Nursing and Midwifery Council Fitness to Practise Committee Substantive Order Review Meeting 28 March 2018 Nursing and Midwifery Council, 114-116 George Street, Edinburgh, EH2 4LH Name of Registrant Nurse: NMC PIN: Part(s) of the register: Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Order being reviewed: Outcome: Tanya Petrova 08D0034C RM: Registered Midwife England Lack of Competence Nigel Hallam (Chair, Lay member) Mary Monnington (Registrant member) Patricia Lynch (Registrant member) Michael Bell Elaine Stewart Suspension Order 6 months Suspension Order (12 months) to come into effect on 22 May 2018 in accordance with Article 30 (1) 1
Service of Notice of Meeting The panel was informed that the notice of this Meeting was sent to Ms Petrova on 9 February 2018 by recorded delivery and first class post to her registered address. The panel noted that notice of this meeting was collected from the Royal Mail delivery office by Ms Petrova on 16 February 2018. The panel accepted the advice of the legal assessor. In the light of the information available the panel was satisfied that notice had been served in accordance with Rules 11 and 34 of The Nursing and Midwifery Council (Fitness to Practise) Rules Order of Council 2004 (as amended February 2012) (the Rules). Decision and reasons on review of the current order: The panel decided to extend the suspension order for a period of 12 months. This order will come into effect on 22 May 2018 in accordance with Article 30 (1) of the Nursing and Midwifery Order 2001 (as amended) (the Order). This is the first review of an order imposed by a panel of the Fitness to Practise Committee. The original order was one of suspension for a period of 6 months imposed on 19 October 2017 and is due to expire at the end of 21 May 2018. The panel is reviewing the order pursuant to Article 30(1) of the Order. The charges found proved which resulted in the imposition of the substantive order were as follows: That you failed to demonstrate the standards of knowledge, skill, and judgement required to practise without supervision as a band 6 midwife in failing to demonstrate the required level of understanding of Basic Life Support in that: 1. On 13 January 2016, 2
1.1 During an Acute Life Threatening Events Recognition (ALERT) assessment on general understanding of the topic scored 6 out of a possible 30 points 1.2 Were unable to demonstrate how to recognise that an unresponsive patient was breathing 1.3 Were unable to demonstrate what action to undertake on a patient with low blood sugar 1.4 Were unable to demonstrate your understanding of the need for neurological observations on an unresponsive patient 2. On 18 January 2016, during a Mandatory Skills and Drills Training Day, you were unable to demonstrate adequate knowledge of how to perform adult resuscitation 3. On 8 February 2016, during a one to one training session, you 3.1 Were unable to demonstrate that you understood how to check for breathing on an unresponsive patient 3.2 Were unable to demonstrate sufficient grasp and retention of knowledge of the practical skills for basic life support 3.3 Were unable to demonstrate proper management of a shoulder dystocia using the HELPERR mnemonic 3.4 Were unable to demonstrate correct finger placement during a reverse Woodscrew manoeuvre 4. On 14 April 2016, during a formal assessment you: 4.1 Did not give oxygen when it would have been appropriate to do so 3
4.2 Did not check the respiratory rate during the breathing assessment 4.3 Did not check the pulse rate 4.4 Did not assess correctly for disability and/or exposure 4.5 Were unable to demonstrate that you could confirm a cardiac arrest 4.6 Were unable to demonstrate that you started chest compressions at an appropriate time 5. On 14 July 2016, during the final ALERT test on competencies in a post natal ward, you: 5.1 Delayed in commencing compressions, and/or delayed in restarting chest compressions after placing the defibrillator pads 5.2. 5.3 Ignored the prompts from the Automatic External Defibrillator machine not to shock the patient, on two occasions 5.4 Were unable to demonstrate your knowledge on appropriate modifications for a pregnant patient 5.5 Were unable to achieve a pass in the Resuscitation Level 2 assessment AND that, by reason of the above, your fitness to practise is impaired by reason of your lack of competence. The original panel determined the following with regard to impairment: 4
The panel concluded that Ms Petrova had in the past acted so as to put patients at unwarranted risk of harm. It accepted that although patient harm had not occurred, she had failed to demonstrate the necessary skills required in an emergency situation, such as those faced by midwives and therefore there was a potential for harm to occur. Her clinical failings related to basic midwifery practice and to the fundamental tenets of midwifery. She has demonstrated a concerning lack of knowledge and ability to demonstrate basic skills required of a midwife and is therefore liable in the future to bring the midwifery profession into disrepute. The panel was mindful that the issue it had to determine was that of current impairment as of today. It therefore had to consider whether Ms Petrova is liable in future to act in such a way as to put patients at unwarranted risk of harm, breach fundamental tenets or bring the profession into disrepute. The decision about the risk of repetition in this case was informed by consideration of the level of insight Ms Petrova has demonstrated and by whether her lack of competence is capable of being remedied and, if so, whether it has been remedied. In regards to insight, the panel considered Ms Petrova s insight into her ability to demonstrate and retain the necessary skills and concluded that it had minimal information on insight before it, apart from a short statement she provided to the Trust s investigation. The panel noted that in this statement, Ms Petrova had shown a limited amount of insight into her failings, particularly, I really regret that this situations have developed so that this Formal hearing has occurred and I was happy to go on the ALERT Course as I wanted to improved knowledge especially after that situation. The panel further noted points set out by Ms Petrova in her statement: I recognise that I have been given training opportunities to learn from all these events and I feel that I have engaged with them and that I have improved my practice. 5
