Conditions of Practice. Tuesday, 28 May 2013 Monday, 3 June And. Monday 16 September 2012 Tuesday 17 September 2013

Transcription

1 Conditions of Practice Tuesday, 28 May 2013 Monday, 3 June 2013 And Monday 16 September 2012 Tuesday 17 September 2013 Nurse: NMC PIN: Geraldine Atando 67H1567E Part of the register: Registered Nurse sub part 2 Adult (Level 2) August 1967 Sanction: Interim Order: Conditions of Practice Order 18 Months 18 Month Interim Conditions of Practice Order Page 1 of 28

2 Decision on application to amend the charges At the outset of the case, Ms Bayley on behalf of the NMC, made an application to amend the charge under Rule 28 of the NMC s Rules 2004, by replacing the word in charges 1 (d) and (e) which reads any with the word adequate. You told the panel that you agreed with these amendments. The panel accepted the advice of the legal assessor, who referred to Rule 28 of the Nursing and Midwifery Rules The panel concluded that the proposed amendments do not cause you any injustice and have therefore decided to allow the amendment. Application to adjourn At the outset, the panel recorded that no party suggested that it would be appropriate for any of the registrants cases to be dealt with separately, or that the reasons why the cases had been joined together on 7 January 2013 were no longer valid. The panel agreed that it remained appropriate, proportionate and in the interests of justice that the cases be heard together. The registrants individual positions are set out below. The panel heard an application from you to adjourn these proceedings. You explained that your representative, Mr Lloyd Franklin (a retired UNISON representative), is unable to attend as he is currently in Jamaica and has not been able to return in time for this hearing. The panel heard that Mr Franklin made a request to adjourn these proceedings on 8 May The NMC scheduled a pre-meeting for 24 May 2013 where this application to adjourn was refused. The panel was not bound by that decision but gave due regard to the reasons why it had been made. Page 2 of 28

3 You told the panel that you have done a lot of preparation with Mr Franklin regarding this hearing, and as such, you do not believe that you would have a fair hearing without him being present. Ms Bayley, on behalf of the NMC, objected to the application to adjourn. She told the panel that Mr Franklin had provided three pages of submissions on your behalf. Ms Bayley explained that the dates for this hearing were listed in March 2013, after consultation with all of the parties involved in these proceedings. She said that on 4 April 2013 the notice of hearing was sent to you and Mr Franklin. Further, Ms Bayley told the panel that there has been no information provided to indicate if/when Mr Franklin will return to the UK. Ms Bayley submitted that it would not be in the interests of justice to adjourn these proceedings. The panel carefully considered the submissions of both parties. It has heard and accepted the advice of the legal assessor who referred the panel to Rule 32 of The Nursing and Midwifery Council (Fitness to Practise) Rules Order of Council The panel is well aware of your right to a fair hearing and its duty to ensure you have a fair hearing. The panel was also mindful of the public interest in the expeditious disposal of the case and the potential inconvenience that would be caused to the parties by an adjournment. The panel noted that there were two other registrants, a representative and two witnesses in attendance. In reaching its decision on whether to grant your request for an adjournment, the panel had regard to the passage of time since the incidents in 2010 which gave rise to the allegations in this case. It also bore in mind that the dates for this hearing had been set since March Further, there has been no information placed before the panel to confirm if and when Mr Franklin would return to the UK and whether he would be able to represent you at that time. The panel determined that there is a clear public interest in dealing with this hearing expeditiously. The panel observed that the legal assessor would be available throughout to give you appropriate guidance and advice on, for example, the statutory procedure. Balancing all factors, it concluded that it would be in the interest of justice and fairness to proceed. Page 3 of 28

4 The panel assured you that it would take into account the fact that you are representing yourself and would give you every opportunity to fully present your case. Charges: That you, whilst working as a Registered Nurse at Paternoster House Care Home: 1. Between 16 January 2010 and 18 February 2010 failed to provide an adequate standard of care to Resident A's pressure ulcers in that you: a) Did not complete adequate assessment the pressure ulcers on Resident A's heel and sacrum in that you did not: i. describe the wounds ii. measure the wounds Found proved b) Did not create a short-term care plan. Found not proved c) Did not adequately complete a wound care evaluation of Resident A's sacral and heel pressure ulcers. Found proved d) Did not take any steps to ensure the provision of suitable pressure relieving devices [Amended to read: Did not take adequate steps to ensure the provision of suitable pressure relieving devices] Found not proved e) Did not take any steps to ensure that senior staff were aware of the presence of the Resident's pressure ulcers [Amended to read: Did not take adequate steps to ensure that senior staff were aware of the presence of the Resident's pressure ulcers] Found not proved Page 4 of 28

