Conduct and Competence Committee Substantive Hearing 29 August 2013 NMC, 61 Aldwych, London, WC2B 4AE Name of Registrant: NMC PIN: Amanda Elizabeth Settle 06A1906E Part of the register: Registered Nurse Sub part 1 Adult Nurse (12 May 2006) Area of Registered Address: Type of Case: Panel Members: Legal Assessor: Panel Secretary: Ms Settle: Nursing and Midwifery Council: Facts proved: Facts not proved: Fitness to practise: Sanction: England Misconduct David Flinter (Chair, lay member) Eileen Skinner (Lay member) James Richardson (Registrant member) Ben Stephenson Mairead Shenton Not present but represented in her absence by Mick Barraclough, Unison Represented by Louise Hartley, Counsel, NMC Regulatory Legal Team All N/A Impaired Caution order 2 years Details of charge: That you, whilst employed as a registered nurse at Springfield Care Home, Bradford: 1. On 4 June 2012:- a) Incorrectly administered medication to Customer A when it should have been administered to Customer B. b) Did not check the medication administration charts for approximately 20 customers prior to administering their medication. c) Did not record that you had administered medication to approximately 23 customers at the time you administered their medication. Page 1 of 7
d) Retrospectively recorded that you had administered medication to approximately 23 customers. And, in light of the above, your fitness to practise is impaired by reason of your misconduct. Consensual Panel Determination: The panel considered the provisional agreement reached by the parties, which read as follows: The Nursing and Midwifery Council and Amanda Settle, PIN 06A1906E ( the Parties ) agree as follows: Charge 1. Ms Settle admits the following charges: That you, whilst employed as a registered nurse at Springfield Care Home, Bradford: 1. On 4 June 2012: a) Incorrectly administered medication to Customer A when it should have been administered to Customer B. b) Did not check the medication administration charts for approximately 20 customers prior to administering their medication. c) Did not record that you had administered medication to approximately 23 customers at the time you administered their medication. d) Retrospectively recorded that you had administered medication to approximately 23 customers. And, in light of the above, your fitness to practise is impaired by reason of your misconduct. Facts 2.1 The facts are as follows: 2.1. The NMC received a referral from Anchor Trust on 29 October 2012 following a medication error that took place on 4 June 2012. The Registrant was employed by Anchor Trust from 4 October 2010. The Registrant was based at Springfield Care Home and worked as a Nurse Team Leader. 2.2. Following the Registrants successful appointment she attended Safe Handling of Medication and Systems in October 2010, May 2011 and April 2012. In addition the Registrant had completed Boots Care of Medicines Advanced Level in November 2010 and had her competencies assessed in October 2011 and March 2012 2.3. On 4 June 2012 the Registrant was on duty and working from 07:45 until 20:15. Following a medication round the Registrant reported to the Care Manager, Kay Alderson who was off duty at the time, that she administered medication to the wrong customer. The Registrant had administered amoxicillin to Customer A instead of Customer B. Customer A was allergic to penicillin and amoxicillin is a penicillin based medicine. 2.4. The Registrant followed the correct procedures following the medication error in that she contacted a doctor and carried out regular observations on Customer A. Customer A Page 2 of 7
developed a rash the following day and was seen by the community matron who prescribed antihistamine. There were no other adverse effects reported. 2.5. An alert sheet was completed by the Registrant on 4 June 2012 at 14.35. This confirms that the Registrant contacted the doctor following the incident and that she observed the customer. The alert document also confirms that the Registrant contacted the daughter of Customer A and the Home Manager, Kay Alderson, at 9.50. It can be seen on the entry alert sheet on 5 June 2012 that an entry has been made which relates to the rash that Customer A developed. The Registrant s entry reads as follows, At 8.40 during the morning medication round I administered Customer B antibiotic amoxicillin 250mg/5ml to Customer A. The drugs error occurred due to not checking the MAR chart or the bottle. I did not realise I had made the mistake until I was going to give customer B her medication. 2.6. As a result of the error the Registrant was suspended from duty pending an investigation into the incident. The investigation was carried out by Kay Alderson and an investigatory meeting was held on 21 June 2013. It was during this investigation that the Registrant stated that she had not checked approximately twenty customers medication charts prior to administering their medication. The Registrant was asked, Can you describe to me how you administered medication that morning to the Customers? and the reply was, Because I know the meds I didn t check the MAR charts whilst I was giving medications. 2.7. The Registrant however later when asked to sign the investigation minutes disputed some of the questions asked and her responses. The Registrant then went on to say that she administered the medication by referring to the MAR chart for each customer. 2.8. Following the incident being reported to the Home Manager, Kay Alderson, she attended at lunch time on 4 June 2012. When she attended at the Home, none of the morning medication charts had been signed for and these then had been signed by the Registrant on the afternoon of 4 June 2012 after the matter had been reported. The Registrant stated, to save time, I was going to sign after I had finished the medication round. 