Nursing and Midwifery Council Fitness to Practise Committee Substantive Order Review Hearing 1 March 2018 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of registrant: NMC PIN: Mrs Christine Lauder 09C0989E Part(s) of the register: Registered Nurse sub part 1 Adult Nursing (26 June 2009) Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Registrant: Nursing and Midwifery Council: Order being reviewed: Outcome: England Lack of Competence Andrew Gell (Chair, Lay member) Linda Tapson (Registrant member) John Penhale (Lay member) Margaret Dodd Anjeli Shah Not present and not represented in absence Represented by Michelle Terry, Case Presenter Suspension Order for 12 months Conditions of Practice Order for 12 months to come into effect at the end of 20 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 Mrs Lauder was not in attendance, and she was not represented in her absence. The panel was informed that the notice of this hearing was sent to Mrs Lauder on 29 January 2018 by recorded delivery and first class post to her registered address. The panel noted that notice of this hearing was delivered to Mrs Lauder s registered address on 31 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 ). 2
Proceeding in absence The panel then considered proceeding in the absence of Mrs Lauder. 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 Terry, on behalf of the Nursing and Midwifery Council ( NMC ). The panel accepted the advice of the legal assessor. Ms Terry referred the panel to correspondence between Mrs Lauder and the NMC. Mrs Lauder had confirmed that she was not in a position to attend this hearing, she would not be attending and that she was happy for the panel to proceed in her absence. Ms Terry informed the panel that Mrs Lauder had submitted representations for this hearing, and she had not indicated that she would attend a future hearing if today s hearing were to be adjourned. Ms Terry submitted that it was in the interests of justice for this matter to proceed expeditiously, and therefore invited the panel to proceed in the absence of Mrs Lauder. The panel took into account the correspondence between Mrs Lauder and the NMC, including a letter from Mrs Lauder dated 26 February 2018 in which she confirmed that she would not be attending this hearing due to work commitments. In that letter, she enclosed representations and documentations for the panel to consider. The panel considered that Mrs Lauder had voluntarily absented herself from this hearing and that she also intended for this matter to proceed in her absence, and for the panel to consider the submissions that she had made. Mrs Lauder is subject to a substantive order which is due to expire on 20 March 2018. The panel therefore recognised that there was a public interest in dealing with this matter expeditiously. In these circumstances the panel determined that it was in the interests of fairness and justice to proceed in the absence of Mrs Lauder. 3
Decision and reasons on application under Rule 19 At the outset of this hearing Ms Terry, on behalf of the NMC, made an application for parts of this hearing to be heard in private, as there would be references to Mrs Lauder s health. This application was made pursuant to Rule 19 of the Rules. The panel accepted the advice of the legal assessor. While Rule 19 (1) of the Rules provides, as a starting point, that hearings shall be conducted in public, Rule 19 (3) states that the panel may hold hearings partly or wholly in private if it is satisfied that this is justified by the interests of any party or by the public interest. Having heard that there would be references to Mrs Lauder s health, the panel determined to hold those parts of the hearing in private. The panel determined to rule when to go into private as and when such sensitive matters are raised. 4
Decision and reasons on review of the current order: The panel decided to impose a conditions of practice order for a period of 12 months. This order will come into effect at the end of 20 March 2018 in accordance with Article 30(1) of the Nursing and Midwifery Order 2001 (as amended) ( the Order ). This is the first review of a suspension order, originally imposed by a panel of the Conduct and Competence Committee on 15 February 2017 for 12 months. The current order is due to expire on 20 March 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, between 28 December 2013 and 25 October 2014, failed to demonstrate the standards of knowledge, skill, and judgement required to practise without supervision as a band 5 nurse in that:- 1. On or around 29 December 2013 you put Oxycodone into Patient A s syringe driver instead of Morphine; 2. On or around 29 December 2013 you failed to administer IV antibiotics to Patient B; 3. On or around 29 December 2013 you administered the incorrect IV fluids to Patient C; 4. On 4 or 5 March 2014, following a deterioration in Patient D s condition you failed to; a) notify the on-call medical team that Patient D s condition had deteriorated; b) take hourly observations of Patient D; 5. On 24 and/or 25 October 2014, with regards to Patient E you failed to; 5