5 2. On 13 February 2010, you noted an offensive smell from Resident A's heel and sacral wounds but failed to : a) Record that swabs were taken from these wounds. Found proved b) Produce a care plan. Found not proved c) Adequately assess the wound. Found proved As a result of the facts set out above your fitness to practice is impaired by reason of your misconduct. Decision on the facts The panel has carefully considered both the oral and the documentary evidence presented in this case. It has taken into account the submissions of the NMC s case presenter, Ms Bayley, Mr Short on behalf of Mr Twum-Barimah and Miss Atando. Mrs Pikuda chose not to make any submissions. It has heard and accepted the advice of the legal assessor. The panel acknowledged that the burden of proof rests on the NMC and that the standard of proof to be applied is the civil standard, namely the balance of probabilities. The panel heard that at the time of the allegations, Mr Twum-Barimah, Miss Atando and Mrs Pikuda were employed as Staff Nurses at Paternoster House Care Home, Waltham Abbey, Essex ("the Home"). The Home provides residential and nursing care. Resident A was a clinically obese, elderly resident with dementia. As a result of her dementia, she did not understand the need to alleviate pressure and found it difficult to move physically. She needed nursing input to ensure that she had sufficient pressure relief. In early 2010, Resident A was admitted to Princess Alexandra Hospital in Essex where she received treatment for a respiratory illness. On 16 January 2010, Resident A Page 5 of 28

6 returned to Paternoster House Care Home for ongoing care. At this time, a body map was completed by Miss Atando. The body map indicated that Resident A did not have any sacral or heel pressure marks. On 18 February 2010, Resident A was visited by a Tissue Viability Nurse (TVN) who identified that Resident A was suffering from grade 3 and 4 pressure ulcers. There are four recognised grades of pressure sores in the European Pressure Ulcer Advisory Panel Wound Classification System. Grade 1 is the least severe pressure sore and grade 4 is the most severe. Grade 4 represents full thickness skin loss with extensive destruction and necrosis extending to underlying tissues. The pressure ulcers noted on Resident A by the TVN were: - One grade 3 pressure ulcer on left heel - One grade 4 pressure ulcer on right buttock - One grade 4 pressure ulcer on left buttock Mr Twum-Barimah worked exclusively on night duty on the Dementia Unit between 16 January 2010 and 18 February He worked 15 shifts on the Dementia Unit where Resident A was nursed during the period when Resident A s pressure ulcer s developed and deteriorated. Miss Atando worked exclusively on day duty on the Dementia Unit between 16 January 2010 and 18 February She worked 22 shifts on the Dementia Unit where Resident A was nursed during the period when Resident A s pressure ulcer s developed and deteriorated. Mrs Pikuda worked exclusively on night duty on the Dementia Unit between 16 January 2010 and 18 February She worked 13 shifts on the Dementia Unit where Resident A was nursed during the period when Resident A s pressure ulcers developed and deteriorated. The Dementia Unit at the Home usually had one Staff Nurse per shift and one Health Care Assistant ( HCA ) for every 4 to 5 residents on day shifts, and either 1 or 2 HCAs on night shifts. Page 6 of 28

7 Every shift at the Home began and ended with a handover between trained staff. During this handover information would be passed on. There was also a Ward Diary for new events to be noted. The Ward Diary and daily record of care were the main, but not the only, ways by which nurses recorded information related to the care of residents. Within the Home, short term care plans were used to manage short term issues concerning care for the residents. As most of the residents at the Home have long term care needs, this was intended to differentiate long term needs from short term issues that might need more focussed attention. Following the discovery of the seriousness of Resident A s pressure sores, an investigation was conducted by Ms 2, the Matron at the Home. Mr Twum-Barimah, Miss Atando and Mrs Pikuda resigned shortly afterwards. The panel heard live evidence from the following witnesses: Ms 1, General Manager of the Home; Ms 2, the Matron at the Home during the time of the incidents. The evidence of the following witnesses was tendered in the form of signed witness statements: Ms 3, Healthcare Assistant at the Home; Ms 4, Healthcare Assistant at the Home; The panel has borne in mind that it must evaluate what weight to attach to this evidence, not having had the opportunity to assess or question these witnesses in person. The panel also heard evidence from Miss Atando. Mrs Pikuda chose not to give evidence in relation to the factual allegation she denied. Page 7 of 28

