Nursing and Midwifery Council Fitness to Practise Committee Substantive Order Review Meeting 2 July 2018 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE Name of registrant: NMC PIN: Susan Hunter 76E2787E Part(s) of the register: Registered Nurse Sub Part 1 Adult Nursing November 1979 Nurse Independent, Supplementary Prescriber June 2004 Area of Registered Address: Type of Case: Panel Members: Legal Assessor: England Misconduct Richard Davies (Chair, lay member) Jodie Banner (Registrant member) Julia Thompson (Registrant member) George Alliott Order being reviewed: Outcome: Conditions of Practice Order (3 months) Striking off order to take effect on the expiry of the current order on 16 August 2018 in accordance with Article 30(1) 1
Service of Notice of Hearing The panel was informed that the notice of this hearing was sent to Susan Hunter on 11 May 2018 by recorded delivery and first class post to her registered address. The panel was provided with an email from Royal Mail referring to signed for items that had been delivered but without a signature being obtained. However, none of the reference numbers in the email appeared to correspond with the reference number on the recorded delivery despatch document in the proof of posting pack. In any event service is proved by proof of posting which the panel had. The panel noted that on the last review there was some evidence that Susan Hunter may have left her address on the Register. However, it is Susan Hunter s duty as a registered Nurse to inform the NMC of any change of address. 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 impose a Striking off order. This order will come into effect at the end of 16 August 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 conditions of practice order originally imposed by a Conduct and Competence Committee on 14 April 2016 for 18 months. The order was reviewed on 4 October 2017 when the conditions of practice order was extended for 6 months. The order was further reviewed on 6 April 2018 when the conditions of practice order was further extended for 3 months. The current order is due to expire on 16 August 2018. 2
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 as a Lead Nurse by The Hurley Group between 2010 and 2015 1. Administered a Pre School Booster to one or more of the patients listed in Schedule 1 when an Infant Vaccination should have been administered 2. On 5 August 2014, in relation to Patient 8's prescription for 20mg of Atorvastatin 2.1.1. did not review the patient's prescription and/or record that you had reviewed the patient's prescription 2.1.2. did not alter the patient's prescription 3. On 27 August 2014 increased Patient 7's prescription for Perindopril without taking the patient's blood pressure on three occasions and/or recording that you had taken the patient's blood pressure on three occasions 4. On 16 September 2014, in relation to Patient 16 4.1.did not record whether the patient's wheeze was present on inspiration or expirations 4.2.did not record the patient's normal respiration rate 4.3. did not consider asthma when diagnosing the patient and/or record that you had considered asthma when diagnosing the patient 3
5. On 16 September 2014, in relation to Patient 17 5.1.Did not record the site of the patient's pain and/or the patient's temperature 5.2.Prescribed Amoxicillin without clinical indication 6. On 16 September 2014, in respect of Patient 19, did not make a record of the consultation with the patient 7. On 1 October 2014 and in respect of Patient 2 7.1. incorrectly recorded that the patient had 'excellent control' when the patient did not have excellent diabetic control 7.2. in relation to the patient's prescription for Metformin 7.2.1. did not review the patient's prescription and/or record that you had reviewed the patient's prescription 7.2.2. did not alter the patient's prescription 8. On 1 October 2014 did not provide advice to Patient 13 on how to look for signs of infection and/or did not record that you gave Patient 13 advice on how to look for signs of infection 9. On 1 October 2014, did not review Patient 15's prescription for 80mg of Glicazide and/or record that you had reviewed Patient 15's prescription for 80mg of Glicazide 10. On 9 October 2014, in respect of Patient 24 4
10.1. in relation to the prescription for Amoxicillin 10.1.1. incorrectly recorded a prescription for 212 capsules of Amoxicillin 10.1.2. prescribed Amoxicillin without clinical indication 10.1.3. did not record a rationale for prescribing Amoxicillin 10.2. did not record the duration of the patient's sinusitis 11. On 9 October 2014, in respect of Patient 25 11.1. prescribed 28 500mg tablets of Naproxen when only 14 500mg tablets of Naproxen should have been prescribed 12. On 9 October 2014, in respect of Patient 28 prescribed Flucloxacillan without providing a rationale for the prescription and/or without clinical indication 13. On 14 October 2014, in relation to Patient 8 13.1. incorrectly recorded that the patient's diabetic control 'could be improved' when the patient had good diabetic control 13.2. in relation to the patient's prescription for Metformin 13.2.1. increased the patient's prescription without clinical indication 13.2.2. did not record a rationale for increasing the patient's prescription 5