If it is felt that I need further training than I would be very happy to engage with that I do feel I am a safe practitioner I do feel that I can practice according to the NMC code of Conduct 4 pillars of: Prioritise people Practise effectively Preserve safety Promote professionalism and Trust. However, the panel determined that Ms Petrova has not engaged with the NMC and has not provided any representation or attended the hearing. It therefore determined that due to her lack of engagement no meaningful evidence of insight was adduced before the panel. The panel next consider Ms Petrova s evidence of remediation; the panel formed the view that the clinical deficiencies identified were remediable. However, it had not been presented with any evidence of remediation or whether or not Ms Petrova was still practising as a midwife at this time. The panel determined that Ms Petrova had undergone a number of training courses and assessments across several months, on similar components of basic care and she was still unable to remediate these shortcomings. The panel concluded that Ms Petrova s lack of competence has not been remedied and, consequently, there is a real risk of repetition. Therefore, the panel concluded that a finding of impairment on the grounds of public protection is necessary. The panel bore in mind the overarching objective of the NMC: to protect, promote and maintain the health safety and well-being of the public and patients and the 6
wider public interest which includes promoting and maintaining public confidence in the nursing and midwifery professions and upholding the proper professional standards for members of those professions. In the judgement of the panel, irrespective of the risk of harm, public confidence in the profession and the regulator would be undermined if a finding of impairment was not made in the particular circumstances of Ms Petrova s case. Having regard to all of the above, the panel was satisfied that Ms Petrova s fitness to practise is currently impaired by reason of her lack of competence. The original panel determined the following with regard to sanction: The panel next considered whether placing conditions of practice on Ms Petrova s registration would be a sufficient and appropriate sanction. The panel was mindful that any conditions imposed must be relevant, proportionate, measurable and workable. The panel acknowledged that Ms Petrova s lack of competence was theoretically capable of remediation, however, the panel noted that over a six month period Ms Petrova had been given training, including one-to-one support, in the areas of concern, but had failed to significantly improve her practice or her ability to retain knowledge. The panel noted that in her brief statement to the Trust, Ms Petrova stated that she was willing, at that material time, to complete any training necessary, stating: If it is felt I need further training then I would be very happy to engage with that. However, the panel considered that given Ms Petrova s lack of engagement with the NMC and minimal insight, it has no evidence that Ms Petrova would be willing or able to comply with conditions. In these circumstances, the panel concluded that placing conditions on Ms Petrova s registration would not adequately protect the public nor address the wider public interest concerns. The panel therefore determined a conditions of practice order is not workable in these circumstances. 7
The panel took into account the SG which states that A striking off order is not an available sanction where fitness to practise is impaired on the basis of lack of competence, until the nurse or midwife has been subject to either a suspension order or a conditions of practice order for a continuous period of no less than two years. The panel were therefore drawn inevitably to consider whether a suspension order would be an appropriate and proportionate sanction. The panel considered that Ms Petrova s lack of competence related to basic midwifery skills and knowledge. It found that Ms Petrova lacked insight into her serious clinical shortcomings and there was no evidence of remediation. Cumulatively, the panel was of the view that in the circumstances, if Ms Petrova was allowed to continue to practise there would be a risk to patient safety. The panel determined that a suspension order for a period of 6 months was appropriate to mark the seriousness of the lack of competence and would be a proportionate sanction at this stage. It could give Ms Petrova the opportunity to engage with the NMC, develop her insight and knowledge and her ability to demonstrate these skills, without having an adverse impact on her maintenance of her other midwifery skills. A suspension order was also the only order available to the panel which would address the wider public interest concerns. At the end of the period of suspension, another panel will review the order. At the review hearing the panel may revoke the order, or it may confirm the order, or it may replace the order with another order. Any future panel may be assisted by evidence of: Ms Petrova s engagement with the NMC; A detailed reflective account to demonstrate that she has developed insight into the importance of having the knowledge and skills for safe and effective midwifery practice; Any evidence of steps taken to remediate and address the lack of competence identified; 8