8 Further, the panel considered the bundle of documents (Exhibit 3) provided by the NMC and written submissions made by Mr Twum-Barimah, Miss Atando and Mrs Pikuda, which are exhibits 6, 7 and 8. In reaching its decision, the panel has carefully considered all the evidence and has determined as follows: At the outset of this hearing, you made no admissions. Accordingly, the panel went on to consider the charges you face in their entirety. The first part of the charge relates to the period between 16 January 2010 and 18 February 2010 and alleges you failed to provide an adequate standard of care to Resident A's pressure ulcers in that you: a) Did not complete adequate assessment the pressure ulcers on Resident A's heel and sacrum in that you did not: i. describe the wounds ii. measure the wounds The panel finds this charge proved. In her evidence, Ms 1 told the panel that the Skin Inspection Record, Wound Assessment Chart, Wound Care Evaluation and Tissue Viability Patient Referral Form completed by you in relation to Resident A during this period were not adequate as they failed to describe the pressure ulcers sufficiently. She added that no short-term care plan was ever created by you. Ms 2 told the panel that on 16 January 2010 Resident A returned to the Home from a hospital admission. About 8 days prior to Resident A s return, Ms 2 attended the hospital and performed an assessment, in which she noted that Resident A had Grade 1-2 pressure ulcers on her left and right heels and sacrum and that her skin was swollen and dry. She spoke to you about that assessment when Resident A was readmitted to the Home. Page 8 of 28

9 Upon Resident A s readmission to the Home on 16 January 2010, you produced a body map, which indicated some discolouration on Resident A's right arm, the back of her left hand and her lower right leg. Ms 2 said that as this body map did not indicate any wounds on Resident A's heels or sacrum, she understood that Resident A did not have any pressure ulcers at this point in time. Ms 2 said that the progress and evaluation record dated 6 February 2010 only referred to a blister lateral tibia with no mention of sacral or heel pressure sores. Ms 2 told the panel that the first note of a sacral wound on Resident A was recorded on 30 January There was a changing of a sacral dressing on that date, and again on 31 January There is no further evidence that care was provided to Resident A's sacral wound until you completed a body map on 6 February On this body map you noted the presence of a tibial wound, right sided sacral sore and a left heel sore. You completed a wound chart in relation the left lateral tibial wound and made a referral to the Tissue Viability Service ( TVS ). The TVS referral form only referred to the left lateral tibial wound. However, on the Wound Assessment Chart (Part 1), you recorded the presence of the Grade 3 left heel wound and a Grade 4 sacral/buttock wound. The Wound Care Evaluation chart recorded that dressings were changed on 6, 8, 11, 13, 14, 16 and 17 February There is no record that the sacral or heel pressure wounds were measured or assessed in line with the wound assessment guidelines. In your evidence, you told the panel that you had completed various documents describing Resident A s wounds, which are contained in exhibit 3, and as identified by you in exhibit 6. Ms Bayley submitted that although there are various documents completed by you relating to blisters or wounds, these related to the left lateral tibia wound of Resident A. She suggested that you accepted that you had not completed an assessment for each individual wound. Ms Bayley said that a description of the grade of the wound was not adequate, and that there was never any description recorded by you of the pressure sores. Further, she reminded the panel that you had accepted, in your oral evidence, that you never took the measurements of the pressure ulcers on Resident A's heel and sacrum. Page 9 of 28

10 The panel acknowledged that you made limited and general assessments of the pressure ulcers on Resident A s heel and sacrum in the Body Map and in the Wound Assessment Chart (Part 1). However, the panel noted that this chart clearly states that a separate sheet should be used for each wound, which you conceded that you did not do, and that Part 2 of the Wound Assessment Chart should be completed at each dressing change. However, on the two Wound Assessment Charts (Part 2), completed by you on 6 February 2010 and 13 February 2010, you only referred to the left lateral tibia wound. The panel has noted that Part 2 of the Wound Assessment Chart clearly sets out the information, including measurements, that is required in order for individual wounds to be properly described. Accordingly, the panel concluded that you did not adequately assess Resident A s heel and sacrum pressure ulcers as you failed to describe these wounds on a Wound Assessment Chart and failed to provide any measurements of these wounds. Accordingly, charge (a) (i) and (ii) are found proved. b) Did not create a short-term care plan. The panel finds this charge not proved. In her evidence, Ms 1 told the panel that body maps were produced in relation to Resident A on 16 January 2010, 6 and 13 February She said that these would have been produced as part of an ongoing wound assessment and should have been part of a short term care plan. Ms 1 told the panel that the Skin Inspection Record, Wound Assessment Chart, Wound Care Evaluation and Tissue Viability Patient Referral Form completed by you in relation to Resident A during the period in question were not a short-term care plan. She said that a short-term care plan for a resident was crucial in ensuring that the patient received the correct care. Ms 2 said that you did record A Plan of Care for a Short Term Problem but that this was not adequate as it was not detailed enough. She said that you did not list details Page 10 of 28