14. On 24 October 2014 and in respect of Patient 32 14.1. prescribed Flucloxacillin without clinical indication and/ or did not record a rationale for prescribing Flucloxacillin 14.2. Prescribed Gentisone without clinical indication and/or did not record a rationale for prescribing Gentisone 15. On 24 October 2014 and in respect of Patient 33 15.1. did not prescribe hydrocortisone cream 15.2. did not advise the patient to purchase hydrocortisone cream and/or record that you had advised the patient to purchase hydrocortisone cream 15.3. did not record how long the patient had had a rash 15.4. did not record the extent of the rash 16. On 24 October 2014, did not ask Patient 34 whether she was pregnant prior to prescribing Trimethoprimand/or did not record that you had asked Patient 34 whether she was pregnant prior prescribing Trimethoprim 17. On 24 October 2014, in respect of Patient 36 17.1. prescribed 125mg Amoxicillin when you should have prescribed 250mg 17.2. did not record the duration that the patient should remain on Amoxicillin 6
17.3. did not consider whether bronchodilator therapy would be suitable for the patient and/ or did not record that you had considered whether bronchodilator therapy would be suitable for the patient 18. On 24 October 2014, prescribed Patient 37 62.5mg of Amoxicillin when you should have prescribed 125mg 19. On 24 October 2014 and in respect of Patient 39 19.1. gave incomplete clinical advice to the patient regarding a dog bite and/ or did not record that you gave clinical advise to the patient regarding a dog bite, in that you 19.1.1. did not advise the patient on how to care for the wound and/or record that you advised the patient on how to care for the wound 19.1.2. did not advise the patient on how to look for signs of infection and/or record that you advised the patient on how to look for signs of infection 19.2. administered a Revaxis injection without clinical indication 19.3. did not clean the patient's wound and/or did not record that you had cleaned the patient's wound 20. On 4 November 2014 and in respect of Patient 1 20.1. Did not provide and/or record that you had provided contraception advice to the patient 20.2. Did not record adequate information in relation to the cervical smear, in that you did not record whether there was 7
20.2.1. post coital bleeding 20.2.2. inter menstrual bleeding 20.2.3. a IUCD coil in situ 21. On 4 November 2014, in respect of Patient 4 21.1. incorrectly recorded that the patient's glycated haemoglobin ("HbA1c") 'indicated reasonable control but could be lower' when the patient's HbA1c should not have been lower 21.2. did not review the patient's prescription for Metformin and/or record that you had reviewed the patient's prescription for Metformin 22. On 4 November 2014 and in respect of Patient 10 22.1. Prescribed the incorrect dosage of Erythromycin to the patient 22.2. did not record a rationale for prescribing 125mg/5ml of Erythromycin to the Patient 23. On 4 November 2014 and in respect of Patient 14 23.1. did not record adequate information in relation to your assessment of the patient, in that you did not record 23.1.1. Where the rash was on the patient's body 23.1.2. The patient's temperature And, in light of the above, your fitness to practice is impaired by reason of your misconduct. 8
The first reviewing panel determined the following with regard to impairment: This panel was mindful that the substantive panel of 14 April 2016 had determined that Mrs Hunter s fitness to practise was impaired as she had: 1. In the past brought and may in the future bring the nursing profession into disrepute. 2. Has breached fundamental tenets of the nursing profession and is liable to do so in the future. The panel today considered that it had no new information that would undermine the previous panel s findings or allow it to reach a different conclusion on impairment. Mrs Hunter has not engaged with the NMC and there is no evidence before the panel to demonstrate whether or not she has complied with her conditions of practice order or of any change since the substantive hearing that would enable it to conclude that Mrs Hunter s fitness to practise is no longer impaired. Therefore the panel could not exclude the risk of repetition of the misconduct found proved. Accordingly, the panel found that Mrs Hunter s fitness to practice is currently impaired. The first reviewing panel determined the following with regard to sanction: The panel first considered whether to take no action but concluded that this would be inappropriate in view of the seriousness of the case. The panel decided that it would be neither proportionate nor in the public interest to take no further action. The panel then considered whether to impose a caution but concluded that this would be inappropriate in view of the ongoing public protection concerns. The panel decided that it would be neither proportionate nor in the public interest to impose a caution order. 9
