Conduct and Competence Committee Substantive Hearing January 2015 NMC, 2 Stratford Place, Montfichet Road, London, E20 1EJ

Transcription

1 Conduct and Competence Committee Substantive Hearing January 2015 NMC, 2 Stratford Place, Montfichet Road, London, E20 1EJ Registrant: NMC PIN: Patience Yakwange Kaya 10I3513E Part(s) of the register: Registered Nurse Sub part 1 Adult Nursing September 2012 Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Nursing and Midwifery Council: Patience Yakwange Kaya: Facts proved: Facts not proved: Fitness to practice: Sanction: England Misconduct Martyn Griffiths Lay member, Chair Jane Davis Registrant member Jacki Pearce Lay member Andrew Prynne QC Hannah Procter Represented by Matthew Kewley, Counsel, NMC Regulatory Legal Team Present and represented by Robin Oliver, Solicitor All by admission None Currently impaired Conditions of practice order 12 months Interim order: Interim conditions of practice order 18 months 1

2 Charges That you, whilst employed as a Registered Nurse at Whipps Cross Hospital, on 3 May 2013: 1. Incorrectly administered the following medication to Patient A intravenously instead of orally: 1.1. Ramipril 5mg 1.2. Ranitidine 150mg 1.3. Bendroflumethiazide 2.5mg 2. Did not ensure a second nurse checked the administration of the medication listed at Charge 1 above, before administering the medication intravenously. 3. Signed Patient A s MAR chart to indicate that Patient A s medication in Charge 1 had been administered orally when it had not. 4. Did not seek advice from a doctor or more senior colleague before administering Patient A s medication intravenously. 5. Recorded on Patient A s MAR that you had administered Fortisip when you had not. And in light of the above, your fitness to practise is impaired by reason of your misconduct 2

3 You admitted the facts set out in the above charges in their entirety. In accordance with the procedure set out in Rule 24(5) of the Fitness to Practise Rules, the panel chairman then pronounced each of those charges proved upon the basis of the admissions. The panel then went on to consider the issues of misconduct and impairment. Background Mr Kewley, on behalf of the NMC, and Mr Oliver, on Ms Kaya s behalf invited the panel to consider a written agreed statement of facts. The agreed statement of facts read as follows:- The parties agree as follows: 1. Ms Kaya received her United Kingdom nursing pin number in September On 11 February 2014, the Nursing and Midwifery Council received a referral concerning Ms Kaya s fitness to practise. 3. The referrer was the Barts Health NHS Trust ( the Trust ). At the material time, Ms Kaya was employed by the Trust as a band five staff nurse. Ms Kaya worked at Whipps Cross Hospital ( the Hospital ) and was based on the Cedar Ward ( the Ward ). The Ward is a gastroenterology ward with capacity for 21 patients. 4. On 3 May 2013, Mrs Kaya was working a day shift on the Ward. Ms Kaya was responsible for the care of Patient A. Ms Kaya had not previously cared for Patient A. Ms Kaya had been allocated around four or five patients and was working with a newly qualified nurse. At approximately 08:00, Ms Kaya began to administer Patient A s medication. Patient A had been prescribed 5mg of 3

4 Ramipril, 150mg of Ranitidine and 2.5mg of Bendroflumethiazide. Ramipril and Bendroflumethiazide are used to treat hypertension by lowering a patient s blood pressure. Ranitidine is a medication that is used to reduce gastric acidity and helps to settle a patient s stomach. 5. Patient A s medication was due to be administered orally. Patient A s care notes indicated that the medication was to be administered via the oral route. Prior to Ms Kaya administering the medication, she noticed that Patient A was in fact nil by mouth. Patient A told Ms Kaya that she should not have oral medication. As a result, Ms Kaya decided to crush the medication. Ms Kaya then mixed the crushed medication with saline solution. Ms Kaya injected the medication solution intravenously into Patient A s previously inserted cannula (charge 1.1). 6. As Ms Kaya began to inject the solution into Patient A s cannula, she was observed by Ms 1, Band 6 Ward Sister. Ms 1 confronted Ms Kaya about her actions. Ms Kaya was honest from the outset and explained to Ms 1 that she had crushed Patient A s oral medication and administered the medication intravenously through Patient A s cannula. It is a Trust requirement that intravenous medication should be given in the presence of two nurses, however, Ms Kaya did not get a second nurse to check the intravenous medication (charge 1.2). Ms 1 checked Patient A s notes following the incident. Ms Kaya had signed Patient A s notes to indicate that the medication had been given, but did not indicate that the medication had been given intravenously (charge 1.3). There was no guidance in place at the Trust to indicate what should be recorded on a MAR chart in this situation. 7. Ms Kaya also signed Patient A s notes to indicate that Fortisip had been administered. Fortisip is a dietary supplement that was to be administered orally. 8. Ms Kaya did not seek the assistance of a doctor or a more senior colleague to see whether an alternative route could be prescribed (charge 1.4). 4