11 such as the desired outcome, what action had been taken and what action was further required and how often photographs should be taken and what equipment was necessary. You told the panel that you did create a Plan of Care for Short Term Problem for Resident A, and you referred the panel to page 114 in exhibit 3. Ms Bayley submitted that the short-term care plan you referred the panel to related only to the left lateral tibia wound, as you recorded the problem as Blisters deteriorate to ulcers and not to pressure ulcers. The panel had sight of the Plan of Care for Short Term Problem document for Resident A, completed by you. It had regard to the fact that you said you believed all of Resident A s sores resulted from blisters rather than pressure. The panel noted that the charge does not refer to an adequate short-term care plan. The panel therefore determined that you had completed a short-term care plan in relation to Resident A. Accordingly, charge (b) is found not proved. c) Did not adequately complete a wound care evaluation of Resident A's sacral and heel pressure ulcers. The panel finds this charge proved. In her evidence, Ms 1 told the panel that the Wound Care Evaluation form completed in relation to Resident A was inadequate. On 6 February 2010, you recorded: wound one: left tibia; wound two: left heel; cleaned; warm water dressing applied alleyn; wound no 3 sacrum cleaned with warm water - applied hydrocolloid plus mepore. She said that you failed to provide sufficient information describing the wounds and regarding Resident A s sacral and heel pressure ulcers treatment. Ms 2 told the panel that the Wound Care Evaluation completed by you was inadequate as you failed to provide an adequate assessment of Resident A s wounds. Page 11 of 28

12 You told the panel that you were not aware that you were completing the forms incorrectly, and that if you were misdirecting yourself, the Matron should have picked up on this and given you guidance. You did concede that you maybe should have elaborated. Ms Bayley submitted that the Wound Care Evaluation completed by you was inadequate and that you accepted this in your oral evidence. The panel noted that, as you had not provided an adequate description of the wounds initially, you did not track the progress or deterioration of the wounds sufficiently in the Wound Care Evaluation form. The entries made by you were about the care provided and there was no information regarding the condition of the wounds. The panel noted that, although you made entries on the Wound Care Evaluation form for Resident A, you could not track the changes in the wounds as you never adequately completed a Wound Assessment Chart (Part 2), as mentioned in charge 1 (a). Accordingly, the panel concluded that you did not adequately complete a Wound Care Evaluation of Resident A's sacral and heel pressure ulcers. Therefore, charge (c) is found proved. d) Did not take adequate steps to ensure the provision of suitable pressure relieving devices The panel finds this charge not proved. Ms 2 said that the Barchester Healthcare s Strategy for the Prevention and Management of Pressure Ulcers outlined the actions a nurse should take if a pressure ulcer is discovered. This includes the use of pressure relieving aids. She told the panel that once you were aware that a pressure sore had developed, you should have ensured that the correct pressure relieving mattress was used. You told the panel that Resident A was already on a pressure relieving mattress and that you were not aware that it was unsuitable until the TVN directed that it needed to be replaced. Page 12 of 28

13 Ms Bayley submitted that you did not take adequate steps to ensure that Resident A was provided with the correct pressure relieving mattress. She said that in your oral evidence, it appeared that you did not consider this your responsibility but rather that of the senior staff. Ms Bayley reminded the panel of the evidence of Ms 1, who explained that a pressure relieving mattress could be obtained through various methods, such as borrowing one from another Home or hiring one. She submitted that the ease with which this could be achieved was demonstrated when Resident A was placed on a suitable pressure relieving mattress the day after the TVN had made the assessment. The panel noted that in Resident A s Progress and Evaluation Record form, on 3 February 2010 at 19:40 you recorded All care given she is now on pressure relieving mattress. You drew the panel s attention to the fact that the words she is now showed a deletion mark. The panel bore in mind that you had admitted that you were not aware of what level of mattress Resident A required. The panel also noted that in the Tissue Viability Patient Referral Form you sent to the TVN regarding Resident A on 6 February 2010, you ticked Propad in the section Pressure Reducing/Relieving Mattress. However, on the second Tissue Viability Patient Referral Form you sent to the TVN, dated 13 February 2010, the panel noted that in the same section, you had ticked Auto x cell. Therefore, it appears that Resident A s mattress had been upgraded between 6 February 2010 and 13 February Based on this documentation, the panel was satisfied that consideration had been given by you regarding Resident A s mattress during the relevant period. In the light of this, the panel determined that there was insufficient evidence provided to conclude that you did not take adequate steps in this regard. Accordingly, the panel finds charge (d) not proved. e) Did not take adequate steps to ensure that senior staff were aware of the presence of the Resident's pressure ulcers The panel finds this charge not proved. Page 13 of 28

