Nursing and Midwifery Council Fitness to Practise Committee Substantive Order Review Hearing 21 March 2018 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of registrant: NMC PIN: Part(s) of the register: Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Mrs Cording: Nursing and Midwifery Council: Order being reviewed: Outcome: Mrs Kim Cording 06H0026E Registered Midwife Midwifery (29 August 2007) England Misconduct Hilary Nightingale (Chair, Lay member) Emily Young (Registrant member) Linda Redford (Lay member) John Caudle Anjeli Shah Present by telephone and not represented Represented by Kim Elcoate May, Case Presenter Conditions of Practice Order for 12 months Conditions of Practice Order for 9 months to come into effect at the expiry of the current order, namely at the end of 22 March 2018 in accordance with Article 30 (1) 1
Decision and reasons on review of the current order: The panel decided to impose a conditions of practice order for a period of 9 months. This order will come into effect at the end of 22 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 12 months conditions of practice order. This was originally imposed as a 6 month suspension order by a panel of the Conduct and Competence Committee on 26 February 2016. The current order is due to expire on 22 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, a registered midwife at Derriford Hospital on 16/17 September 2014; 1. Failed to conduct and/or observe hourly testing of Patient A s blood glucose levels; 2. Recorded an entry or entries in Patient A s notes regarding the timing of blood glucose levels which: a) you did not take and/or b) c) you did not witness the patient taking; 3. Recorded an entry or entries in Patient A s notes regarding results of blood glucose levels tests which: a) you did not take and/or b) c) you did not witness the patient taking; 4. At 20:00, 00:12 and 05:30 did not record Patient A s glucose level; 2
5. On one or more occasion failed to keep accurate records and/or failed to keep contemporaneous notes in: a) The nursing notes b) The sliding scale administration record pro-forma; 6. On one or more occasion administered incorrect dose/s of insulin to Patient A; 7. On one or more occasion did not administer insulin to Patient A when required; 8. On one or more occasion failed to sign for the insulin you administered; 9. Did not correctly calculate the amount of insulin required by Patient A at: a) 21:00 b) 23:00 c) 06:39 10. Failed to identify potential hypoglycaemic episodes and take action; 11. Failed to recognise and treat Patient A s hypoglycaemic episode/s; 12.... The second reviewing panel determined the following with regard to impairment: The panel considered whether your fitness to practise remains impaired. While it considered that the insight you have shown into your actions and their consequences has developed since the last hearing, the panel was not satisfied that you had fully taken responsibility for them. The panel was concerned that you have been out of midwifery practice for two and half years, and have not therefore had the opportunity to undertake any 3
supervised practice or demonstrate compliance with the existing conditions of practice order. The panel considered that without evidence of how you have addressed the concerns raised about your practice in a clinical environment, it could not be satisfied that your practice was sufficiently remediated and there was no ongoing risk of harm to the public. The panel therefore determined that a finding of impairment was necessary to protect the public. For these reasons, the panel finds that your fitness to practise remains impaired. The second reviewing panel went on to determine the following with regard to sanction: The panel next considered the imposition of a conditions of practice order. The panel noted the letter, dated 15 May 2017, from the Lead Midwife at St Helier Hospital who was prepared to offer you a practice programme, and the detail provided as to what it would cover. It noted your evidence regarding the level of supervision you expected to receive, and how you planned to practically manage the programme with your other commitments. The panel was impressed that you had taken the time to explore your options and develop a programme that addressed the risk associated with your practice. In light of this, the panel was of the view that a conditions of practice order is sufficient to protect patients and the wider public interest and that conditions could be formulated which would protect patients during the period they are in force. The panel considered that, given your engagement with the process and willingness to remediate your practice, a suspension order would be disproportionate. Further, there is a public interest in returning a midwife to work once her practice has been appropriately remediated. Accordingly, the panel determined, pursuant to Article 30(4)(b) and (d) of the Nursing and Midwifery Order 2001, to vary the existing conditions of practice order and extend it so that it lasts for a period of 9 months, which will come into effect immediately. This period will provide you with the opportunity to 4
demonstrate remediation of your practice. It decided to impose the following conditions which it considered are appropriate and proportionate in this case: 1. You must not work as a registered midwife, other than to undertake supernumerary midwifery work, at all times under the direct observation of a registered midwife of band 7 or above, at St Helier Hospital, Carshalton, Surrey, SM5 1AA. 2. You must secure a practice placement at St Helier Hospital and successfully complete a practice programme of at least 450 hours. This should address the areas of clinical competence in caring for high risk women in pregnancy, labour, and post-natal episodes, to specifically include, but not limited to: a. Diabetes, to include gestational, type 1 and type 2 b. Medicines management c. Monitoring of maternal wellbeing d. Documentation e. Critical decision making and escalation f. Accountability 3. You must forward to the NMC a copy of your practice programme within 14 days of the date on which these conditions become effective or the date on which the practice programme is approved by your supervisor, whichever is sooner. 4. You must provide the NMC with a report from your line manager, mentor or supervisor (or their nominated deputy) about your progress on the practice programme within 14 days of completion of the practice programme, and/or at least 14 days before any review of this order. 5. Before you return to practice, you must be assessed as competent by a senior midwife, band 7 or above, in all areas of the practice programme 5
