competence; and, Page 29 of 34