References and testimonials in relation to any work she has undertaken, currently or previously, whether paid or unpaid and whether or not in a healthcare setting; Evidence of keeping her midwifery skills or knowledge up-to-date. Decision on current fitness to practise The panel has considered carefully whether Ms Petrova 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 but noted that there was no new information available from Ms Petrova and no evidence of any engagement with the NMC. 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 Ms Petrova s fitness to practise remains impaired under reference to the test suggested in CHRE v NMC & Grant [2011] EWHC 927 and the guidance provided in Cohen v GMC [2008] EWHC 581 (Admin). Regarding her insight, the panel had no evidence of any change or development in Ms Petrova s insight due to her apparent disengagement with these proceedings and therefore supported the conclusion of the original panel that Ms Petrova had very limited insight into her failings. 9
In its consideration of whether Ms Petrova has remedied her practice the panel again noted that no evidence of any attempts towards remediation have been produced. The panel supported the view of the original panel that the failings in Ms Petrova s clinical practice are and should be remediable but that no evidence of any efforts to do so have been made available to this panel. The last panel determined that Ms Petrova was liable to repeat matters of the kind found proved. This panel has heard no new information to support any change in this view and considered the risk of repetition to be exacerbated by the passage of time and Ms Petrova s apparent disengagement with the regulatory process. The panel therefore decided that a finding of continuing impairment remains necessary on the grounds of public protection. The panel had borne in mind that its primary function was 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 on public interest grounds is also required. For these reasons, the panel finds that Ms Petrova s fitness to practise remains impaired. Determination on sanction Having found Ms Petrova s 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 are set out in Article 30 of the Order. The panel has also taken into account the NMC s Sanctions Guidance (SG) 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 considered whether to take no action or impose a caution order but concluded that this would be inappropriate in view of the risk of repetition identified and seriousness of the case. The panel decided that it would be neither proportionate nor in the public interest. 10
The panel next considered the imposition of a conditions of practice order. The panel noted that competence issues are generally remediable and this can often be addressed by conditions of practice. However, the panel noted that Ms Petrova has received significant training and support in her workplace but with little improvement in her practice. The panel noted that for conditions to be formed, there must be evidence of engagement and willingness to comply with the conditions but the panel has no evidence to suggest Ms Petrova could or would comply with any conditions. In these circumstances, the panel concluded that placing conditions on Ms Petrova s registration would not adequately protect the public nor address the wider public interest concerns. The panel therefore determined a conditions of practice order is not workable in these circumstances. The panel considered the imposition of a further period of suspension. It was of the view that a suspension order would allow Ms Petrova further time to fully reflect on her previous failings and make efforts to remedy her practice. The panel concluded that a further suspension order for the longer period of 12 months would be the appropriate and proportionate response and would afford Ms Petrova adequate time to consider her commitment to the profession, to re-engage with her regulator and to develop her insight and remediation of her failings. The panel was aware that a striking off order was not an available sanction until Ms Petrova had been subject to a suspension order or conditions of practice order for a continuous period of 2 years. Prior to the expiry of the suspension order a panel of the Fitness to Practise Committee will review the order. Ms Petrova or the NMC may request an early review hearing. At this hearing the panel may allow the order to lapse, or replace it with another order, which could be a caution order, conditions of practice order or a further suspension order. This panel urge Ms Petrova to consider her future commitment to the profession and to utilise the time of this further period of suspension to address the matters found proved by the first panel. The panel remind Ms Petrova that only by demonstrating that she has 11
remedied her practise and developed full insight into her failings will she be able to practice without restriction as a registered midwife. In order to demonstrate this, the panel suggest that a future panel reviewing this case would be assisted by: Ms Petrova s engagement with the NMC; A detailed reflective account to demonstrate that she has developed insight into the importance of having the knowledge and skills for safe and effective midwifery practice; Any evidence of steps taken to remediate and address the lack of competence identified; References and testimonials in relation to any work she has undertaken, currently or previously, whether paid or unpaid and whether or not in a healthcare setting; Evidence of keeping her midwifery skills or knowledge up-to-date. This decision will be confirmed to Ms Petrova in writing. That concludes this determination. 12