a) administer IV fluids to Patient E; b) administer a phosphate enema; c) seek assistance from colleagues to ensure that Patient E received that IV fluids and/or a phosphate enema was administered; 6. On 24 and/or 25 October 2014, following a deterioration in Patient F s condition you failed to; a. notify the medical team that Patient F s condition had deteriorated; b. take repeat observations ; c. take blood cultures. 7. On 24 and/or 25 October 2014 you failed to administer PRN pain relief to Patient G; 8. On 24 and 25 October 2014 you failed to check Patient H s syringe driver or in the alternative, failed to record the checks you had made on the syringe drive checklist; 9. During the period of 23 to 25 October 2014 with regards to Patient I you failed to; a) ensure that Patient I received high-flow oxygen; b) handover to your colleagues that Patient I had received a chest x-ray which required a review by the medical team; The original substantive meeting panel determined the following with regard to impairment: The panel next went on to decide if as a result of lack of competence Mrs Lauder s fitness to practise is currently impaired. 6
Regarding insight, the panel noted Mrs Lauder s early admissions to the Trust. It considered that Mrs Lauder has limited insight into the effect of her actions with regards charges 1-3. In its consideration of whether Mrs Lauder has remedied her practice, the panel acknowledged the training courses and support mechanisms that were put in place by the Trust during the period of supervision required under the action plan. The panel considered that Mrs Lauder s repetition in failings, some three months following the signing off of her performance improvement plan, demonstrated that her practice had not in fact been remedied. The panel was also concerned that there was no evidence of any further training courses, up to date references, or further reflection on Mrs Lauder s part. The panel is of the view that there is a risk of repetition based on the lack of insight and remediation on Mrs Lauder s part. The panel therefore decided that a finding of impairment is necessary on the grounds of public protection. The panel bore in mind that the overarching objectives of the NMC are to protect, promote and maintain the health safety and well-being of the public and patients, and to uphold the 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. The panel determined that, in this case, a finding of impairment on public interest grounds was also required. This was necessary because public confidence in the nursing profession and the NMC as a regulator would be undermined if no finding was made. Having regard to all of the above, the panel was satisfied that Mrs Lauder s fitness to practise is currently impaired. 7
The original substantive meeting panel went on to determine the following with regard to sanction: The panel then went on to consider whether a suspension order would be an appropriate sanction. ISG paragraph 68 indicates that a suspension order may be appropriate where some of the following factors are apparent: 68 This sanction may be appropriate where the misconduct is not fundamentally incompatible with continuing to be a registered nurse or midwife in that the public interest can be satisfied by a less severe outcome than permanent removal from the register. This is more likely to be the case when some or all of the following factors are apparent (this list is not exhaustive): 68.2 No evidence of harmful deep-seated personality or attitudinal problems. 68.3 No evidence of repetition of behaviour since the incident. 68.6 In cases where the only issue relates to the nurse or midwife s lack of competence, there is a risk to patient safety if they were allowed to continue to practise even with conditions. The panel determined that, although there had been a clear breach of fundamental tenets of the profession, there are in Mrs Lauder s case mitigating circumstances. The panel was aware that the sanction of striking off was not available to them. The period of suspension would afford Mrs Lauder the opportunity to undertake the relevant training required. The panel had no evidence before it that Mrs Lauder had remediated her lack of competence. The panel previously noted that Mrs Lauder had demonstrated very limited insight into her lack of competence and it was of the view that there was a significant risk that she would repeat the behaviour without further training and support. Balancing all of these factors the panel has concluded that a suspension order would be the appropriate and proportionate sanction. 8
The panel noted the hardship such an order will inevitably cause Mrs Lauder. However this is outweighed by the public interest in this case. The panel considered that this order is necessary to mark the importance of maintaining public confidence in the profession, and to send to the public and the profession a clear message about the standard of behaviour required of a registered nurse. The panel determined that a suspension order for a period of 12 months was appropriate in this case to mark the seriousness of the misconduct. 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: A written reflective essay on the impact of her lack of competence on patients and the nursing profession; Evidence of any training course undertaken; Attendance and engagement at any review hearing; and Up to date testimonials. 9