14 In her evidence, Ms 1 told the panel that every nursing shift at the Home begins and ends with a handover between trained staff. She explained that there is a Ward Diary to record any new events. Further, Ms 1 told the panel that every month each unit at the Home produces a Clinical Governance report. She said that this is completed by the day staff, where staff nurses are asked to report on their patients. Ms 1 said that you would produce this report, as the nurse working the day shift on this unit, and give it to the Matron (Ms 2 at that time), who would then input it onto the record system of the Home. Ms 1 said that Ms 2 reported to her any information that needed to be escalated. This monthly report could be used as a prompt for staff to ensure that any issues that needed to be reported were escalated to senior staff. Ms 1 said that she would expect that any residents who had pressure ulcers had this noted on the clinical governance report. She told the panel that she would also expect any staff nurses who had noted a pressure ulcer on a resident to inform senior staff and seek management support. Any pressure areas that had been noted should appear on the governance report and a care plan should be produced. Ms 1 told the panel that you did not report that Resident A had any pressure ulcers at any stage, until she was informed that Resident A had a grade 4 pressure ulcer. She said that she was horrified that a patient in the Home could deteriorate to such a level without anybody more senior being made aware of the situation. Ms 1 said that she felt it was the responsibility of the Staff Nurses providing direct care to Resident A, who were aware that the pressure sores were present and deteriorating, to draw these to the attention of senior staff so that a combined package of care could be provided to the resident. Ms 1 said that the entries appearing on the Wound Care Evaluation sheet completed by you between 6 February 2010 and 17 February 2010, did not provide sufficient detail or any objective assessment of the wounds. She conceded that details of the dressings that were applied had been noted. However, without an objective assessment, it was difficult for any other member of staff to accurately assess the progression of the wound. Page 14 of 28

15 Finally, Ms 1 said that she would have expected any qualified nurse to have the basic knowledge essential to preventing pressure sores from arising. Ms 2 said that you did not report that Resident A had any pressure ulcers. She said that on 18 February 2010, Resident A was assessed by the TVN who had attended the Home to review her grade 4 pressure sores. Ms 2 said that this was the first time that she was made aware of Resident A s pressure sores since her readmission to the Home. Ms 2 s attention was taken to the Skin Inspection Record, Wound Care Evaluation, Wound Assessment Chart and Tissue Viability Patient Referral Form, completed by you on 6 February 2010, but she said that no information regarding Resident A s pressure sores was brought to her attention prior to 18 February She would not have routinely read such documentation at or about the time it was created. You said that you informed the Matron of Resident A s pressure ulcers both orally, at the stand-up meetings and through written reference, in Resident A s care plan and the daily diary. You told the panel that by 6 February 2010, Resident A s pressure ulcers had been brought to Ms 2 s attention and that on 18 February 2010, Ms 2 ran onto the Unit and said Geraldine, we ve got a problem. I forgot to upload the pressure ulcer form onto the system. You said that Resident A was the only resident on the unit with these conditions and, accordingly, that you had definitely brought this to the attention of the Matron and other nurses at stand-up meetings. You said you had no reason to withhold the information from senior staff. Ms Bayley submitted that the evidence of Ms 1 and Ms 2 was unequivocal and that both were completely unaware of Resident A s pressure ulcers. She said that had either of them known about Resident A s wounds, they would have immediately taken action. Ms Bayley referred the panel to the Home Investigation Meeting between you and Ms 2, dated 23 February The panel was mindful of the conflicting evidence provided by you and the two witnesses. The panel weighed up the witnesses evidence against your evidence. Given the numerous references made by you in the documentation of Resident A s condition Page 15 of 28

16 between 6 17 February 2010, and the emphasis the witnesses gave regarding the open-door policies within the Home, the panel determined that it preferred your evidence over that of the witnesses on this issue. The panel acknowledged that your softly spoken style of presentation might have permitted the Matron and General Manager to miss the significance of what was being said. However, on a balance of probabilities, the panel concluded that adequate efforts were made by you to tell the senior staff of Resident A s pressure ulcers. Therefore, the panel finds charge (e) not proved. In making these findings, the panel has not overlooked the notes of the Investigatory Meeting provided by the Home, and which were relied on by the NMC. However, it bore in mind that you, Mr Twum-Barimah and Mrs Pikuda were not given the opportunity to read these notes after the meeting. Further, the panel bore in mind that all three nurses were not represented or provided with the opportunity to be represented. It noted that a number of the questions in the meeting were leading questions and, having had the chance to observe your demeanour during evidence, the panel concluded that it is not in your nature to be confrontational and as such you may have been reluctant to directly challenge what was being put to you. The panel also considered that the meeting may have been of a very different character to the one you had expected. In the light of this, the panel has felt unable to give any evidential value to the notes. The second part of the charge relates to 13 February 2010, when you noted an offensive smell from Resident A's heel and sacral wounds but it is alleged you failed to: a) Record that swabs were taken from these wounds. The panel finds this charge proved. Ms 2 said that any pressure wound with an offensive smell can indicate the presence of infection and a deteriorating clinical situation. Ms 2 said that any nurse who is aware of an offensive smell coming from a wound should take various actions, including taking a wound swab and sending it for microbiological analysis. She told the panel that it was Page 16 of 28

