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What should happen to a nursing home manager after a resident died following a fire incident?

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A manager at a nursing home was charged with failing to ensure a resident’s risk assessment, care plan and smoking care plan were suitable, and the patient died after a fire incident in the home 

Nursing Times you are the panel logo

Nursing Times you are the panel logo

The charge

Nurse A was charged with:

  • Not ensuring that Resident A’s risk assessment and/or care plan were specific to his risks and/or needs;
  • Not ensuring that Resident A’s smoking care plan was specific to his needs;
  • Failing to document and/or carry out an assessment of Resident A’s mental capacity;
  • Failing to document and/or carry out a best interests decision for Resident A;
  • Failing to review resident A’s smoking care plan after becoming aware that he habitually placed clothing around his smoking apron; 
  • Not ensuring that staff members followed/recorded the use of the smoking apron;
  • Not ensuring that staff monitored Resident A while he was smoking/recorded that he had been monitored;
  • Not ensuring that Resident A was wearing his smoking apron;
  • Nurse A’ actions or omissions as set out in any or all of the charges above saw Resident A lose a significant chance of survival.

The background

Nurse A was employed as a manager at a nursing home. Resident A was an 83-year-old man who had been atthe home for 11 years and frequently smoked. He was also registered blind. In November 2015, Resident A was found in the designated smoking room having discarded lit matches. The fire brigade attended and after assessing the incident made recommendations to the home. One of these was to create a smoking care plan for Resident A, which was completed in December 2015.

In February 2016, Nurse A was in the home when Resident A requested to smoke his pipe. He was taken to the designated smoking area and left to smoke, in accordance with his smoking care plan, with supervision on a 30-minute cycle. Around 15 minutes later the smoke alarm went off. Nurse A located the source of the fire in the smoking area, where Resident A’s clothing was on fire. An ambulance was called and Resident A was taken to the local hospital where he died later that month.

At the hearing

The panel recognised the need to safeguard the public interest in this case, which includes the maintenance of public confidence in the profession, and the upholding of proper standards of conduct and behaviour. The panel concluded that Nurse A had put a patient at unwarranted risk of harm; and breached a fundamental tenet of the nursing profession; concluding that at the time of these events, Nurse A’s fitness to practise was impaired by reason of his misconduct.

The panel then considered whether his fitness to practise was currently impaired. It noted that Nurse A had admitted the charges and fully engaged with the NMC. The panel was satisfied that he understood and appreciated the severity of his actions.

The panel took into account Nurse A’s oral evidence and testimonials and references that highlighted his good character, knowledge and practice in an otherwise long and unblemished career. The panel was particularly impressed by Nurse A’s candid disclosure that he had failed to properly address the risks associated with smoking. However, the panel was assured that he has now fully addressed these and shown considerable remorse.

Nurse A provided evidence of the changes that he implemented within the home before and after the incident, which included ensuring that the home is now non-smoking and that staff undertake record keeping, risk assessment training, mental capacity assessments and fire evacuation and use of fire extinguisher training. NT

Results of the fitness-to-practise panel


The FTP panel can impose four different sanctions:

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

  • Suspensions: 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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