and send a copy of your results to the NMC within 7 days of you receiving them. 6. You must inform the NMC of any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 7 days of you receiving notice of them. 7. You must within 7 days of accepting any substantive post of employment with St Helier Hospital, 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. 8. 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 (7) above, to them: a. St Helier Hospital b. 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 before its expiry in accordance with Article 30(1) of the Order. At any review, a panel may revoke, extend or vary any condition of the order. At any time, you or the NMC may request an early review of this order. 6
Decision on current fitness to practise This panel has considered carefully whether your 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. It took account of the submissions made by Ms Elcoate May, on behalf of the NMC, and your oral evidence. You told the panel that you have secured a placement on a practice programme at St Helier Hospital ( the Hospital ) and accept that condition 2 of the current substantive order needs to remain in place in order for you to complete that placement. In relation to condition 3, you said that this has been complied with, as Ms 1, the Lead Midwife at the Hospital, who is overseeing the practice programme, has forwarded a copy of the practice programme competency document to the NMC. In relation to condition 4, you said that you asked Ms 1 to send a report detailing your progress in relation to the practice programme to the NMC. However, she had been off sick and had been unable to submit this report. You said that once Ms 1 had returned to work, which you envisaged to be on 26 March 2018, you would ask her to send this report to the NMC. In relation to condition 8, you said that you provided a copy of your conditions to the Hospital. In relation to conditions 1, 5, 6 and 7 you accepted that these remained relevant but that you had been unable to fully comply with them to date. In relation to why you have only been able to complete 100 hours of the practice programme to date, you said that you had other personal commitments during December 2017 and that you also took your time completing the orientation part of the programme. You said that this was in order to build up your confidence, as prior to this you had been out of practice as a midwife for around three years. After completing the orientation part of the programme you said you now felt more confident to move onto the clinical phase of the programme, which would commence on 26 March 2018. You 7
said that you understood the importance of the programme remaining in place and accepted that you still had to work on specific areas of your clinical practice in order to demonstrate that you are capable of safe and effective practice in the future. You said that a 6-9 month extension of the current conditions of practice order would enable you to do this. You said that you are always supervised at work by a Band 7 midwife, and that all of the Band 7 s midwives at the Hospital have been informed of the requirement in condition 1, and have been extremely supportive with what you need to achieve in this regard. Ms Elcoate May referred the panel to an email from you dated 7 September 2017, which stated that you would be starting a practice programme of a minimum of 450 hours at the Hospital. This commenced on 1 November 2017. Ms Elcoate May informed the panel that you have completed 100 hours of this programme, and that you have estimated that if you complete 20 hours a week, you would be able to complete the programme within 17 weeks, alongside your current job. Additionally you have been undertaking supervised clinical work, a number of reflections, reading and research and study days at the Hospital. Ms Elcoate May referred the panel to correspondence from Ms 1, who had provided a copy of the practice programme competency document to the NMC. Within this document it stated that it was intended for the programme to be completed within 6 months, but that a single extension could be made at the discretion of the NMC. Ms Elcoate May invited the panel to consider whether your fitness to practise remains impaired. She invited the panel to assess your oral evidence at this hearing and your attempts to address the concerns of previous panels. Ms Elcoate May submitted that this panel may feel that the concerns of previous panels still remain in place. You have accepted the necessity of the current practice programme in order for you to practise safely as a midwife in the future, and that you still have further work to do to improve your clinical competence. Ms Elcoate May invited the panel to consider whether a risk of repetition remained, and whether the public interest was engaged. She submitted that as you have not been able to fully comply with the current conditions of practice order, your fitness to practise does remain impaired. 8
If the panel were to find that your fitness to practise remained impaired, Ms Elcoate May invited it to consider the relevant action to take. In relation to condition 3 of the current order, she submitted that this has been complied with and therefore the panel may feel it is no longer necessary for this to remain in place. Ms Elcoate May submitted that all other conditions remain relevant, including condition 8, as you would still need to disclose any update of the current conditions of practice order, such as an extension or amendment, to your employer. She submitted that the panel may feel it appropriate to extend the current conditions of practice order for a period it saw fit, with any appropriate amendments, to give you the further opportunity to fully comply with the order. 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 your fitness to practise remains impaired. The panel noted that you have started to complete the practice programme at the Hospital, and you have so far undertaken 100 hours, out of a required minimum of 450 hours. Whilst you have completed the orientation part of the programme, you still have yet to commence the clinical phase of the programme. In light of this the panel considered that the current conditions of practice order had not been fully satisfied and that a risk of repetition of the failings in this case remained. The panel therefore determined that a finding of impairment remained necessary on public protection grounds. 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 upholding proper standards of conduct and performance. Whilst you have not completed at least 450 hours of the practice programme at the Hospital, and therefore still have yet to address areas of clinical competence, the panel considered that the 9