Decision on current fitness to practise This panel has considered carefully whether Mrs Lauder 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 had regard to all of the documentation before it, including a reflective piece written by Mrs Lauder and two testimonials. It took account of the submissions made by Ms Terry, on behalf of the NMC. Ms Terry informed the panel that the original substantive panel had made recommendations as to what this panel may be assisted by. She referred the panel to a reflective piece written by Mrs Lauder, which she submitted illustrated some insight and awareness of the implications of her actions. Ms Terry submitted that it was clear from the reflective piece that Mrs Lauder was now taking responsibility for her actions. Mrs Lauder now appreciated that her actions could have caused serious harm to patients and that her clinical errors fell far below the standard required of a registered nurse. Furthermore, Mrs Lauder had shown an awareness of how her errors could undermine the nursing profession as a whole. Ms Terry referred the panel to the testimonials provided by Mrs Lauder. A testimonial had been provided by the Director of Nursing at Risedale Estates Limited. The Director had confirmed that she was aware of the nature of these proceedings, and that she had previously worked with Mrs Lauder. She stated that she would be happy to offer Mrs Lauder a period of supervised practice, if the panel considered this to be an option. She said that she believed Mrs Lauder would respond positively to retraining. Ms Terry submitted that although Mrs Lauder had developed insight into her failings, she had not had an opportunity to demonstrate safe and effective practice, given that she has not been practising as a nurse or in another healthcare environment. Ms Terry 10
submitted that a risk of repetition remained. Ms Terry invited the panel to find that Mrs Lauder s fitness to practise remained impaired on the grounds of public protection and in the wider public interest. The panel 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 Mrs Lauder s fitness to practise remains impaired. The panel recognised the positive steps that Mrs Lauder had undertaken whilst being subject to a suspension order. She had reengaged with the NMC s proceedings, expressed a desire to return to nursing practice and she had provided the panel with positive testimonials and a reflective essay. The panel had regard to the latter and considered that Mrs Lauder s insight had developed since the original substantive meeting. She had recognised the impact her failings had, or could have had, on patients and the wider nursing profession. She had expressed remorse, and a determination not to repeat her failings in the future. The panel went on to consider whether Mrs Lauder had taken any steps to remedy the failings in this case. The panel noted that there was no evidence that Mrs Lauder had undertaken any training in relation to the risks identified, by the original substantive meeting panel. Mrs Lauder had not been working in a healthcare environment, where she could demonstrate any improvement in her clinical skills. Whilst recognising the positive steps Mrs Lauder had taken, the panel considered that the failings in this case had not been remedied. Therefore, a risk of repetition remained. The panel therefore determined that a finding of impairment was necessary on the grounds of public protection. The panel bore in mind that its primary function is to protect patients and the wider public interest which includes maintaining confidence in the nursing profession and 11
upholding proper standards of conduct and performance. The panel determined that a finding of impairment remained necessary on public interest grounds. For these reasons, the panel finds that Mrs Lauder s fitness to practise remains impaired. 12
Determination on sanction Having found Mrs Lauder 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 29 of the Order. The panel also took into account the NMC s Sanctions Guidance ( SG ) and bore in mind that the purpose of a sanction is not to be punitive, although any sanction imposed may have a punitive effect. The panel first considered whether to take no action, but concluded that this would be inappropriate as it would neither protect the public nor satisfy the wider public interest. The panel then considered whether to impose a caution order but also concluded that this would be inappropriate, given that it would not restrict Mrs Lauder s practice. The panel determined that a caution order would not protect the public nor satisfy the wider public interest. The panel next considered whether to impose a conditions of practice order. The panel noted that Mrs Lauder had engaged with the NMC s proceedings and had expressed a desire to take steps to return to safe nursing practice. She had demonstrated insight and a willingness to address her failings. In these circumstances the panel considered that there was evidence that Mrs Lauder would respond positively to retraining. The panel considered