The panel next considered the imposition of a further conditions of practice order. It was mindful that Mrs Hunter has not engaged and has not provided any evidence of compliance with her conditions of practice order. However, the panel was of the view that at this stage a conditions of practice order remains sufficient to protect patients and the wider public interest. It considered that this would give Mrs Hunter another opportunity to engage, comply with her conditions of practice and satisfy a future panel that she has remediated her misconduct and that she is ready to return to unrestricted nursing practice. Accordingly, the panel determined, pursuant to article 30(1), to make a conditions of practice order for a period of 6 months, which will come into effect upon the expiry of the current order at the end of 16 November 2017. This will provide Mrs Hunter with a further opportunity to engage with the NMC should she wish to continue her practice. It decided that the following conditions remain appropriate and proportionate in this case: 1 You must tell the NMC within 7 days of any nursing or midwifery 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 immediately tell the following parties that 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 12. Any organisation or person employing, contracting with, or using you to undertake nursing work. Any agency you are registered with or apply to be registered with (at the time of application) to provide nursing services. Any prospective employer (at the time of application) where you are applying for any nursing appointment. Any educational establishment at which you are undertaking a course of study connected with nursing, or any such establishment to which you apply to take such a course (at the time of application). 10
3 You must tell the NMC about any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 7 days of you receiving notice of them. 4 a) You must within 7 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. b) You must within 7 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. 5. 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 manager, mentor or supervisor nominated by your employer, such supervision to consist of: Working at all times under the indirect supervision of a registered nurse. Weekly meeting with your line manager or supervisor. 6. 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: The treatment and management of diabetes The treatment and management of respiratory disorders, including asthma and chronic obstructive pulmonary disease The administration and management of medications (including vaccinations) Adherence to the NMC s standards of record keeping. 7. You must meet with your line manager, mentor or supervisor (or their nominated deputy) weekly to discuss the standard of your performance and 11
your progress towards achieving the aims set out in your personal development plan. 8. 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. 9. 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 14 days before any NMC review hearing or meeting. 10. At least 14 days before any NMC review hearing you must provide a reflective piece that demonstrates your insight into your failings and the potential impact on patients, the reputation of the profession and the public interest. 11. 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. 12. You must not practise as a nurse independent/supplementary prescriber until you have provided evidence of your updated knowledge with regards to independent supplementary nurse prescribing and have been assessed and deemed competent by a senior registered clinician. This order will be reviewed prior to its expiry and the panel conducting the review may be assisted by the following: Mrs Hunter s attendance; Cogent evidence of compliance with the conditions of practice order; 12
A clear indication by Mrs Hunter of her intentions with regard to her future practice; Evidence of reflection on her misconduct. This order will be reviewed shortly before expiry. At any review the panel may revoke the order or any condition of it, it may confirm the order, or vary any condition of it, or it may replace the order with another order, including with a striking-off order. At any time, Mrs Hunter or the NMC may ask for the order to be reviewed by a panel if any relevant new information becomes available. The second review panel came to substantially the same conclusions and gave the same indications as to what would be of assistance to the subsequent review panel. Accordingly, the second review panel determined, pursuant to Article 30(1) (c) of the Nursing and Midwifery Order 2001, to make a conditions of practice order for a period of 3 months. The second review panel determined that a further three months would allow Mrs. Hunter a final opportunity to demonstrate her intention to continue practicing as a registered nurse and her willingness to engage with these regulatory proceedings. Decision on current fitness to practise The panel has considered carefully whether Susan Hunter s fitness to practise remains impaired. Whilst there is no statutory definition of fitness to practise, the Nursing and Midwifery Council ( 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. 13
