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Final panel decision: What should happen to a nurse who administered insulin without checking a medication chart?

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Find out how the NMC panel acted in this case. Not yet read the case? Read the charge and background here

The panel stated that nurses occupy a position of privilege and trust in society and are expected at all times to be professional. Patients and their families must be able to trust nurses with their lives and the lives of their loved ones. To justify that trust, nurses must be honest and open and act with integrity.

The panel found that Nurse A has in the past acted, and is liable in the future to act, so as to put patients at unwarranted risk of harm. The panel noted that Nurse A was candid with her employer and acknowledged most errors. Regarding insight however, the panel noted Witness 1s evidence that she “didn’t think that Nurse A understood the full impact of her actions, or the potential for patient harm.

The panel considered that Nurse A had failed to demonstrate significant insight, remorse or reflection into her actions. The panel considered that Nurse A’s actions were remediable. However, it was presented with no evidence of remediation on Nurse A’s part, nor had it seen any evidence of testimonials.

The panel noted that Nurse A has repeatedly expressed that she is no longer working as a nurse and that she wishes to retire. However, the panel could not be satisfied that this was a settled intention on Nurse A’s part. In the light of the significant and persistent lack of insight and remediation on Nurse A’s part, the panel is of the view that there is a real risk of repetition. The panel therefore decided that a finding of impairment is necessary on the grounds of public protection.


The panel decided to make a suspension order for a period of 12 months. The panel assessed the aggravating and mitigating factors in this case as follows: 


  • Nurse A’s actions involved repeated errors in basic nursing practice;
  • There was a potential for risk of harm to Patient A and Patient B;
  • Nurse A demonstrated a significant and persistent lack of insight; and
  • There has been no real effort to address the concerns raised.


  • There were no previous referrals to the NMC in respect of Nurse A’s practice;
  • The evidence demonstrates that Nurse A was well considered by her colleagues; and
  • Nurse A was candid with her employers in respect of the concerns at local level.

Balancing all of these factors the panel concluded that a suspension order was the appropriate and proportionate sanction.

The panel had no evidence before it that Nusre A had repeated this misconduct. The panel noted that Nurse A previously demonstrated a level of remorse at a local level but that there was a significant and persistent lack of insight and remediation on her.

The panel considered that this period of suspension would afford Nurse A a final opportunity to reflect on her misconduct and develop her insight and remediation should she wish to return to nursing. A suspension order would also protect the public whilst it is in force and would be reviewed before its expiry.

The panel determined that, although there has been a clear breach of safe practices, there are in Nurse A’s case mitigating circumstances. Particularly that:

  • No evidence of harmful deep-seated personality or attitudinal problems;
  • No evidence of repetition of behaviour since the incident.
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