Nursing and Midwifery Council Fitness to Practise Committee Substantive Order Review Hearing 9 February 2018 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of registrant: NMC PIN: Grace Arkoh-Ankrah 99J1120O Part(s) of the register: Registered Nurse Sub part 1 Adult Nursing October 1999 Mental Health Nursing February 2008 Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Registrant: Nursing and Midwifery Council: Order being reviewed: England Lack of Competence Anne Asher (Chair, registrant member) Elizabeth Burnley (Lay member) John Vellacott (Lay member) Nicholas Wilcox Virginia Sardeli Not present and not represented in absence Represented by Bryony Dongray, Case Presenter. Conditions of practice order 24 months Outcome: Conditions of practice order extended 8 months, to come into effect at the end of 24 March 2018 in accordance with Article 30 (1) 1
Service of Notice of Hearing The panel was informed at the start of this hearing that Ms Arkoh-Ankrah was not in attendance, nor was she represented in her absence. The panel was informed that notice of this hearing was sent to Ms Arkoh-Ankrah on 10 January 2018 by recorded delivery and first class post to her registered address. The panel was also informed that the Royal Mail Track and Trace system showed that the notice had been delivered on 12 January 2018 and signed for in the name of ANKRAH. Further, the panel noted that notice of this hearing was also sent to Ms Arkoh-Ankrah s representative, Thomas Montford, on 10 January 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). Proceeding in absence The panel then considered proceeding in the absence of Ms Arkoh-Ankrah. The panel was mindful that the discretion to proceed in absence is one which must be exercised with the utmost care and caution. The panel considered all of the information before it, together with the submissions made by Ms Dongray, on behalf of the Nursing and Midwifery Council (NMC), who referred to the case of R. v Jones (Anthony William), (No.2) [2002] UKHL 5. Ms Dongray referred the panel to the letter dated 7 February 2018 from Ms Arkoh- Ankrah s representative, explaining that she would not be attending the hearing and her reasons for this. Ms Dongray invited the panel to proceed in Ms Arkoh-Ankrah s 2
absence. She submitted that it would be in the public interest and of limited prejudice to Ms Arkoh-Ankrah for this hearing to go forward. The panel heard and accepted the advice of the legal assessor. It noted Ms Arkoh- Ankrah s engagement throughout the history of these proceedings and accepted the reasons for her non-attendance put forward via her representative s letter dated 7 February 2018 (stated in full later in this determination). The panel further accepted Ms Dongray s submission that there would be limited prejudice to Ms Arkoh-Ankrah by this hearing going forward, given the detailed submissions from her representative. The panel was satisfied that Ms Arkoh-Ankrah was aware of today s hearing and it was of the view that she had chosen voluntarily to absent herself. It further decided that, in light of the submissions on her behalf, an adjournment would be of little use. Having weighed the interests of Ms Arkoh-Ankrah with those of the NMC and the public interest in an expeditious disposal of this hearing, the panel determined to proceed in Ms Arkoh- Ankrah s absence. Decision and reasons on review of the current order The panel decided to extend the current conditions of practice order by a further 8 months. This order will come into effect at the end of 24 March 2018 in accordance with Article 30 (1) of the Nursing and Midwifery Order 2001 (as amended) (the Order). This is the third review of a substantive order originally imposed by a panel of the Conduct and Competence Committee on 19 February 2015 for 12 months. That panel imposed a suspension order for 12 months, which was replaced by a 24-month conditions of practice order following a review on 18 March 2016. A further review, which concluded on 10 August 2017, took place in order to address issues with the current conditions of practice order. No new order was made at that review. The current order is due to expire on 24 March 2018. 3
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, whilst employed by the Warrington and Halton Hospitals NHS Trust as a staff Nurse, and whilst subject to an action plan / formal capability procedure between 18 February 2011 and 4 June 2012 failed to demonstrate the standards, knowledge, skills and judgement required to practise as a Staff Nurse in that you: Whilst working on Ward A8 between 18 February 2011 and 13 November 2011: 1...: a. 2. On or around 2 March 2011: a. Failed to provide Patient 6 with a drink b. c. 3. On or around 2 June 2011: a. Failed to handover Patient 10's "nil by mouth" status at the end of your shift 4. On or around 11 August 2011: 4