5 9. The incident was investigated by Mr 2, a band 7 registered nurse. Mr 2 is also employed as the Trust s Medicines Safety Nurse. Mr 2 stated in his witness statement to the Nursing and Midwifery Council that: It is never acceptable to crush oral medication and administer it intravenously. Medication that is administered intravenously is much faster acting than oral medication as it is administered directly into the vein. Due to this, the doses of IV medications and oral medications can vary significantly as a higher dose of oral medication may have the same effect as a lower dose of IV medication due to the way that this is processed in the body. By crushing and administering oral medication intravenously, the patient may receive a much higher dose of medication that intended by the prescribing practitioner. By crushing oral medication and dissolving it in saline before administering it intravenously, Ms Kaya also placed (Patient A) at risk of embolism, which is a blockage in a blood vessel that could ultimately result in death. 10. Following the incident, the Poisons Information Centre ( PIC ) was contacted to seek advice about the potential consequences of administering the medication intravenously rather than orally. The PIC advised that Patient A should be closely monitored for at least six hours. Consequently, Patient A was transferred to the intensive care unit for close observations. Patient A was due to undergo a stent procedure on 3 May 2013, however, this had to be postponed as a result of the incident. Patient A did not suffer any harm as a result of Ms Kaya s actions. 11. Ms Kaya breached a number of trust policies. In particular: a. Section 3 of the Medicine Management Administration Policy states A registered nurse is responsible for the correct administration of prescribed drugs to patients in his/her care, as delegated to by the use of the patient s medicines administration document (MAR). 5

6 b. Paragraph 3.6 of the Intravenous Drug Policy states All intravenous drugs, fluids and solutions used as dilutents, must be checked and signed on the medicines administration chart by two nurses/midwives, one of whom must have a clear understanding of the principles and practice of intravenous therapy and drug administration 12. Patient A s notes show that at around 09:15 on 3 May 2013, a member of staff explained the morning s incident to Patient A. Patient A is recorded as having been very understanding and accepted our apology. 13. Ms Kaya was interviewed about the incident by Mr 2 on 5 July Ms Kaya accepted that she had been wrong to crush oral medication and administer the medication intravenously rather than orally. Ms Kaya also accepted that she did not ask a second nurse to check the administration of medication to Patient A. Ms Kaya also confirmed during the interview that she had been assessed in the administration of IV medication in January and was aware of the requirement that intravenous medication should be checked by another nurse. Ms Kaya accepted that she had not in fact administered Fortisip, but had signed the MAR chart to indicate that it had been administered. Ms Kaya stated that this was her common practice. 14. Ms Kaya attended a disciplinary hearing on 14 January 2014 during which she advanced a number of matters of personal mitigation. 15. Ms Kaya stated during the investigatory interview I did take it seriously, I had put the patient in danger. What I did was wrong, to this day I do not know what I doing. I was not short on the shift that day, I have never put anyone in danger. I make sure my patient are safe. This day I can only blame myself, I have let everyone down. I can t justify it. 16. Ms Kaya has admitted the allegations throughout the investigation and the disciplinary process. The disciplinary hearing was chaired by Ms 3, Assistant 6

