Nursing and Midwifery Council Fitness to Practise Committee Substantive Order Review Meeting 10 May 2018 Nursing and Midwifery Council, Regus, Forsyth House, Cromac St, Belfast BT2 8LA Name of Registrant Nurse: NMC PIN: Part(s) of the register: Area of Registered Address: Type of case: Miss Diane Melanie Hart 12H1537E Registered Midwife England Lack of Competence Panel Members: Legal Assessor: Panel Secretary: Order being reviewed: Outcome: Richard Davies (Chair, Lay member) Claire Gill (Registrant member) John Vellacott (Lay member) Conor Heaney Tafadzwa Taz Chisango Suspension Order, 3 months Striking off order to be imposed upon expiry in accordance with Article 30 (1), namely at the end of 21 June 2018. 1
Service of Notice of Hearing The panel was informed that a letter had been sent by recorded delivery and first class post to Miss Hart s registered address on 3 April 2018 informing her that this matter would be considered at a meeting on or after 8 May 2018. In the light of the above information, and having heard and accepted the advice of the legal assessor, the panel concluded that service had been effected in accordance with the Rules. Decision and reasons on review of the current order: The panel is reviewing the order pursuant to Article 30(1) of the Nursing and Midwifery Order 2001(the Order). The panel decided to impose a striking off order. This order will come into effect at the end of 21 June 2018 in accordance with Article 30 (1). This is the third review of a suspension order, originally imposed by a panel of the Conduct and Competence Committee on 27 February 2016 for 12 months. A reviewing panel on 13 February 2017 extended the order for 12 months. On 8 February 2018 a reviewing panel extended the order for a further 3 months. The current order is due to expire on 21 June 2018. The panel is reviewing the order pursuant to Article 30(1) of the Order. The charges found proved by way of admission which resulted in the imposition of the substantive order were as follows: That you, whilst employed as a Registered Midwife by Oxford University Hospitals NHS Trust ( the Trust ), failed to demonstrate the standards of knowledge, skill and judgement required for practise without the supervision of a Registered Midwife on but not restricted to the following occasions:- 1. On 28 February 2013, when caring for Patient G, you: 2
1.1. Failed to continuously monitor the foetal heart rate. 1.2. Failed to seek prompt assistance from an obstetrician and/or senior midwife when you could not trace the foetal heart rate on the cardiotograph ( CTG ). 2. On 14 March 2013, when caring for Patient A, you: 2.1. Failed to recognise and /or escalate the abnormal foetal heart rate. 2.2. Failed to accurately monitor the foetal heart rate. 3. On 15 March 2013, you failed to recognise that as Patient B was suffering a primary postpartum haemorrhage, she required immediate medical assistance. 5. On 24 March 2013, you failed to identify the abnormal foetal heart rate in Patient H. 6. On 3 April 2013, when caring for Patient I, you: 6.1. Failed to conduct fresh eyes reviews of the CTG on an hourly basis until prompted to do so. 6.2. Failed to promptly complete observations of the baby s vital signs post-delivery until prompted to do so. 7. Failed to promptly weigh the baby until prompted to do so. 8. On 4 April 2013: 3
8.2. In respect of Patient N, you failed to act when the foetal heart rate was not being monitored due to a loss of contact. 9. On 18 April 2013, in respect of an unknown patient, you failed to recognise and/or escalate foetal bradycardia. 10. On 25 April 2013, failed to take action when Patient D had an abnormal foetal heart rate. 11. On 29 April 2013, when caring for Patient H, you: 11.2. Did not recognise that Patient H s baby was not pinking up ; 12. On 9 May 2013, in respect of Patient O, failed to identify a deceleration in the foetal heart rate. 13. On 28 August 2013, you were unable to demonstrate, without prompting, sufficient knowledge of how to react to an abnormal CTG trace. 14. On 9 September 2013, you failed to:- 14.1. Monitor the CTG of an unknown patient 14.2. Identify and/or react to a tachycardic fetal heart trace on the CTG for an unknown patient 15. On 10 September 2013, you failed to identify and/or deal with hyper stimulation of the uterus of an unknown patient. 16. On 17 September 2013, you did not systematically analyse the CTG of an unknown patient using the Dr C Bravado method and/or did not identify abnormalities on the CTG until prompted. 4
17. On 2 October 2013, when caring for Patient K, you failed to:- 17.1. Prime both the lines intended to be used to administer fluid intravenously to Patient K; 17.2. Record a Visual Infusion Phlebitis score on Patient K s MAR chart; 17.3. Either flush the cannula, or record the use of sodium chloride to flush the cannula on Patient K s MAR chart. That you, whilst employed as a Registered Midwife by Leeds Teaching Hospitals Trust (LTHT) and undertaking a Local Supervising Authority Practice Programme (LSAPP) between 6 October 2014 and 12 March 2015, failed to demonstrate the standards of knowledge, skill and judgement required for practise without the supervision of a Registered Midwife on but not restricted to the following occasions:- 18. On 6 October 2014, your completion of documentation was inadequate. 19. On 14 October 2014: 19.1. Your completion of documentation was inadequate. 19.2. You did not use SBAR principles in your handover to the doctor 19.3. Your handover to the doctor was not clear or concise 20. On 17 October 2014 in relation to a high risk patient: 20.1. You did not use SBAR principles when seeking a review by the medical team, resulting in a delay in the escalation of the patient s care. 5