a. Gave a very brief handover to Ms 1 during which you used abbreviations which you did not understand b. Failed to request clarification of abbreviations you did not understand when patients were handed over to you at the start of your shift c. Communicated with staff in a manner which appeared abrupt and/or aggressive d. Communicated with patients in a manner which appeared abrupt and/or aggressive 5. On or around 2 September 2011: a. Reported that Patient 12's mouth was "just a bit red" or words to that effect when Patient 12 had a thrush infection and swollen ulcers b. Failed to show empathy for Patient 12's condition 6. On or around 7 September 2011: a. Failed to gain the consent of Patient 13's family before transferring Patient 13 to a rehabilitation unit 7. On an unknown date between June and October 2011: a. Failed to check Patient 1's blood sugar levels b. Failed to re-dress Patient 1's leg sores 5
c. Did not know that you should not commence suction on the chest drain for Patient 2 before the doctor had specified the correct pressure to be used d. Failed to ensure that Patient 3's pressure sores were covered e. Failed to notify the doctor that the prescription in respect of Patient 5 needed to be altered 8. Between 22 and 28 September 2011 a. Failed to complete fluid balance charts for Patient 20 b. In the absence of an accurate record of urine output for patient 20, scored zero on this aspect of the Modified Early Warning Score (MEWS) Whilst working on Ward A7 between 14 November 2011 and 4 June 2012: 9. On or around 8 December 2011: a. Requested a one:one for Patient 15 without taking steps to find out the reason for the change in his condition b. Failed to request a medical review for Patient 15 for a period of around 45 minutes c. Failed to check how frequently the sedative prescribed to Patient 15 could be administered d. Did not know the steps you should take pre-administration and post-administration of Patient 15 s sedative. 6
10. : a. 11. On or around 1 January 2012: a. Failed to attend Patient 21 when he indicated that he was about to suffer a hypoglycaemic episode b. Failed to demonstrate an adequate understanding of diabetic care 12. On or around 9 January 2012: a. Did not know how Patient 22, who had a pneumothorax with chest drain in-situ, should be cared for 13. On or around 18 January 2012: Patient 23 a. Failed to administer a prescribed dose of calcium resonium to levels b. Did not know the potential consequences of raised potassium 14. On or around 9 February 2012: a. Did not know if any of Patient 24's medications had been altered b. Did not know if Patient 24 had been administered any analgesia 15. On or around 10 February 2012: 7
a. Failed to complete a pain score in respect of Patient 25 b. Failed to complete a bowel chart in respect of Patient 25 c. Did not know the correct steps to take on recording a Modified Early Warning Score of two for Patient 25 d. Failed to record the appearance of Patient 27 s pressure sores 16. On or around 14 February 2012: a. Inadequately completed documentation in respect of Patient 28's chest drain 17. On or around 15 February 2012: a. Caused Patient 33 to be brought up to Ward A7 when there was no bed for Patient 33 b. Failed to handover that Patient 30 was not for resuscitation c. Did not wash your hands prior to taking Patient 31 s blood sugar d. Used poor technique to take Patient 31s blood sugar, resulting in contamination of the test e. Failed to update the careplans of the patients in your care 18. On or around 16 February 2012 you failed the medication competency assessment. 19. On or around 24 February 2012: 8
a. b. Required prompting to complete a food chart for a patient c. Required prompting to change a fluid bag for a patient d. e. 20. On or around 29 February 2012: a. Required prompting to note down the necessary information at the handover of shifts b. Failed to record observations in respect of Patient 39 who had a chest drain in-situ c. Failed to speak with the relatives of Patient 40 who had attended Ward A7 for this purpose d. Gave handover to the late shift at 3.30pm when this should have been done at 1.30pm e. Failed to complete necessary documentation, including fluid balance charts during the course of the shift f. Failed to monitor Patient 43 who was on chest drain suction g. Incorrectly attempted to take blood sugars for Patient 44, who was not diabetic and did not require a blood sugar test at that time h. 9
21. On or around 4 March 2012: a. Failed the medication competency assessment b. Did not know that an anti-emetic could be omitted when a patient was not feeling sick c. d. 22. On or around 3 March 2012: tests a. Failed to complete the necessary blood card for Patient 45's blood 23. On or around 15 March 2012: a. Failed to handover to an oncoming member of staff that a patient had a red buttock area b. Failed to handover to an oncoming member of staff that a patient had very low blood pressure and therefore required four-hourly observations c. Did not know whether or not Patient 46 had had an International Ratio (INR) to test the consistency of his blood d. e. 10