7 Director of Nursing at the Trust. Ms 3 concluded that Ms Kaya was extremely apologetic and appeared to fully understand the potential for harm to Patient A. So far as the facts of the case are concerned, the panel evaluated the matter purely upon the basis of this agreed statement. Decision on misconduct and impairment In determining whether or not your fitness to practise is currently impaired, the panel adopted a two stage process. The panel first considered whether the facts found proved amounted to misconduct. Only if the panel concluded that they did, would it proceed to consider whether your fitness to practise is currently impaired. There is no burden or standard of proof; misconduct and current impairment are matters for the panel s judgment. The panel considered the submissions from Mr Kewley, on behalf of the NMC, and from Mr Oliver, on your behalf, and all the evidence presented to it so far, including your sworn oral evidence. Regarding the question of misconduct, Mr Kewley referred the panel to the case of Roylance v GMC (No 2) [2000] 1 AC 311 and the guidance therein that misconduct is a word of general effect, involving some act or omission which falls short of what would be proper in the circumstances. The standard of propriety may often be found by reference to the rules and standards ordinarily required to be followed by a [registrant] in the particular circumstances. Mr Kewley referred the panel to the NMC document: The code: Standards of conduct, performance and ethics for nurses and midwives (2008) ( the Code ) and drew the panel s attention to the paragraphs which he submitted your acts and omissions had breached. He also referred the panel to the NMC s Standards for medicines management and its relevant provisions which he submitted you had breached. 7

8 In relation to the question of current impairment, Mr Kewley referred the panel to the cases of Cohen v GMC [2008] EWHC 581 Admin and Council for Healthcare Regulatory Excellence v (1) NMC (2) Grant [2011] EWHC 927 (Admin). He asked the panel to consider the issues of your insight and remediation. He submitted that the panel should address any future risk to patients as well as the wider public interest when making its decision. Mr Oliver, on your behalf, accepted that there was some basis on which a finding of current impairment could be made in the public interest. He asked the panel to find that the risk of your behaviour being repeated was very remote. He submitted that the incident was a one-off occurrence that arose from your particular personal circumstances at the time. Further, he submitted that the panel could be reassured by your testimony that you would now recognise if you were beginning to experience similar personal circumstances and would handle it appropriately. The panel heard and accepted the advice of the legal assessor. Misconduct The panel first considered whether the facts found proved amounted to misconduct. The panel determined that your actions and omissions breached the following provisions of the Code: Preamble you must: make the care of people your first concern, treating them as individuals and respecting their dignity provide a high standard of practice and care at all times As a professional, you are personally accountable for actions and omissions in your practice, and must always be able to justify your decisions. Paragraph 26 8

9 You must consult and take advice from colleagues when appropriate. Paragraph 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. Paragraph 61 You must uphold the reputation of your profession at all times. The panel also considered that you had not adhered to the following provisions of the NMC s Standard for medicines management: Standard 8 You must have considered the dosage, weight where appropriate, method of administration, route and timing. Standard 16 The mechanics of crushing medicines may alter their therapeutic properties rendering them ineffective and are not covered by their product licence. Medicinal products should not routinely be crushed unless a pharmacist advises that the medication is not compromised by crushing, and crushing has been determined to be within the patient s best interest. Standard 20 Wherever possible two registrants should check medication to be administered intravenously, one of whom should also be the registrant who then administers the intravenous (IV) medication. The panel was aware that not every breach of the Code is sufficient to constitute misconduct. 9

10 The panel also noted that you had breached aspects of the Trust s policy as set out in the agreed statement of facts. The panel considered that your actions were sufficiently serious to constitute misconduct. You had given drugs that were to be administered orally to the patient by IV instead, and in doing so you had placed her at serious risk of harm, although the panel was aware that no actual harm had been caused to the patient. The panel considered that when you were faced with the dilemma of having to administer drugs prescribed for oral administration to a patient who was nil by mouth, you should have sought advice from a more senior practitioner or a doctor. What you in fact did fell well below the standards to be expected of a registered nurse. Impairment The panel then considered whether your fitness to practise is currently impaired by reason of your misconduct. The panel was mindful of its duty to protect patients and the public, and to protect the public interest by maintaining public confidence in the profession and declaring and upholding proper standards of conduct. The panel took account of the case of Grant and the guidance in it on assessing whether a registrant s fitness to practise is currently impaired. The panel was satisfied that there was clear evidence that your misconduct had placed Patient A at risk of harm. In doing so, you damaged the reputation of the profession. The panel took account of your evidence that you were experiencing particularly challenging personal circumstances at the time of the incident, both in terms of your family situation and your health. In your evidence, you stated that this had been at the forefront of your mind rather than your patient. 10