that this was supported by the testimonial from the Director of Nursing at Risedale Estates Limited, offering Mrs Lauder a period of supervised practice at St Cuthbert s Care Home. The panel recognised that this Director had previously worked with Mrs Lauder, and was willing to offer her a position with support, training and supervision. In these circumstances, the panel considered it was possible to formulate practical and workable conditions which could facilitate Mrs Lauder s return to safe nursing practice, in a controlled working environment. The panel determined that a conditions of practice order would protect the public. The panel recognised that there was a wider public interest in facilitating the return of a nurse to safe and effective practice, and therefore considered that a conditions of practice order would also uphold confidence in the nursing profession. 13
The panel considered whether to impose a suspension order but considered that this would be disproportionate in circumstances where it was possible to formulate workable conditions of practice. Accordingly, the panel determined, pursuant to Article 30(1) (c) of the Order, to make a conditions of practice order for a period of 12 months, which will come into effect on the expiry of the current order. It decided to impose the following conditions which it considered are appropriate and proportionate: 1. At any time that you are employed or otherwise providing nursing services, you must place yourself and remain under the supervision of a workplace line manage, mentor or supervisor nominated by your employer. Such supervision to consist of: a) Working at all times on the same shift as, but not necessarily under the direct observation of, a registered nurse of band 6 or above, who is physically present in or on the same ward, unit, floor or home that you are working on; b) Weekly meetings to discuss your clinical caseload, with a particular focus on managing deteriorating patients, escalating concerns and providing safe and effective care to these patients. 2. You must work with your line manager, mentor or supervisor (or their nominated deputy) to create a personal development plan designed to address the concerns about the following areas of your practice: a) Administration of medication; b) Escalation of concerns particularly in relation to patient deterioration; c) Good practice in handing over and taking over patient care; d) Safe practice in caring for a deteriorating patient. 3. You must meet with your line manager, mentor or supervisor (or their nominated deputy) at least every four weeks to discuss the standard of your performance and your progress towards achieving the aims set out in your personal development plan. 14
4. You must forward to the NMC a copy of your personal development plan within 28 days of the date on which these conditions become effective or the date on which you take up an appointment, whichever is sooner. 5. You must send a report from your line manager, mentor or supervisor (or their nominated deputy) setting out the standard of your performance and your progress towards achieving the aims set out in your personal development plan to the NMC, at least every three months and before any NMC review hearing or meeting. 6. You must allow the NMC to exchange, as necessary, information about the standard of your performance and your progress towards achieving the aims set out in your personal development plan with your line manager, mentor or supervisor (or their nominated deputy) and any other person who is or will be involved in your retraining and supervision with any employer, prospective employer and at any educational establishment. 7. You must disclose a report not more than 28 days old from your line manager, mentor or supervisor (or their nominated deputy) setting out the standard of your performance and your progress towards achieving the aims set out in your personal development plan to any current and prospective employers (at the time of application) and any other person who is or will be involved in your retraining and supervision with any employer, prospective employer and at any educational establishment. 8. You must not administer medication until assessed as competent to do so by your line manager, mentor or supervisor (or their nominated deputy). 9. You must notify the NMC within 14 days of any nursing (whether paid or unpaid) you accept within the UK or elsewhere, and provide the NMC with contact details of your employer. 15
10. You must inform the NMC of any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 14 days of you receiving notice of them; 11. 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 midwifery, provide the NMC with the name/contact details of the individual or organisation offering the post, employment or course of study; 12. 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 (11) 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) where you are applying for any nursing appointment; 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). This order will be reviewed shortly before it is due to expire. This decision will be confirmed to Mrs Lauder in writing. That concludes this determination. 16