f. Failed to check Patient 46A's feet, despite a note from the doctor mentioning that Patient 46A's feet were discoloured g. Did not know that Patient 46A had swollen and discoloured feet h. Failed to chase referrals for patients, including Patient 47 i. Failed to attend to Patient 47 who had a dry and coated mouth notes j. Required prompting to refer to Care Plans when writing up your k. Spent more than an hour writing up notes for the care given to your patients 24. On or around the weekend of 24-25 March 2012: a. Failed to offer Patient 48 alternative nutrition when he refused breakfast b. Failed to re-check Patient 48's blood sugars after his refusal to take breakfast c. Did not know the correct treatment for a patient with low blood sugar levels d. Required prompting to re-check Patient 48's blood sugar levels after they had been recorded as below a normal level e. Required prompting to re-check Patient 49's blood sugar after they had been recorded as low. f. Failed to administer a second dose of colyamicin to Patient 50 11
g. Failed to carry out risk assessments for Patient 50 25. On or around 7 April 2012: a. Failed to complete observations of any patients for the first three and a half hours of your shift 26. On or around 12 April 2012: a. Failed to complete patient care plans b. Failed to document wound care given to Patient 52 who had a Grade 2 sacral sore c. Failed to carry out an assessment of Patient 52's sacral sore 27. On or around 16 April 2012 a. Gave an inadequate handover of information to oncoming staff b. Recorded Patient 53's respiration rate as 17, when it was in fact 22 28. On or around 18 April 2012: a. Failed to hand over information which was required to enable to the transfer of Patient 54 from Ward A7 29. On or around 19 April 2012: a. Ordered blood for a non-urgent transfusion for Patient 55 for a time when you would not be able to administer it 12
b. Asked a carer to give the blood to Ms 3 to deal with as you did not have time to do so yourself c. Asked a carer to put the blood in a fridge on Ward A7 when this was not correct procedure d. Failed to handover to Ms 4 that Patient 56 had a broken hip e. Had to be asked three times by Patient 57 before you took down the empty blood bag following Patient 57's transfusion 30. On or around 24 April 2012: a. Used the incorrect nebuliser for Patient 59 31. On or around 26 April 2012: a. Recorded in a patient's notes that the Medical Team had "no idea" about the Home Oxygen Therapy required for the patient on discharge, even though they had previously documented the requirement in his notes. 32. On or around 8 May 2012: a. Required prompting to give assistance to Patient 62 who was unwell and short of breath b. Failed to provide an adequate handover Patient 62's condition to the nurse who took over the care of Patient 62 at the time the nurse took over care 13
c. Failed to handover information relating to Patient 62's planned transfer to the High dependency Unit d. Failed to chase up test results for patients allocated to you 33. On or around 10 May 2012: a. Failed to carry out instructions given to you by Ms 2 in respect of Patient 63 and instead handed this patient over to another member of staff 34. On or around 18 May 2012: a. Requested that the ward clerk send a fax referring Patient 64 to the district nursing team, when that fax did not contain: i. Information as to medication dosages ii. The time for the patient's discharge iii. The weight of the patient upon discharge b. Failed to provide Patient 64 with a sharps bin on discharge AND in light of the above, your fitness to practise is impaired by reason of your lack of competence. The reviewing panel of 18 March 2016 determined the following with regard to impairment: The panel considered that although you had demonstrated a level of insight both in your reflective statement and whilst giving oral evidence today, this insight was limited. 14
The panel noted that you had reflected at length on your failings in dealing with patients, patients families and your colleagues. However, the panel considered you had failed to develop full insight as you sought to attribute some of your failings to the pressure you felt you were under from colleagues who were working with you to improve your performance. The panel was concerned that you did not appear to accept that you may be in similar pressurised situations in the future if you return to practise, when your competence may be scrutinised. The panel considers that this might impact upon your ability to fully recognise your limitations. In its consideration of whether you have remedied your practice the panel took into account the fact that you have undertaken a number of training courses. The panel acknowledged that you have taken significant steps to address your failings, however the panel noted that the courses you have undertaken are theoretical. The panel considered that whilst you have made progress, you have not fully remedied your failings as you have not been able to put into practice the theoretical training that you have undertaken. The panel is of the view that there is a risk of repetition based on the fact that you have been unable to demonstrate practical remediation of your failings and you do not have full insight into your failings. 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 was 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 also required given the wide ranging nature of your failings and the lack of opportunity you have had to remedy these. In these circumstances, an informed member of the public exercising reasonable judgment would be concerned to learn you had been allowed back into practice unrestricted. 15