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 that it had no new information before it to undermine the previous panel s findings of impairment. Susan Hunter has not engaged with the NMC for some time. She has not provided any information regarding any change of address, about her intentions with regard to her future practice and has not submitted any evidence of remediation, or provided a reflection piece demonstrating her insight. The panel determined that there has been no material change in circumstances. The risk of repetition remains and, if the misconduct were repeated, then there would be a significant risk of harm to patients and public trust and confidence in the nursing profession would be undermined. The panel has borne in mind that its primary function is to protect patients and the wider public interest which includes maintaining confidence in the nursing profession and upholding proper standards of conduct and performance. The panel determined that, in this case, a finding of continuing impairment on public interest grounds and public protection grounds is required. For these reasons, the panel finds that Susan Hunter s fitness to practise remains impaired. Determination on sanction Having found Susan Hunter 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 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. 14
The present panel considered the aggravating and mitigating factors identified at the substantive hearing in April 2016. It agreed that the misconduct involved wide ranging and basic failures in Susan Hunter s nursing practice. She held a senior leadership role line managing others yet did not provide safe and effective nursing care in core skills of record keeping, medicines administration and appropriate treatment and management. The misconduct was not isolated and covered a 4 month period. In the panel s judgment her actions placed patients at unwarranted risk of harm. Save for at the outset, Susan Hunter has not engaged with the NMC. She did not attend the substantive hearing or the two reviews. She has not taken advantage of the opportunities to remedy her misconduct and to demonstrate that she is capable of safe and effective practice. The panel first considered whether to take no action 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 to take no further action. Further, it would not protect the public. The panel then considered whether to impose a caution 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 to impose a caution order. Further, it would not protect the public. The panel next considered the imposition of a conditions of practice order. The panel took account of the fact that previous panels had determined that it was possible to formulate conditions of practice. However, the panel was now at a point where conditions of practice have been in place for over 2 years and Susan Hunter has not demonstrated any potential and willingness to respond positively to training. The panel determined that a conditions of practice order was no longer appropriate as it could not now be regarded as workable or practicable. The panel next considered imposing a suspension order. The panel was not satisfied that Susan Hunter had provided evidence of significant remorse for her misconduct. She had not demonstrated that she had taken any remedial steps or had acquired 15
reliable insight into her failings. The panel had no evidence before it that she had complied with the conditions of practice order imposed upon her. Against this background the panel detected that Susan Hunter had demonstrated a serious attitudinal problem. She had made it abundantly clear that she was very unlikely to engage with NMC proceedings in the future. In these circumstances the panel determined that a period of suspension would not serve any useful purpose. The last reviewing panel made it expressly clear that the 3 month extension of the conditions of practice order was a final chance to demonstrate her intention to continue practising as a registered nurse and her willingness to engage with these regulatory proceedings. She has not taken that opportunity. The panel determined that she has shown a serious departure from the relevant professional standards. There is a continuing potential for harm and a persistent lack of insight into the seriousness of her actions or their consequences. In the panel s judgment her continuing non-engagement with the NMC was fundamentally incompatible with her remaining on the register. The panel determined that it was necessary to take action to prevent Susan Hunter from practising in the future and concluded that the only sanction that would adequately protect the public and serve the public interest was a striking-off order. The panel therefore directs the registrar to strike Susan Hunter s name off the register. In accordance with Article 30 (1) of the Order this striking off order will come into effect upon the expiry of the existing suspension order, namely 16 August 2018. This decision will be confirmed to Susan Hunter in writing. That concludes this determination. 16