2.9. The Registrant submitted her resignation on 2 August 2012 and a disciplinary hearing therefore did not take place. The Registrant was instead invited to attend a postresignation meeting and disputed the comments she had made during the earlier investigation meeting. Lisa Wright met with the Registrant on 23 August 2012 who admitted that she had failed to sign the MAR charts and stated, I hold my hand up to not signing, purely to save time; I know bad practice as well. 2.10. It is correct to point out that once the matter had proceed to the Investigating Committee, who found there was a case to answer, the Registrant made full admissions to the charges and also admitted current impairment. Misconduct 3. Ms Settle admits that the facts amount to misconduct because her standards fell short of the requirements of the NMC code, in particular: Impairment Provide a high standard of practice and care at all times 22 You must work with colleagues to monitor the quality of your work and maintain the safety of those in your care. 43 You must complete records as soon as possible after an event has occurred 61 - You must uphold the reputation of your profession at all times Page 3 of 7
4. Ms Settle additionally admits that her fitness to practise is impaired by reason of her misconduct because she: Sanction (a) Has in the past acted and so as to put a patient or patients at unwarranted risk of harm. a. Ms Settle admits that her current fitness to practise is impaired on the basis of a restriction of some form being necessary in the public interest. This is in light of the nature of the matters admitted. b. In relation to future risk of repetition the panel will note that the only issue that should be noted was that the Home Manager mentioned that there had been a minor medication errors previouly but these were dealt with informallly by the Home and there appear to have been no real concerns regarding the Registrant s abilities as a nurse until this particular incident. c. Following the incident, Ms Settle has demonstrated genuine remorse and insight into her conduct. Ms Settle acted in the correct manner following the incident in that she contacted a doctor, completed observations of the customer and contacted the Home Manager. It is also of note that full admissions have been made at an early stage in the proceedings 5. It is respectfully submitted that the appropriate sanction in this case is a Caution Order for 3 years. 5.1 Since the incident Ms Settle has attended the Medication Awareness on 22 October 2012. Then on 23 May 2013 she completed the Safe Management and Administration of Medication. The NMC has received a reference from Elderhomes group, namely the home manager Carol Page. Ms Page confirms that Ms Settle has been employed as a bank RGN since January 2013. As part of the induction Ms Settle completed 3 Medication Administration Competency drug rounds and was deemed to be competence. Ms Page confirms that there have been no issues around her competency in all areas of her work as well as medication administration. In relation to the sanction the panel s attention is drawn to the following parts of the Indicative Sanctions Guidance: 5.2 Paragraph 8: Although panels must exercise their own judgment in making decisions on sanction, they must also take into consideration the standards, guidance and advice the NMC has established to secure the health and well-being of those persons who use the services of nurses and midwives. The starting point for any panel is the extent to which the nurse or midwife has departed from those standards. 5.3. Paragraph 14: Mr Justice Newman, in R (on the application of Abrahaem) v GMC 1 described indicative sanctions guidance in the following terms: Those are very useful guidelines and they form a framework which enables any tribunal, including this court, to focus its attention on the relevant issues. But one has to come back to the essential exercise which the law now requires in what lies behind the purpose of sanctions, which, as I have already pointed out, is not to be punitive but to protect the public interest; public interest is a label which gives rise to separate areas of consideration. 1 [2004] EWHC 279 (Admin) Page 4 of 7
5.4. Paragraph 25: In every case, when considering sanction, panels will wish to pay careful regard to any evidence presented as mitigation at any stage in the proceedings. Mitigation can be considered in three distinct categories: 25.1 Evidence of the nurse or midwife s insight and understanding of the problem, and their attempts to address it. This may include early admission of the facts, apologies to the complainant or the person(s) affected, any efforts to prevent reoccurrence or any efforts to correct the difficulties, and/or 25.2 Evidence of the nurse or midwife s observance of the principles of good practice. This may include a demonstration of keeping up to date with their area of practice, or their previous good character or history, 5.5. Paragraphs 64-65: Therefore, a caution may be appropriate where the case is at the lower end of the spectrum of impaired fitness to practise and the panel wishes to mark that the behaviour was unacceptable and must not happen again. When fitness to practise is impaired by reason of misconduct and a panel is minded to impose a caution order, it should consider whether such an order provides adequate public protection, bearing in mind that it does not restrict the nurse or midwife s practice rights. It might be appropriate where the nurse or midwife s history is such that the panel is confident that there is no risk to the public or to patients which requires the nurse or midwife s practice rights to be restricted. Conclusion 6. Given the evidence of remediation it is not felt that a Conditions of Practice order is appropriate in this case as the matter has already been remedied. 7. It is further felt that a Caution Order serves to reflect the situation of a registrant who has made early, full and frank admissions as to her conduct, with evidence of genuine remorse. Though during a shift Ms Settle made a medication adminsitration error, the public interest is met by marking what is a serious incident in the context of Ms Settle s nursing career. 