The reviewing panel of 18 March 2016 determined the following with regard to sanction: The panel considered substituting the current suspension order with a conditions of practice order. Your failings were serious; however there has been evidence produced to show that you have developed some insight, that you have undertaken relevant theoretical training and that 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 considered that a further period of suspension would be disproportionate. The panel decided that the public would be suitably protected as would the reputation of the profession by the implementation of conditions of practice Decision on current fitness to practise The panel has considered carefully whether Ms Arkoh-Ankrah s fitness to practise remains impaired. Whilst there is no statutory definition of fitness to practise, the NMC has defined it 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. It has taken account of the submissions made by Ms Dongray on behalf of the NMC, and those made by Mr Montford on Ms Arkoh-Ankrah s behalf, in his letter dated 7 February 2018. Ms Dongray provided the panel with a background to the proceedings. She referred to the communications between the NMC and Ms Arkoh-Ankrah clearly showing that she has not yet embarked on a return to practice course, as required by the current conditions of practice order. Ms Arkoh-Ankrah has not worked as a registered nurse since 2012, and in the circumstances, she has not been able to ameliorate the NMC s 16
concerns, and is therefore still impaired. Ms Dongray noted that it is commendable that Ms Arkoh-Ankrah is attempting to get accepted on a return to practice course and it appears that she may well achieve this in the next 6 months. Ms Dongray invited the panel to continue the current conditions of practice order, as it is currently set out, for a period of 8 months, in order to enable Ms Arkoh-Ankrah to undertake a return to practice course. She will then be in a position to provide more information to a future reviewing panel regarding any progress she has made towards her remediation. The panel noted Mr Montford s letter on your behalf, which stated: I spoke with the registrant as regards the forthcoming hearing at the beginning of last week and also engaged her Course Leader at Liverpool John Moores University on the last working day of that same week. I capture what came up in the numbered paragraphs below: 1. Upon speaking with the registrant at the beginning of last week and a couple of times before then, she led me to understand that she is always willing to cooperate with council and attend all requested hearings and reviews as she has done unfailingly in the past. She however noted that on this occasion there are difficulties in the sense that whilst she thought her placement had been arranged, it turns out that there are still some administrative issues to be ironed out, the same emanate from the conditions of practice. 2. Owing to the difficulty captured as per the last sentence of the previous paragraph, the registrant is of the considered opinion that she needs to be available via telephone throughout the week. If she were to proceed to London to attend the review, she would be unable to access her phone whilst driving to London on Thursday and would also not be able to take calls whilst at the NMC on Friday. 17
3. In addition to the aforesaid, the registrant also drew my attention to the fact that she is not just expected to proceed on the placement but she is undertaking various studies as regards placements, some of which are in her study folder, with others being on line. She equally informed me that she has obtained some academic articles as regards placements, which she had started reading and was also accessing background information on YouTube, to enable her benefit maximally from the provision. She made it clear that her studies around placements would continue till the last minute. 4. I equally spoke with the registrant s course leader at Liverpool John Moores University, who confirmed to me in a telephone conversation that the registrant could either complete the course on 7 June 2018 or in August/September 2018. [ She ] also confirmed that the registrant is expected to undertake personal and university recommended study in relation to placements at the run up to the commencement of the placement itself. In view of the foregoing, the registrant has, with sadness, instructed me to inform you that she would not be able to make it to the NMC organised review this time. She would rather appeal to the NMC to extend the Conditions of Practice in their current form till September 2018 and also push the forthcoming review till then. That way, she would be able to attend in person and showcase all that she has done on the course itself, the placement and privately to the respected panel. 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 Arkoh-Ankrah s fitness to practise remains impaired. It noted that, to date, she has not been able to complete a return to practice course. There has therefore been no change as far as her remediation and she remains a risk. 18