17 clear from the clinical records that although you made a TVN referral at that point, no swab had been taken. You told the panel that you took a swab of Resident A s wounds and placed it in the treatment room to be sent on for analysis. You said that you thought that you had recorded this in Resident A s diary but it appears that you missed documenting this. Ms Bayley said that there was no record of you taking any swabs of Resident A s wounds. Further, there is no evidence of your chasing up the swabs or of their results being returned to the Home. The panel had before it no evidence identifying that you noted an offensive smell from Resident A s sacral wound. However, you did document that you noted an offensive smell from Resident A s heel wound in the Wound Care Evaluation. The panel noted that you admitted, during your oral evidence, that you took swabs but did not record them. Accordingly, the panel finds charge (a) proved in relation to your failure to record that swabs were taken from Resident A s heel wound. b) Produce a care plan. The panel finds this charge not proved. Ms 2 said that, although it was clear from the clinical records that you made a TVN referral, no care plan was produced to implement an effective plan of care to prevent further wound deterioration. She said that the Plan of Care for Short Term Problem completed by you did not set out the desired outcome, requirements, photographs or equipment required and was also too vague to identify which wound you were referring to. You told the panel that upon noting an offensive smell from Resident A's heel wound, you produced a Care Plan for Resident A, dated 14 February You referred the panel to this document, titled Plan of Care for Short Term Problem. Page 17 of 28

18 Ms Bayley submitted that the Care Plan referred to by you did not set out how to deal with the wound and did not advise any action. Further, she submitted that this Care Plan was for the problem: Blisters deteriorate to ulcers which related to Resident A s left tibia. Ms Bayley submitted that, in the light of this, the Care Plan produced by you was not relating to Resident A s heel and sacral wounds. The panel determined that, as set out in (b) of the first part of the charge above, the charge does not refer to an adequate care plan. The panel had sight of the Plan of Care for Short Term Problem document produced by you for Resident A. In the light of this document, it determined that you did produce a Care Plan after noting the offensive smell from Resident A s heel wound. Accordingly, charge (b) is found not proved. c) Adequately assess the wound. The panel finds this charge proved. In your evidence you accepted that the Wound Care Evaluation form completed by you in relation to Resident A was not adequately completed as it did not identify the wounds. Ms Bayley submitted that your Wound Care Evaluation form for Resident A did not include measurements, tracings or descriptions of the wounds. Accordingly, she submitted that you had not adequately assessed Resident A s wounds. The panel noted that on the Wound Assessment form, Wound Care Evaluation form and Body Map, you made no specific assessment of Resident A s heel wound. It concluded that, as you failed to describe the wound clearly and did not generate a separate Wound Assessment Chart for this wound, it cannot be said that you adequately assessed Resident A s heel wound. All of the recordings by you related to care of the wound rather than to an assessment of the wound. Accordingly, the panel finds charge (c) proved. Adjournment and interim order Page 18 of 28

19 The panel determined it was necessary to adjourn the proceedings to conclude its decision on impairment. There is insufficient time available to allow the panel to complete its deliberations. It was proposed that the resuming dates for this hearing will be 16, 17 and 20 September Ms Bayley informed the panel that it was not necessary for it to review your position. The hearing resumed on 16 September 2013: Misconduct and Impairment: Having announced its findings on the facts, the panel next considered whether the facts found proved amount to misconduct and, if so, whether your fitness to practise is currently impaired. The NMC has defined fitness to practise as a registrant s suitability to remain on the register unrestricted. In her submissions to the panel regarding misconduct and impairment, Ms Lewiecki, on behalf of the NMC, referred to the 2008 NMC Code The code: Standards of conduct, performance and ethics for nurses and midwives ( the Code ). Ms Lewiecki submitted that your actions or inactions, as described in the charges found proved, illustrated clear breaches of the fundamental tenets set out in the NMC Code. She submitted the elements of patient harm apparent in the charges demonstrated conduct which falls far short of that expected of a Registered Nurse. Mr Franklyn, acting on your behalf, submitted that you have an otherwise unblemished 45 year career. He submitted that your failings should be taken in the wider context of management and supervisory deficiencies at the Home at the time. The panel has accepted the advice of the legal assessor. He referred the panel to the cases of Roylance and the GMC (2) [2000] 1AC 311 and Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011]. The panel bore in mind that, in relation to impairment by reason of misconduct, there is a two stage process and that each is a matter for the panel s professional judgement. It Page 19 of 28

