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Formal warning for senior nurse who failed to report drug error

A senior nurse at a nursing home where a frail elderly woman died following a medication mix-up has been given a formal warning.

Hazel Gillian Stears was the nurse-in-charge at Morfa Newydd Nursing Home in Flintshire when an 89-year-old woman, named locally as Gwen Cartlidge, was given the wrong medicine.

Mrs Cartlidge had been at the home for two days at the time, a tribunal heard.

The Nursing and Midwifery Council said Ms Stears was not responsible for the tragic error, but had “failed to act inappropriately” once it had been discovered.

“It sends a clear message to the public and the profession that such behaviour is not tolerated”

Naseem Malik

An NMC hearing in Cardiff was told the registrant failed to tell the pensioner’s family and GP, as well as not recording the mistake in her patient’s care notes.

A three-person panel ruled Ms Stears’ actions amounted to misconduct and her fitness to practise was impaired as a result.

However, it decided against taking the ultimate sanction and banning the registrant, who had an otherwise “unblemished” career record.

NMC panel chair Naseem Malik instead issued a caution order, which will stay on Ms Stears’ professional record for the next 12 months.

She said: “It is not alleged that Ms Stears was in any way responsible for the medication error, but she failed to act appropriately when she discovered that the medication error had occurred.

“Based on the evidence before it, the panel determined that a caution order was a fair and proportionate response,” she said.

“A caution order would satisfy the wider public interest in that it sends a clear message to the public and the profession that such behaviour is not tolerated,” said Ms Malik. “It was not in the public interest to restrict Ms Stears’ practice.”

The four-day NMC hearing was told that on 2 October, 2011, Ms Stears was the staff nurse of the upstairs section of Morfa Newydd Nursing Home.

At about 9am Mrs Cartlidge – referred to as Resident A by the NMC – needed help eating her breakfast.

The NMC was told that a care assistant went to see her and found a “number of tablets in a pot” on her table.

With the woman’s consent, the care assistant stirred the medication into the porridge and helped feed her.

But shortly after Ms Stears then came into the room with Resident A’s medication – and discovered the wrong prescription had been administered.

The medication she had been given belonged to an elderly man who lived in the downstairs section of Morfa Newydd.

Less than two hours later, Mrs Cartlidge became unwell and went back to bed.

“Resident A’s son visited just as staff had got her into bed,” noted panel chair Ms Malik.

“Ms Stears made no record of informing Resident A’s son that a medication error had occurred.”

The registrant then failed to inform the pensioner’s GP about the mix-up that same day – with doctors only discovering the mistake two days later when Mrs Cartlidge died on 4 October.

The panel said the evidence was enough to find Ms Stears’ misconduct had been proven.

It highlighted strict NMC guidelines saying nurses must “provide a high standard of practice and care at all times” and added the home’s policy on administration errors were “unclear”.

Ms Malik added: “Ms Stears had failed to provide Resident A with a level of care reasonably expected of a registered nurse – therefore exposing Resident A to unwarranted risk of harm.”

“Ms Stears has demonstrated her remorse as well as insight into the incident”

Naseem Malik

Following the misconduct ruling, it then also decided her fitness to practise was impaired as a result.

However, the NMC described the incident an “isolated” one on Ms Stears’ otherwise “unblemished career”. It listed two “aggravating factors” in the case, but five mitigating ones.

Ms Malik said; “Resident A was an elderly lady whose condition was extremely frail at the time of her transfer to the home…(but) Ms Stears made early admissions to the charges, the incident was isolated relating to one patient (and) Ms Stears has demonstrated her remorse as well as insight into the incident.”

The panel also noted the home was a “challenging” one where drug procedures “appeared to vary”.

Ms Malik added: “The panel concluded that, in all the circumstances, the misconduct in this case was at the lower end of the spectrum of impaired fitness to practise.

“Furthermore, the panel did not consider that there was any evidence of general incompetence or specific areas of Ms Stears’ practice in need of assessment or retraining,” she said.

“The panel was satisfied that a caution order, in this respect, would keep in the forefront of Ms Stears’ mind that she needs to be aware of the conduct expected of a nurse.”

The caution order will stay on Ms Stears’ record for one year. It means the registrant will have to disclose the formal warning to any current or future employer about the sanction for the next 12 months.

It is still unknown how the medication mix-up occurred – and whether the mistake was caused by staff or another patient.

The Morfa Newydd Nursing Home was last inspected by the Care and Social Services Inspectorate Wales in September 2013. Its report identified a number of areas needing improvement.

Readers' comments (20)

  • michael stone

    'The Nursing and Midwifery Council said Ms Stears was not responsible for the tragic error, but had “failed to act inappropriately” once it had been discovered.'

    An 'in' too far, surely ?

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  • I am sorry to learn of the situation and pain and suffering for patient, family, nurse, and facility.