public interest remained engaged, in order to declare and uphold proper standards of conduct and performance. The panel therefore determined that a finding of impairment also remained necessary on public interest grounds. For these reasons, the panel finds that your fitness to practise remains impaired. 10
Determination on sanction Having found your 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, though any sanction imposed may have a punitive effect. The panel first considered whether to take no action but concluded that this would be inappropriate in view of the risk of repetition identified as it would not restrict your practice. The panel determined that taking no action would not protect the public and it would not satisfy the wider public interest. The panel then considered whether to impose a caution order but concluded that this would also be inappropriate in view of the risk of repletion identified as it would not restrict your practice. The panel determined that imposing a caution order would not protect the public and it would not satisfy the wider public interest. The panel next considered whether to impose a conditions of practice order. The panel took into account that you have remained engaged with these proceedings and that you have started to complete a suitable practice programme, of which you have undertaken 100 hours. You have also accepted that you still have further work to do to demonstrate that you are capable of safe practice. The panel noted that your employer has been supportive in allowing you to undertake the practice programme, and that Band 7 midwives at the Hospital have also been supportive in supervising your practice, in accordance with condition 1 of the current substantive order. In light of this the panel considered that a conditions of practice order remained practical and workable, and that it was possible to devise conditions which would protect patients during the period in which they were in force and that would satisfy the wider public interest in this case. The panel considered whether to impose a suspension order. It found that you have remained engaged with these proceedings, secured a placement on a practice programme and have commenced this. You wish to complete this programme and return to safe practice. In light of this, and the fact that there is a public interest in 11
returning a midwife to work, the panel determined that a suspension order would be disproportionate. The panel assessed the existing conditions of practice order. It considered that conditions 1, 5, 6, 7 and 8 should remain in their current form. The panel considered that condition 2 should be varied in light of the fact that you have secured a placement on a practice programme. The panel considered that condition 3 should be removed as Ms 1 had forwarded a copy of the practice programme to the NMC. The panel noted that you have not complied with condition 4. However, it took into account that you said this was due to your supervisor being on sickness absence from work. You assured the panel that you intended to ask her to send a report to the NMC when she returns back to work. The panel therefore considered that this condition should remain in its current form. Accordingly, the panel determined, pursuant to Article 30(1) (c) of the Order, to make a conditions of practice order for a period of 9 months, which will come into effect on the expiry of the current order. The panel considered that 9 months would give you sufficient opportunity to complete the remainder of the practice placement programme, noting that you have only completed 100 hours of at least 450 hours. Furthermore, you have yet be assessed as competent to practice by a midwife. In extending and varying the current conditions of practice order, the panel noted from the practice programme competency document that the programme could be subject to a single extension at the discretion of the NMC and decided to exercise that discretion. As such the panel decided to impose the following conditions which it considered are appropriate and proportionate: 1. You must not work as a registered midwife, other than to undertake supernumerary midwifery work, at all times under the direct observation of a registered midwife of band 7 or above, at St Helier Hospital, Carshalton, Surrey, SM5 1AA. 2. You must successfully complete the practice programme at St Helier Hospital of at least 450 hours. This should address the areas of clinical competence in 12
caring for high risk women in pregnancy, labour, and post-natal episodes, to specifically include, but not limited to: a. Diabetes, to include gestational, type 1 and type 2 b. Medicines management c. Monitoring of maternal wellbeing d. Documentation e. Critical decision making and escalation f. Accountability 3. You must provide the NMC with a report from your line manager, mentor or supervisor (or their nominated deputy) about your progress on the practice programme within 14 days of completion of the practice programme, and/or at least 14 days before any review of this order. 4. Before you return to practice, you must be assessed as competent by a senior midwife, band 7 or above, in all areas of the practice programme and send a copy of your results to the NMC within 7 days of you receiving them. 5. You must inform the NMC of any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 7 days of you receiving notice of them. 6. You must within 7 days of accepting any substantive post of employment with St Helier Hospital, 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. 7. 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 (6) above, to them: a. St Helier Hospital 13
b. 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. At any review, a panel may revoke, extend or vary any condition of the order. At any time, you or the NMC may request an early review of this order. This decision will be confirmed to you in writing. That concludes this determination. 14