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What should happen to a nurse charged with failing to ensure that a patient was promptly reviewed?

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A case study showing an example of a nurse who was charged with contributing to a reduction in a patient’s chance of survival and how their case was brought before a fitness to practise panel

The charges

Nurse A was charged with failing to ensure that Patient A was promptly reviewed by medical staff when she knew or, alternatively, should have known that the patient had a high National Early Warning Score (NEWS). It was alleged that this contributed to a reduction in patient A’s chance of survival; and that at or around 5:15am, she left the ward unattended by a nurse for approximately five minutes. She did not complete an incident form following Patient A’s death.

The background

The charges arose while Nurse A was employed as a nurse by an NHS trust in Hertfordshire.

Nurse A was working in the obstetrics and gynaecology department and had returned to work following a week of annual leave. Patient A was admitted to A&E from the care home in which she lived and had complex care needs. Patient A was reviewed by a doctor at 5pm for a prescription of intravenous fluids and a NEWS of 6 was recorded.

Ms 2 took Patient A’s observations at around 9:20pm and was unable to obtain a blood pressure (BP) reading. She made an entry on the NEWS chart indicating this. Ms 2 said that she informed Nurse A and Nurse B that she had been unable to take Patient A’s BP. Nurse B took Patient A’s observations at midnight, escorted her to bed and commenced oxygen therapy. She recorded observations (including BP) in the nursing continuation notes. Nurse B also checked Patient A’s BP at 00:30 and made a record in the notes. Nurse B said that she bleeped the doctor at this time, however, the record of bleeps made did not support this.

By 5am, Patient A was cold and clammy with low BP. A doctor was called and observations conducted at 5.45am. While the doctor was attending to Patient A, she suffered a cardiac arrest. Resuscitation was unsuccessful and Patient A was pronounced dead at 6.30am.

At the hearing

Nurse A admitted the third and fourth charges and these charges were found proved by way of admission. The panel found the first charge to be proved. The panel noted that Nurse A was in charge of the ward.

The allocation of this role was agreed by the night nurses on a shift by shift basis; she was the more experienced of the two nurses on shift and had worked on the ward for over 28 years. The panel was informed that neither registered nurse was allocated specific patients; there were 16 patients on the ward that night and both nurses had a responsibility for all those patients.

Ms 2 stated in her written evidence that she had informed Nurse A and Nurse B that she had been unable to take a BP reading from Patient A at 9.30pm. She stated that both Nurse A and Nurse B were standing at the nurses’ station at the time. Nurse B responded and said she would find a manual BP device. In Ms 2’s oral evidence she stated that she told both nurses of her other concerns about Patient A. Nurse B could not recall her saying anything other than that she had been unable to take a BP reading, and there was no other evidence of Ms 2 raising concerns about Patient A’s condition at this time in her written evidence. Nurse A stated that she could not recall this conversation, and even if she had heard it, Nurse B had indicated she would deal with it and, the matter would not concern her.

The panel determined that Patient A’s low BP and the unanswered bleep to the medical team should have raised concern. 

Results of the fitness-to-practise panel


The ftp panel can impose four different sanctions: 

  • Not impaired: the panel finds that the registrants’s fitness to practise is not impaired; therefore they can continue to practise
  • Caution: the nurse or midwife is cautioned for their behaviour, but is allowed to practise without restriction

  • Conditions of practice: this will prevent a registrant from carrying out certain types of work or working in a particular setting, it may require them to attend occupational health or do retraining. The order can be applied for up to three years and must be reviewed by an FTP panel again before expiry
  • Suspension: the nurse or midwife will be suspended from practice for a period of initially not longer than one year, but this can be extended after review by an FTP panel

  • Striking off: a nurse or midwife is removed from the register and not allowed to practise in the UK. The nurse or midwife must apply to be readmitted to the register

Share what you believe is the right action for the NMC panel to take below and then find out what they decided: Final panel decision and reasons

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