11 In the panel s view, your misconduct involved two aspects. Firstly, the poor clinical practice you exhibited in the way you administered the oral drugs intravenously. Secondly, your inability at the time to deal with emotionally challenging personal situations. Both of these issues could be remedied. The panel next considered whether you have adequately remedied both of these matters. The panel took account of the fact that you have undergone a significant amount of training since the incident occurred, including a course on drugs administration which you took of your own accord only a few weeks after the incident occurred. The panel noted that you have secured employment as a health care assistant in a GP surgery and that your employer appears to view you as a potential practice nurse once these NMC proceedings have been concluded and you have undertaken the appropriate training. You provided the panel with references which speak positively of you. The panel considered that you demonstrated a good level of insight into the causes of your misconduct and have reflected on what you would do differently were you to be faced with similar circumstances. You have recognised the need to ask for help when you are unsure what to do. The panel found you to be honest and credible in your evidence. The panel was certain that you have learnt from what happened and that you intend not to make a similar mistake again. However, the panel noted that this incident occurred when you were only qualified as a nurse for less than a year and that the error you made was of a very basic nature. You have not been employed as a nurse, within a clinical setting, since the incident occurred and thus have not had, as yet, a sufficient opportunity to demonstrate remediation of your nursing practice to an extent that the panel is persuaded that there is no longer any residual impairment. For that reason, the panel concluded that there is a small but significant risk that your misconduct might be repeated. Given the seriousness of the incident and its potential to cause the patient serious harm, the panel also concluded that a finding of impairment is required on the 11

12 grounds of the public interest, in order to maintain public confidence in the profession and the NMC as regulator as well as to declare and uphold proper standards. Accordingly, the panel concluded that your fitness to practise is currently impaired by reason of your misconduct. Determination on Sanction Having determined that your fitness to practise is impaired by reason of your misconduct, the panel considered what sanction, if any, it should impose. In reaching its decision on sanction, the panel has considered all the evidence that has been placed before it and the submissions of Mr Kewley and Mr Oliver. Mr Kewley, on behalf of the NMC, directed the panel to the NMC Indicative Sanctions Guidance (ISG). He asked the panel to consider the issues of public protection, public confidence in the profession and the need to declare and uphold proper professional standards when making its decision. Mr Oliver, on your behalf, acknowledged that because this incident occurred early on in your career, the panel did not have a large amount of evidence about your general practice as a nurse. He acknowledged that the panel may wish to restrict your ability to practise in light of the risk of repetition it had identified. Mr Oliver informed the panel that you would be willing to comply with a conditions of practice order, that you are happy in your current place of employment and that you believe that practice nursing is more suited to your personality. The panel heard and accepted the advice of the legal assessor. The panel considered Article 29 of the Nursing and Midwifery Council Order (2001), which sets out the powers available to it at this stage. The panel recognised that the purpose of sanctions is not to be punitive, although a sanction may have a punitive effect. 12

13 In considering the most appropriate sanction to impose, the panel considered the aggravating and mitigating factors. The panel identified the following aggravating features in this case: Your patient was placed at risk of serious harm The incident occurred despite you having recently undertaken IV training and having been qualified for less than a year The panel has found there is a risk your misconduct might be repeated There were a number of failings within the incident relating to drugs administration and record keeping. The panel identified the following mitigating features in this case: You made full and early admissions You have fully engaged with the NMC You have identified personal health mitigation and have taken appropriate steps to address those issues You have expressed genuine remorse You have demonstrated a good level of insight No actual harm was caused to the patient You undertook self-initiated relevant training soon after the incident occurred You have good references relating to your current employment as a health care assistant in a GP s surgery and your employer appears to be supportive of your goal of becoming a practice nurse The incident was isolated in that it related to one patient on one date Whilst subject to the interim conditions of practice order you had an offer of employment as a nurse at a care home, which you were subsequently unable to take up as your would-be supervisor went on sick leave. The panel first considered taking no action. The panel decided that this would be inappropriate due to the seriousness of your failings. It would not meet the public 13

