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”
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”
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.