    When I read stories like this I have lots of questions about staffing and resources that involve organizational accountability along with the nurse's.

    This post helps to explain my reasoning.

    "Shortcuts in Medication Administration: Why Do We Do It Wrong If We Know How to Do It Right? (and We Do!)"

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  • We know the level of responsibility is high,
    It is suggested by the NMC, Nursing Care Managers:
    Have implied responsibility.
    Regards all issues within the workplace,
    Also, It has been stated and suggested in past cases, Even when not personally on Duty.
    I welcome more guidance, and debate here The fact serving Police officer's, have less duty of care, then Health workers, is an muted point, beyond reasonable doubt, 100% or balance of probability, 51%

    Is it time for a change, YES, we need to educate and be open to change and learn by are mistakes, embrace them own them.

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  • Much of the tragedy is contained in this sentence: "It is still unknown how the medication mix-up occurred – and whether the mistake was caused by staff or another patient."


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  • "failed to act inappropriately"? So, this nurse failed to do the 'right thing' which would have been appropriate, or failed to do the 'wrong thing' which would have been inappropriate? Confusing. Sounds like the nurse who discovered, was alerted about the administering nurse's medication error but did not take 'appropriate' action to follow up on the error. Therefore, the senior (presiding head nurse) did not follow hospital policy regarding medication errors--and by failing to act was 'inappropriate' in her duties.

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  • It seems that this frail lady was killed by a gross fatal error. Then surely some one was responsible and accountable here she did not do this to herself. How can such a lot of errors occur at one time and be excusable. This is wrong on so many levels.

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  • We need to understand why the wrong patient's medication was in the ladies room to start with. My understanding is that medication should only be signed for once it has been given/administered and this instance calls into question administration of medication policy in this nursing home. Perhaps the CQC should look at this standard by carrying out an inspection there.

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  • The report says "senior nurse." This unfortunate nurse was a "staff" nurse. Since when was a "Staff nurse" senior? when the only other staff are untrained HCA's perhaps? In every trust I have worked in "staff" nurses are not senior, and have little management experience.

    Due to the "leniency" of the judgement, there are obvious flaws in the homes staffing and management system.

    And why haven't the 5 mitigating circumstances in the case been reported? Is it that there would then be sympathy with the poor staff nurse involved who now has the weight of all this on her shoulders? Is it because the finger would then be pointed at the poor management practice of the nursing home?

    This appears to be a terrible accident in which one staff nurse has been hung out to dry and now has to bear this burden on her shoulders for life. My heart goes out to her as well as the family of the unfortunate lady.

    Take this article as a warning shot. The journalism will always be heavily weighted against the nurse.

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  • michael stone

    I'm guessing - and only guessing - that:

    'Mrs Cartlidge had been at the home for two days at the time, a tribunal heard.'

    might have something to do with this ?

    If staff are busy, and 'something is new/changed' then that does presumably increase the risk of this type of mistake happening.

    And although this type of thing has to be prevented from happening, I do agree that this expectation that the senior nurse 'oversees everything' is at times an impossible expectation.

    However, she was - from the title - only 'formally warned': she wasn't struck off (and the NMC, which is far from perfect, does need to be seen to be trying to prevent patient harm: which was a death in this case - the NMC cannot just 'ignore' that the unfortunate lady dies, can it ?).

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  • I administered a wrong drug noticed by relatives. Informed my superior, notified GP on call, completed incident form and monitored patient. Nothing more was said.
    Sorry, if this nurse knew the wrong medication had been given then she is to be held responsible for the demise of this patient if it was found to be caused by the medication error.
    I think she was very lucky to be let off so lightly.

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  • Hold on says that "Mrs Stears was not in any way responsible for the medication error......."

    You actually administered a wrong drug!

    Good for you that you reported appropriately. Pat on the back.

    But I am presuming that you are not very long in the tooth as you are so condemning. Walk a mile in another's shoes before you start to rig up a noose for other nurses.

    I am a senior nurse, band 8a, and have witnessed many good, kind and well meaning nurses demolished and crestfallen not only by management and omissions of procedure; but totally crushed by those who are busy knitting at the bottom of the guillotine.

    Mrs Stears was NOT "responsible for the patients demise" as you allege. In other words, she did not killl that patient. She made an error of not reporting appropriately what others had done. She was expected to act as a senior nurse when in fact she was being paid as a staff nurse.

    This says more about the system of caring for the elderly, nursing homes, and looking after the wellbeing of the staff who work in these places, than it does this particular incident.

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  • "The panel did not think there was any evidence or general incompetence or specific area's of Ms Stears practice in need of assessment or retraining."

    If you live in glasshouses, (as we all do), you should not throw stones! A lady has died, we dont know what of, the drug error could have been only a small contributory factor, we dont have the coroners report.