14 interest in declaring and upholding proper standards of care nor protect patients in any way. The panel next considered a caution order. The panel was mindful of its finding that there is a risk that your misconduct might be repeated. It considered that your practice therefore needed to be restricted to mitigate that risk. A caution order would not restrict your ability to practise and the panel therefore determined that this was not an appropriate sanction. The panel then considered a conditions of practice order. It noted that you are willing to comply with conditions of practice and that there are identifiable areas of your practice which should be addressed. The panel was satisfied that an appropriately formulated conditions of practice order would provide the necessary level of public protection whilst allowing you to practise as a nurse, thereby striking a proportionate balance. In satisfying itself that a conditions of practice order was the appropriate sanction, the panel also considered a suspension order. However, the panel concluded that a suspension order in your case would be disproportionate having regard to the degree of residual impairment it had found. Your failings are remediable and you have taken a number of steps to remediate them so far. The panel determined that a conditions of practice order for a period of 12 months was the appropriate and proportionate sanction. 12 months would allow you sufficient time to gain employment as a nurse and to demonstrate that you have remediated your failings in a practical setting. It was also an appropriate period of time to satisfy the public interest in maintaining public confidence in the nursing profession and the NMC as its regulator, as well as declaring and upholding proper professional standards. The conditions of practice are as follows: 14

15 1. You must notify the NMC within 14 days of any nursing appointment (whether paid or unpaid) you accept within the UK or elsewhere, and provide the NMC with contact details of your employer. 2. You must inform the NMC of any professional investigation started against you and/or any professional disciplinary proceedings taken against you within 14 days of you receiving notice of them. 3. a) You must within 14 days of accepting any post or employment requiring registration with the NMC, or any course of study connected with nursing or midwifery, provide the NMC with the name/contact details of the individual or organisation offering the post, employment or course of study. b) You must within 14 days of entering into any arrangements required by these conditions of practice provide the NMC with the name and contact details of the individual/organisation with whom you have entered into the arrangement. 4. You must work with your line manager, mentor or supervisor (or their nominated deputy) to formulate a Personal Development Plan specifically designed to address the deficiencies in the following areas of your practice: Drug administration Record keeping Seeking guidance and advice about professional issues and any personal problems which may impact upon your ability to practise as a nurse. 5. You must meet with your line manager, mentor or supervisor (or their nominated deputy) at least every month for the first six months and thereafter at intervals agreed as appropriate by your mentor to discuss the standard of your performance and your progress towards achieving the aims set out in your personal development plan. 15

16 6. You must forward to the NMC a copy of your personal development plan within 28 days of the date on which you take up an appointment as a registered nurse. 7. You must send a report from your line manager, mentor or supervisor (or their nominated deputy) setting out the standard of your performance and your progress towards achieving the aims set out in your Personal Development Plan to the NMC every 3 months and at least 14 days before any NMC review hearing or meeting. 8. You must allow the NMC to exchange, as necessary, information about the standard of your performance and your progress towards achieving the aims set out in your personal development plan with your line manager, mentor or supervisor (or their nominated deputy) and any other person who is or will be involved in your retraining and supervision with any employer, prospective employer, and at any educational establishment. 9. You must immediately inform the following parties that you are subject to a conditions of practice order under the NMC s fitness to practise procedures, and disclose the conditions listed at (1) to (8) above, to them: Any organisation or person employing, contracting with, or using you to undertake nursing work Any agency you are registered with or apply to be registered with (at the time of application) Any prospective nursing employer (at the time of application) Any educational establishment at which you are undertaking a course of study connected with nursing or midwifery, or any such establishment to which you apply to take such a course (at the time of application). This order will be reviewed before its expiry. 16

17 Decision on interim order Mr Kewley made an application for an interim conditions of practice order for a period of 18 months on the grounds of it being necessary for public protection and it being otherwise in the public interest. This would cover the 28 day appeal period and the time needed to conclude an appeal if one were to be lodged. Mr Oliver did not oppose the application. The panel accepted the advice of the legal assessor. The panel considered the application carefully, bearing in mind its findings at the previous stages. It decided to impose an interim conditions of practice order in the same terms as the substantive order for 18 months on the grounds that it is necessary for public protection and that it is otherwise in the public interest. The panel considered that this interim order would be consistent with its earlier findings and the substantive sanction that it imposed. This decision will be confirmed to you in writing. You have the right to appeal this decision. If no appeal is made then the substantive 12 month conditions of practice order will take effect 28 days after you are sent the decision in writing. That concludes this determination. 17