20.2. You struggled to make a plan of care. 20.3. You were unable to maintain adequate records for the patient alongside caring for her. 21. On 23 October 2014, when providing care to two patients: 21.1. You failed to recognise a pathological CTG. 21.2. You failed to recognise a prolonged deceleration of the fetal heart rate. 21.3. You failed to escalate a patient to the multidisciplinary team. 21.4. You were unable to care for a high risk patient without considerable support. 21.5. You demonstrated limited knowledge in recognising early warning signs on the MOEWS chart. 21.6. You were unable to undertake blood pressure monitoring in a timely manner. 21.7. You were unable to organise and plan ongoing care without support. 22. On 24 October 2014, when providing care to a high risk patient: 22.1. You failed to recognise the early warning signs of low oxygen saturation. 22.2. You were unable to continue to take the lead in caring for the patient and left the room. 6
23. On 30 October 2014: 23.1. You required constant assistance and guidance in caring for a patient. 23.2. You required guidance with record keeping. 23.3. You failed to recognise the baby s poor airway following delivery. 23.4. You required prompting to cut and clamp the cord quickly to assist with the baby s airway. 24. On 3 November 2014: 24.1. You did not use SBAR principles during a ward round. 24.2. You were unable to recognise a pathological CTG. 24.3. You had to be prompted to take curative measures to alleviate stress from a baby. 24.4. You were unable to appropriately manage a pathological CTG and escalate appropriately. 24.5. Your record keeping was inadequate. 25. On 7 November 2014, you failed to distinguish a pathological CTG and so did not carry out appropriate actions and corrective measures to alleviate stress from the baby. 26. On 12 February 2015: 7
26.1. You failed to support a patient during the second stage of labour. 26.2. You failed to observe the CTG and document care. 26.3. You did not provide care to the patient during the forceps delivery. 27. On 15 February 2015, your care of a patient was inadequate in that: 27.1. You delayed in commencing a syntocinon infusion. 27.2. You failed to recognise the need to perform a vaginal examination prior to commencing syntocinon. 27.3. Your communication with the patient and her birth partner was poor. 27.4. You were unable to focus on more than one task at a time. 27.5. You failed to recognise the need for a CTG. 28. On 4 March 2015, you failed to recognise a pathological CTG. 29. On 25 March 2015: 29.1. You failed to recognise a prolonged deceleration in the CTG and act upon it. 29.2. You required constant assistance and guidance in caring for a patient. 29.3. You failed to manage and monitor intravenous paracetamol to a patient. 8
And in light of the above, your fitness to practise is impaired, by reason of your lack of competence. The reviewing panel on 8 February 2018 determined the following with regard to impairment: The panel today first considered whether Miss Hart s fitness to practise remains currently impaired. The panel had received no new evidence that might enable it to conclude that Miss Hart s fitness to practise is no longer impaired. In the absence of any engagement from Miss Hart, the panel had no information before it to demonstrate that Miss Hart has remedied her lack of competence or intends to begin that process, or has developed any insight into her failings. The panel could not be satisfied that Miss Hart no longer poses a risk to patients. Therefore, a finding of continuing impairment is necessary on the ground of public protection. The panel has borne in mind that its primary function is to protect patients and the wider public interest which includes maintaining confidence in the nursing and midwifery professions and upholding proper standards of conduct and performance. The panel determined that, in this case, a finding of continuing impairment on public interest grounds is also necessary. For these reasons, the panel determined that Miss Hart s fitness to practice remains impaired. The reviewing panel on 8 February 2018 determined the following with regard to sanction: The panel considered extending the current suspension order. It noted that there has been no engagement by Miss Hart with the proceedings. Given the lack of engagement with the regulatory process, and Miss Hart s failure to demonstrate any insight or remediation, the panel concluded that the public could only be 9
adequately protected, and the public interest upheld, by extending the current suspension order. The panel was mindful of the submission made by Mr Harper that the period of a sanction should be no longer than necessary. The panel was of the view that a further three month suspension would protect the public and satisfy the public interest whilst at the same time allowing Miss Hart a further opportunity to develop her insight and take steps towards remediating her practice should she wish to reengage with these proceedings. The panel noted that the option of striking Miss Hart from the register was not available to it at this time, but will be available to the next reviewing panel. Decision on current fitness to practise The panel has considered carefully whether Miss Hart s fitness to practise remains impaired. Whilst there is no statutory definition of fitness to practise, the NMC has defined fitness to practise as a registrant s suitability to remain on the register without restriction. In considering this case, the panel has carried out a comprehensive review of the order in light of the current circumstances. It has noted the decision of the last panel. However, it has exercised its own judgment as to current impairment. The panel has had regard to all of the documentation before it, including the NMC bundle. The panel heard and accepted the advice of the legal assessor. In reaching its decision, the panel was mindful of the need to protect the public, maintain public confidence in the profession and to declare and uphold proper standards of conduct and performance. The panel considered whether Miss Hart s fitness to practise remains impaired. 10
