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Final panel decision and reasons: What should happen to a nurse whose inaccurate records and inaction led to a patient’s death?

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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

Panel decision

The panel referred to the NMC Code for Nurses and Midwives while deliberating whether the proven facts amounted to misconduct. The panel determined that Nurse A’s actions fell substantially short of the standards expected of a registered nurse, and that he had breached several sections of the NMC Code:

Paragraphs:

1.         You must treat people as individuals and respect their dignity.

16.       You must be aware of the legislation regarding mental capacity, ensuring that people who lack capacity remain at the centre of decision making and are fully safeguarded.

17.       You must be able to demonstrate that you have acted in someone’s best interests if you have provided care in an emergency.

28.       You must make a referral to another practitioner when it is in the best interests of someone in your care.

30.       You must confirm that the outcome of any delegated task meets required standards.

35.       You must deliver care based on the best available evidence or best practice.

42.       You must keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give, and how effective these have been.

54.       You must act immediately to put matters right if someone in your care has suffered harm for any reason.

61.       You must uphold the reputation of your profession at all times.

 

The facts found proved were sufficiently serious to constitute misconduct in a regulatory context. The panel considered Nurse A’s actions in the context of his role as team leader.

The panel next considered whether Nurse A’s fitness to practise is currently impaired and whether he is liable to repeat his misconduct. The panel had careful regard to the issues of insight and remediation. The panel accepted Nurse A’s remorse as genuine. However, despite this, the panel considered that he had failed to demonstrate that he understood the wider impact of his actions. The panel was not satisfied that Nurse A had fully accepted responsibility for his misconduct, as he continued to apportion blame to others.

The panel took into account the training certificates Nurse A had provided and accepted this demonstrated some aspects of his continuing professional development. But the panel felt that it did not address all the identified areas of concern. Whilst the panel accepted that Nurse A had practised without incident in the past five years, the panel had no references before it from Nurse A’s current employer to attest to his current practice. The panel had received a positive testimonial from a work colleague, a specialty forensic psychiatrist. However, this testimonial made no mention of Nurse A’s NMC referral or the charges against Nurse A. Nurse A told the panel that he had not informed his employer of these proceedings against him. Further, Nurse A had not shown evidence of how his management and leadership had changed since the incident.

The panel concluded that Nurse A’s actions had put the patient at unwarranted risk of harm and caused the patient actual harm, brought the profession into disrepute and breached fundamental tenets of the profession. The panel recognised the steps Nurse A had taken in his current clinical practice to address some concerns. However, the panel had no evidence of genuine and focused reflection in relation to the matters found proved. The panel considered Nurse A had not been able to demonstrate the level of insight necessary to satisfy the panel that he has fully remediated his practice. In the absence of sufficient insight or remediation, the panel determined that there remained a real risk of repetition of the misconduct in this case and that Nurse A was liable in the future to place patients at unwarranted risk of harm, bring the profession into disrepute and breach fundamental tenets of the profession. This case involved a potentially avoidable patient death. There was a clear need to declare and uphold proper professional standards. Public confidence in the nursing profession and in the NMC as its regulator would be undermined if a finding of impairment was not made. Accordingly, the panel concluded that Nurse A’s fitness to practise was impaired by reason of his misconduct.

Determination on sanction

The panel made a striking-off order, deciding that a lesser sanction would not be sufficient to satisfy the wider public interest in maintaining confidence in the profession and its regulator and in declaring and upholding proper standards of conduct and performance. Before reaching this decision, the panel weighed public interest with Nurse A’s own interests and took into account the mitigating and aggravating factors. Public interest includes the protection of members of the public including patients, the maintenance of public confidence in the profession and the declaration and maintenance of proper standards of conduct and behaviour within the profession.

The panel took account of the NMC’s ‘Indicative sanctions guidance to panels’ (“ISG”), bearing in mind that the decision on sanction is one for its own independent judgement. The panel recognises that the purpose of sanction is not to punish, although any sanction may have a punitive effect. The panel considered the mitigating and aggravating factors in this case and concluded that Nurse A’s misconduct in its entirety represented a significant and serious departure from the standards expected of him as a registered nurse, and that his misconduct was fundamentally incompatible with him continuing to be a registered nurse.

The panel took into account evidence in relation to the patient’s complex health needs. However, given that Nurse A was a registered nurse who had undergone the relevant training and, in particular, qualified in the field of mental health nursing; it did not consider this to be mitigation in relation to his responsibilities and duties towards the patient during the relevant shifts. The panel considered the available sanctions. It felt that a conditions of practice order would be insufficient to meet public interest concerns, as Nurse A was unable to provide sufficient explanation for his behaviour on the dates in question and the ways in which he was personally accountable. He had not demonstrated sufficient insight for conditions of practice to be an appropriate sanction.

The panel felt that a suspension order was not appropriate. Nurse A’s misconduct was not an isolated incident and took place over two nursing shifts. It involved a series of actions and omissions on his part relating to his lack of leadership and management of the situation, in particular, directly following discovering the patient’s collapse. Nurse A did not ensure that the patient was being cared for and observed in line with his care plan, or properly assess the patient once discovering he had collapsed. Nurse A did not commence CPR or call emergency services or allocate these tasks to another member of staff. These actions seriously compromised the care provided to the patient.

Since the time of the incident, leading up to this hearing, Nurse A had the opportunity to fully reflect upon and seek to remedy the behaviour underlying his misconduct, and develop full insight. The panel had limited evidence of Nurse A’s insight and reflection. The panel noted his recent expression of remorse and regret in relation to the death of the patient. However, the panel did not consider Nurse A to have taken responsibility for his actions. Given the length of time that has now elapsed, the panel considered this to represent an attitudinal problem. Nurse A’s misconduct represented a disregard for professionalism, safe nursing practice and patient care. The panel therefore determined that a suspension order would not be a sufficient sanction. 

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