The panel noted that the charges found proved related to a number of wide-ranging issues, and that she has not worked as a registered nurse since 2012. It had no information before it to show that Ms Arkoh-Ankrah had made any progress towards addressing these, apart from applying to undertake a return to practice course. There was also no new information before the panel in respect of any developments in Ms Arkoh-Ankrah s insight. The panel again acknowledged Ms Arkoh-Ankrah s continued engagement in these proceedings and her continued efforts to gain a place on a return to practice course. The outcome of these efforts will be of interest to a future reviewing panel. The last panel determined that Ms Arkoh-Ankrah was liable to repeat matters of the kind found proved. This panel has received no new information that would indicate otherwise. In light of this, the panel determined that Ms Arkoh-Ankrah is liable to repeat matters of the kind found proved, and that a finding of current impairment is necessary on the grounds of public protection. The panel bore 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 current impairment on public interest grounds is required. For these reasons, the panel finds that Ms Arkoh-Ankrah s fitness to practise remains currently impaired. Determination on sanction Having found Ms Arkoh-Ankrah 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 Articles 29 and 30 of the Order. The panel has also 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. 19
The panel first considered whether to take no action, or to impose a caution order, but concluded that either outcome would be inappropriate in view of the risk of repetition identified by this panel and the consequent risk to the public if she were allowed to practice unrestricted. The panel decided that these outcomes would be neither proportionate, nor in the public interest. The panel next considered the imposition of a conditions of practice order. The panel was of the view that a conditions of practice order is sufficient to protect patients and the wider public interest, noting that appropriate and proportionate conditions could be formulated which would protect patients during the period they are in force. It further took into account Ms Arkoh-Ankrah s continued attempts to comply with the current conditions of practice order, and the fact that she appears to be in the process of undertaking a return to practice course in the near future. Accordingly, the panel determined, pursuant to Article 30(1) of the Nursing and Midwifery Order 2001, to extend the current conditions of practice order for a period of 8 months, in order to give Ms Arkoh-Ankrah the opportunity to complete the return to practice course and possibly gain employment as a registered nurse. This order will come into effect on the expiry of the current order. The conditions remain as follows: 1. You must tell the NMC within 14 days of any nursing appointment (whether paid or unpaid) you accept within the UK or elsewhere, and provide the NMC with contact details of your employer. 2. You must tell the NMC about any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 14 days of you receiving notice of them. 3. a) You must within 14 days of accepting any post or employment requiring registration with the NMC, or any course of study connected with nursing or 20
midwifery, provide the NMC with the name/contact details of the individual or organisation offering the post, employment or course of study. b) You must within 14 days of entering into any arrangements required by these conditions of practice provide the NMC with the name and contact details of the individual/organisation with whom you have entered into the arrangement. 4. Before returning to practice you must successfully complete and pass an NMCapproved return to practice programme. The course should address the following areas of competency and you must be assessed as competent in those areas; a) Communication b) Record Keeping c) The assessment, planning, implementation and evaluation of care d) Time management e) Prioritisation of tasks f) Compliance with procedures and policies g) The ability to assess your own performance and limitations in performance. 5. You must immediately inform the following parties 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) to (4) above, to them: a. Any organisation or person employing, contracting with, or using you to undertake nursing work; b. Any agency you are registered with or apply to be registered with (at the time of application); c. Any prospective employer (at the time of application); and d. Any educational establishment at which you are undertaking a course of study connected with nursing or midwifery, or any such establishment to which you apply to take such a course (at the time of application). A future reviewing panel may be assisted by the following: 21
- Ms Arkoh-Ankrah s attendance at the review hearing - A reflective piece focusing on the return to practice course outcomes and relating to the problem areas identified at the substantive hearing. - Any up-to-date testimonials from registered nursing colleagues who have worked with Ms Arkoh-Ankrah during her return to practice course. This decision will be confirmed to Ms Arkoh-Ankrah in writing. That concludes this determination. 22