20 must first consider whether, on the facts found proved, your behaviour constituted misconduct, and secondly, if so, whether your fitness to practise is currently impaired by reason of that misconduct. The panel has had careful regard to its findings of fact. In considering your fitness to practise the panel reminded itself of its duty to protect patients and its wider duty to protect the public interest which includes the declaring and upholding of proper standards of conduct and behaviour, and the maintenance of public confidence in the profession and the regulatory process. The panel had particular regard to the following provision in the preamble to the Code: The people in your care must be able to trust you with their health and wellbeing To justify that trust, you must: make the care of people your first concern, treating them as individuals and respecting their dignity work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community provide a high standard of practice and care at all times be open uphold the reputation of your profession As a professional, you are personally accountable for actions and omissions in your practice, and must always be able to justify your decisions. The panel concluded by reason of its findings of fact, that you had breached these fundamental tenets of the Code. The panel bore in mind that not every falling short of what would be proper in the circumstances, and not every breach of the Code, would be sufficiently serious that it could properly be described as misconduct. Accordingly, the panel had careful regard to the context and circumstances of the matters found proved. Page 20 of 28

21 You were on day shift duty on several occasions between 16 January 2010 and 18 February 2010 and you had opportunities to take appropriate action in caring for Resident A. Your inattention caused real harm to her and the panel considered that you failed to apply the standards that are reasonably expected of a Registered Nurse. Having regard to the serious nature of the charges found proved, the panel concluded that your actions did amount to misconduct. The panel next considered whether your fitness to practise is currently impaired as a consequence of your misconduct. In doing so the panel has had regard to the issue of remediability. The panel considered whether your misconduct is remediable, whether it has been remedied, and whether it is likely to recur. The panel has also considered whether you continue to present a risk to members of the public, and further, the need to uphold proper professional standards and maintain public confidence in the profession. The panel bore in mind the evidence that Resident A came to harm as a result of your conduct. It was in no doubt that your failings, as outlined in the charges found proved, had brought the profession into disrepute, and had breached other fundamental tenets of the profession. Turning to remediation the panel acknowledged that you have accepted some responsibility for your failings and identified some areas where you had been at fault. The panel accepted that your career has been otherwise unblemished. However the panel was mindful that the courses you have undertaken appear to be general in nature. There was no evidence that they addressed the specific nature of the misconduct found in your case. Your appraisals are similarly unspecific. The panel heard evidence that you had attended a course regarding leg ulcers, however it was not provided with detailed information as to what this course entailed, what you had gained from attending, or, most importantly, how you would act differently if a similar situation to that involving Resident A were to arise in future. Page 21 of 28

22 As regards your insight the panel noted that you had made no admissions at the outset of this hearing. In addition you have demonstrated an inclination to be defensive about your acts and omissions which showed a reluctance to accept your failings in full. In all of these circumstances, the panel was unable to conclude that you were unlikely to repeat the incidents of misconduct found proved. The panel also considered that the need to uphold proper professional standards and public confidence in the profession would be undermined if a finding of impairment were not made in the circumstances of this case. For all the reasons outlined above, the panel determined that your fitness to practise is currently impaired by reason of your misconduct. Determination on sanction: In reaching its decision on sanction, the panel considered all the evidence before it in this case. It took into account the submissions made by Ms Lewiecki on behalf of the NMC and by Mr Frankyln on your behalf. In her submissions to the panel, Ms Lewiecki, referred to the NMC Indicative Sanctions Guidance for panels of the Conduct and Competence Committee (June 2012) (ISG). She highlighted the harm caused to Resident A in this case and submitted that a sanction is necessary for the protection of the public and is otherwise in the public interest to uphold the reputation of your profession and your regulator. In his closing submissions on your behalf, Mr Frankyln informed the panel that you would like to further apologise for the harm caused to Resident A as a result of your failings and that, whatever the context of those failings, you understood that you had neglected your responsibilities. He submitted that your record as a Registered Nurse is otherwise unblemished and that you are capable and willing to take the necessary steps required to ensure you can continue to practise and to prevent a recurrence of your misconduct. He stressed that you would be very willing to take courses to improve your existing skills. Page 22 of 28

23 The panel accepted the advice of the legal assessor. The panel has taken into account the advice set out in the NMC Indicative Sanctions Guidance. It had regard to the principle of proportionality, weighing your interests against the public interest. The panel bore in mind that the purpose of a sanction is not to be punitive, although it may have that effect, and that its purpose is to protect patients and the wider public interest. The wider public interest includes maintaining public confidence in the profession and the NMC, and declaring and upholding proper standards of conduct and behaviour. The panel reminded itself of its findings at the impairment stage, especially with regard to seriousness, insight, and the fact that your failings have not yet been fully remedied. The panel recognised that you have attended the hearing. You indicated that you had been humbled by the panels findings. It noted that it has not been informed of any other incidents relating to your practice before or since The panel was also aware that you have identified areas of your practice where you have improved, although it has not been provided with any detailed information as to its effects upon your current practice. The panel first considered taking no action but concluded that, given the number and seriousness of the charges, which involved harm to Resident A, this would be wholly inappropriate. The panel next considered whether to make a Caution Order. It bore in mind that a Caution Order would not restrict your practice or address the concerns identified. In addition, given the number and seriousness of the charges and the harm to Resident A, the panel concluded that a Caution Order would not be sufficient to protect the public, and, moreover, such a sanction would not satisfy the wider public interest, in declaring and upholding the standards of the profession. The panel then considered a Conditions of Practice Order and determined that this would be a sufficient and appropriate sanction to impose on your registration. The panel determined that conditions could be formulated which would address the deficiencies in your practice and ensure that the public is protected. The panel Page 23 of 28