In its consideration of whether Miss Hart has remedied her misconduct the panel took into account the suggestions made by the previous reviewing panels as to what would be of assistance upon further review. The panel noted that Miss Hart has not presented any material for this panel s consideration nor any reasons for this. The last panel determined that Miss Hart had shown no insight or remediation and this panel has neither heard nor received any information to contradict this. Miss Hart has not engaged with the NMC since 2016. The panel therefore decided that a finding of continuing impairment is necessary on the grounds of public protection. The panel has 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 proper standards of conduct and performance. The panel determined that, in this case, a finding of continuing impairment is also required on wider public interest grounds. For these reasons, the panel finds Miss Hart s fitness to practise remains impaired. Determination on sanction Having found Miss Hart s fitness to practise currently impaired, the panel then considered what, if any, sanction it should impose in this case. The panel has taken into account the NMC s Sanctions Guidance and has borne in mind that the purpose of a sanction is not to be punitive, though any sanction imposed may have a punitive effect. The panel first considered whether to take no action and allow the current order to lapse but concluded that this would be inappropriate in view of the risk of repetition identified and the seriousness of the case. The panel decided that it would be neither proportionate nor in the public interest to take no further action and allow the current order to lapse. The panel then considered whether to impose a caution order but concluded that this would be inappropriate because it would not restrict Miss Hart s practice. The panel also 11
decided that it would be neither proportionate nor in the public interest to impose a caution order. The panel next considered imposing a conditions of practice order but determined that this would not be appropriate. Miss Hart has not engaged with the NMC proceedings since her substantive hearing and the panel had no evidence to suggest that she would comply with any conditions of practice. The panel went on to consider whether to further extend the period of the suspension order. The panel noted that Miss Hart was given a clear indication by the previous panel as to what would be required of her to assist this panel. However, she has failed to follow any of the previous panel s suggestions. Miss Hart s failure to engage with her regulator on matters of substance is a matter of significant concern. She has failed to demonstrate that she has gained any further insight into the seriousness of her actions and their potential consequences, and she has failed to demonstrate a willingness to remediate. In all the circumstances, the panel concluded that a further period of suspension would serve no useful purpose. The panel has borne in mind the serious nature of Miss Hart s lack of competence. The panel wishes to stress that it is incumbent upon a registrant, whose fitness to practise has been found to be impaired, to engage appropriately with her regulator to demonstrate remediation. Miss Hart s lack of engagement and of demonstrated insight since the substantive order was imposed is indicative of a failure to do so on her part. The panel is of the view that Miss Hart has been provided with sufficient opportunities to remediate. This panel paid particular attention to the direction made by the previous panel with regard to her engagement, in particular that The panel noted that the option of striking Miss Hart from the register was not available to it at this time, but will be available to the next reviewing panel. The panel noted that Miss Hart has been subject to a substantive order since 2016 and it is of the view that such a point has now been reached. 12
The panel had regard to the NMC s Sanctions Guidance when considering the imposition of a striking off order. It had particular regard to the following Persistent lack of insight into seriousness of actions or consequences Can public confidence in the professions and the NMC be maintained if the nurse or midwife is not removed from the register? The panel has determined that the only appropriate and proportionate sanction in this case is to replace the current suspension order with a striking-off order. The panel is satisfied that, while a further suspension order would protect the public, a striking-off order is the only order that would be sufficient to satisfy the wider public interest in maintaining public confidence in the profession and the regulatory process and to declare and uphold proper standards of conduct and behaviour. The panel has no up to date information regarding Miss Hart s current personal or professional circumstances. Thus it has no information as to the impact on her of a striking-off order. Nevertheless, the panel is satisfied that the public interest outweighs Miss Hart s own interests in this case. The striking-off order will take effect from the expiry of the current suspension order at the end of 21 June 2018 in accordance with Article 30(1) of the Order. The panel therefore directs the Registrar to strike off Miss Diane Melanie Hart s name from the NMC register. Miss Hart may not apply for restoration until a period of five years after the date the striking-off order takes effect. This decision will be confirmed to Miss Hart in writing. That concludes this determination. 13