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  • I have noticed more nursing homes are being given over to HCAs for not only care but administration of medication, contacting doctors etc. A staff nurse is employed so it can be called a nursing home. The lone nurse is carying a heavy responsibility on their shoulder.
    I have worked with Carers looking after the Elderly in Homes and Hospital and this I can say for sure, monitoring their work and making sure they deliver the right care is a tough job.

    Now if the carer did not stir the medication into the porriage, the nurse coming in with the correct medication would have had a good chance of giving the patient the correct medication as she did come in after with the patient's medication.
    If a carer is helping to give medication to a patient it is usually that the nurse has too much to do in too short a time frame.

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  • This article identifies more questions regarding the culture of the orgainisation in which the adverse event occured.

    Medication management processes and protocols need an immediate review and update. How it could be acceptable for the medication to have been left unattended and accessible to other patients (re: "and whether the mistake was caused by staff or another patient"). Failure of the Care assistant to confirm (by theappearance of the medication at least) that the medication was prescribed for the patient prior to administration (should the medication chart have been checked prior to administration).

    Unfortunately, although it appears that the staff nurse acting as the senior for the shift may have been "hung out to dry", and that the findings were that "she was not responsible for the patient's death" it is important to remember that early notification of the incident could have resulted in a very different outcome for the patient. Even if this were unlikely, failure to notify is negligence, particularly where the health of another is at stake.

    The article appears to be aiming to demonstrate that the community can feel safe that failure to report is not acceptable. Good on this attitude. It fails, however, to identify that the catre Assistant that inadvertently administered the incorrect medication would have also been aware of the error, and they also failed to report the error.

    What is the organisation itself going to do to address the culture currently existent where staff find it acceptable to expect only senior staff to report errors that occur.

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  • Hold on 9.47. I did not suggest that the nurse was responsible for the demise of the patient. Only that if it was proved that the wrong medication had been given.
    Yes I am very long in the tooth 67, So I was trained in the 60's. Actually first trained as an RSCN so am acutely aware of giving the right meds and the correct doses.

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  • We want a system in which residents and relatives can have confidence. It seems this was far from the case in this particular home at the time of the incident. It cannot be acceptable that a care assistant is able to assume that a pot of tablets belongs to the nearest resident, nor that medication is concealed within food.
    The fact that the resident was new to the home should be a red flag, ensuring that nothing is done to or for that resident without reference to the care plan until everyone is familiar with him/her.
    The error having been discovered, how did it not occur to the staff nurse that advice needed to be sought from the GP or pharmacist as a matter of urgency, and certainly before any further medication was administered. There is no indication whether anything could have been done to save this lady but, if so, being in a position to seek help and failing to do so could have contributed to her death.
    The Staff Nurse was unfortunate to have been part of a very inadequate regime, but fortunate that the hearing did not just hang her out to dry.

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  • The NMC never takes account of or examines organisational/structural factors contributing towards harm caused to the patient because, no matter how relevant, it is not part of the NMC remit to do so.

    This is why so many dedicated registrants who work in extremis to make a flawed systems work risk their registration on every single shift they take charge of. The fact they are unaware of this does not alter the fact.

    The manager of this Home will be thanking their God that the NMC has no brief for them.

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  • The Health Care Assistant should have been given the go ahead from the nurse to help the patient with the medication, not just say they patient was in the affirmative for this administration.
    Health Care Assistants must also be accountable for their actions.
    The nurse was wrong not to report the error. I wonder if fear got the better of her.
    Nurses every day is working in fear all over this country, this has to stop.

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  • The home where my mother lives has owners who fail to keep employed a registered home manager and so the manpower, organisation and care is short as the owners are ignorant and bully staff to withhold decent care. I am communicating about this to the relevant authorities but only the CQC are doing anything and very slowly. The NHS Clinical Commissioning Group and Social Services Safeguarding are a bad joke, vicious with it. The home have not contacted a GP and have been deliberately misleading twice, once regarding a pressure ulcer. The staff turnover is so high that you do not get the nurses names and it seems that some who have simply described themselves as nurses, nothing else, may not be on the NMC register.

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  • an interesting read - and your comments raise some valid points. I am reading this articles as I am currently writing my honours project for my Bsc looking at the psychological impact of drug administration errors made by nurses. This case highlights as much as it leaves out - not only that the error was made in 2011 and didn't come before the NMC until 2014. This is not unusual as many of you will know.
    What was the nurse doing in the intervening time? was she sacked from her job? did she resign due to the stress? how did she recover to become competent and confident in her practice again? There is a paucity of qualitative evidence to describe nurses experience of this, but it is something all nurses face each day, and fear of making an error is a reality for most of use.
    I am a senior nurse manager in nursing homes and have been for over 20 years. I would take some issue with some of your comments on the structure and practice of care delivered outside the NHS. In my experience - much of it is very good, and the support from managers and companies excellent. As someone commented - walk a mile in someone's shoes first.

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