24 concluded that a Conditions of Practice Order would allow you the opportunity to address your deficiencies within the framework of structured support. In order to give you ample opportunity to produce the necessary documentation for a Review Panel shortly before the expiry of this order, the panel decided the length of the order should be for 18 months. In reaching this decision, the panel took into account that there is no evidence of attitudinal issues, or of general incompetence. The panel was satisfied on the basis of the evidence before it that you are willing and able to remediate. Although the charges found proved took place during a period of just over a month, the panel took note of the fact that you had an otherwise unblemished career of 45 years and there has been no reported repetition of your failings in the last three and a half years. Therefore the panel concluded that, with sufficient support, direct supervision and the correct conditions imposed, you would be safe to practise as a Registered Nurse. It further considered that there were identifiable areas of your practice that were in need of assessment and training, that patients would be protected by conditions, and that workable conditions could be formulated. The panel did consider whether a Suspension Order would be appropriate. However, it concluded that a suspension would be disproportionate and punitive. It would prevent you from addressing your skills and competence and from demonstrating your capacity for safe practice. It may also cause you financial hardship and would serve no useful purpose to you or to the wider public interest. The panel found that conditions would be a proportionate and sufficient sanction to protect patients from harm and to maintain public confidence in the profession. The panel decided to impose the Conditions of Practice Order for a period of 18 months to give you adequate time to comply with the conditions and demonstrate to a Review Panel that you can practise without restriction. There will be a review shortly before the 18 month period has expired and you can apply for a review at any time if your circumstances change. Page 24 of 28

25 Your record in the NMC register will show that you are the subject of a Conditions of Practice Order and anyone who enquires about your registration will be informed about the order. As already indicated, before the end of the period of the order, a panel will hold a review hearing to see how well you have complied with the conditions set out in the order. At the review hearing the panel may revoke the order or any condition of it, it may confirm the order or vary any condition of it, or it may replace the order with another order. Throughout the period that the conditions are in force, you must comply with them. Failure to do so may result in the Conditions of Practice Order being replaced with a more serious sanction. It may also amount to misconduct. The conditions are as follows: 1. 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: a) Wound assessment b) Wound evaluation c) Record keeping in relation to wound care management 2. You must meet with your line manager, mentor or supervisor (or their nominated deputy) at least every 6 weeks to discuss the standard of your performance and your progress towards achieving the aims set out in your Personal Development Plan. 3. 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. Page 25 of 28

26 4. 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. 5. You must disclose a report not more than 28 days old 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 any current and prospective nursing or midwifery employers (at the time of application) and any other person who is or will be involved in your retraining and supervision with any such employer, prospective employer, and at any educational establishment. 6. You must notify the NMC within 14 days of any nursing or midwifery appointment (whether paid or unpaid) you accept within the UK or elsewhere, and provide the NMC with contact details of your employer. 7. You must inform the NMC of any criminal or professional investigation started against you and any criminal or professional disciplinary proceedings taken against you within 14 days of you receiving notice of them. 8. 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. Page 26 of 28

27 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: a) Any organisation or person employing, contracting with, or using you to undertake nursing or midwifery work. b) Any nursing or midwifery agency you are registered with or apply to be registered with (at the time of application). c) Any prospective nursing or midwifery employer (at the time of application). d) 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). Determination on Interim Order: The panel has decided to impose an interim Conditions of Practice Order for a period of 18 months on the grounds of public protection and in the public interest. Article 31 of the Nursing and Midwifery Order 2001 outlines the criteria for the imposition of an interim order. The panel may only make an interim order if it is satisfied that it is necessary on one or more of three grounds; for the protection of the public, otherwise in the public interest or in the registrant s own interest. The panel heard submissions from Ms Lewiecki on behalf of the NMC who submitted that an interim order was necessary to protect the public. She submitted that an interim order should be imposed for the period of 18 months to cover the possibility of an appeal being made in the 28 day appeal period. You did not make any submissions regarding this matter. The panel heard and accepted the advice of the legal assessor. In the light of its earlier finding as to the ongoing risk of harm to patients were you to practise unrestricted, the panel is satisfied that it is necessary to impose an order on Page 27 of 28