8. The parties understand that this provisional agreement cannot bind a panel, and that the final decision on findings impairment and sanction is a matter for the panel. The parties understand that, in the event that a panel does not agree with this provisional agreement, the admissions to the charges set out at section 1 above, and the agreed statement of facts set out at section 2 above, may be placed before a differently constituted panel that is determining the allegation. --- The Consensual Panel Determination: provisional agreement was signed by Mr Barraclough, on behalf of Ms Settle and with her authority, on 29 August 2013, and by Aja Hall, on behalf of the NMC, on 28 August 2013. The panel heard and accepted the advice of the legal assessor on its role under this procedure. The panel found all the charges proved by way of admission. The panel took account of Ms Settle s admission of current impairment; however it had in mind that this is a matter for the panel s professional judgement. Page 5 of 7
The panel had sight of Ms Settle s reflective statement, in which she said: I now take my time and ensure I give out the medications in line with the NMC's Standards for Practice of Administration of Medications. I check that I have the right resident, the right medication, the right dose, give via the right route and at the right time. I always check that the resident is not allergic to the medication before administering it. I also ensure that immediately after I have administered the medication I sign the medication MAR chart. I am far more diligent in the administration of medications [ ]. If I do not feel comfortable administering a medication I escalate my concerns to my line manager before administering the medication. In relation to her record keeping, Ms Settle stated: My record keeping has improved and I now keep a note pad on me at all times so that I can make brief notes when required. I now follow more closely the NMC's Guidelines for Records and Record Keeping and this has enhanced my overall documentation. I am more factual and accurate. I always include the date, time and sign at the end of each entry. I have found that my care plans have also improved and are more detailed and clear. Through Ms Settle s early admissions of the allegations, and of current impairment, she has demonstrated a high degree of insight. The panel noted that she has reflected on her conduct and has displayed remorse; this was evident in her reflective statement. Further, Ms Settle acted in the correct manner immediately following the incident in that she contacted a doctor, completed observations of the customer and contacted the Home Manager. However, the panel had in mind the judgment of Council for Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011] EWHC 927 (Admin) which cites Dame Janet Smith s Fifth Report from Shipman in relation to the issue of current impairment. The panel considered whether Ms Settle: a. has in the past acted and/or is liable in the future to act so as to put a patient or patients at unwarranted risk of harm; and/or b. has in the past brought and/or is liable in the future to bring the medical profession into disrepute; and/or c. has in the past breached and/or is liable in the future to breach one of the fundamental tenets of the medical profession [ ]. The panel determined that, in incorrectly administering and recording the administration of medication, Ms Settle put patients at risk of harm. Further, the panel was of the view that her actions brought the profession into disrepute, and public confidence in the profession would be undermined if a finding of impairment were not made. Accordingly, the panel agreed with Ms Settle that her fitness to practise is currently impaired by reason of her misconduct. In considering the issue of sanction, the panel exercised its own judgement and applied the principle of proportionality at all times. It took into account the NMC s Indicative Sanctions Guidance (June 2012). The panel had no comments before it from the referrer in respect of the provisional agreement, and the panel was of the view that, having been put on due notice of the provisional agreement in a letter dated 30 July 2013, the referrer had had sufficient time in which to communicate with the NMC. The panel first considered whether to take no action, but determined that this would not be in the public interest; misconduct of this nature requires a sanction. In its consideration of a caution order, the panel took into account the Indicative Sanctions Guidance, which states that a caution order may be appropriate where the nurse or midwife s history is such that the panel is confident that there is no risk to the public or to patients which requires the nurse or midwife s practice rights to be restricted. The panel bore in mind Ms Settle s insight and her reflection on her conduct and the impact that it may have had on patients. This was an incident which occurred on a single shift on one day. The panel took account of the fact that, subsequent to the incident, Ms Settle attended a Medication Page 6 of 7
Awareness course on 22 October 2012. She also completed a Safe Management and Administration of Medication course on 23 May 2013. The panel also had sight of a reference from the Home Manager of Elderhomes Group, Ms Settle s current employer, dated 10 May 2013. This reference confirmed that Ms Settle has been employed by Elderhomes Group as a registered nurse since January 2013. It stated: As part of her induction she completed 3 Medication Administration Competence drug rounds. She was judged to be competent in her administration of medications and has been dispensing medication unsupervised since February 2013. I can confirm that there have been no issues around her competency in all areas of her work as well as medication administration. The panel concluded, from all the material provided to it, that it is highly unlikely that Ms Settle will repeat her misconduct, and did not deem it necessary to restrict her clinical practice in the light of her remediation. The panel was of the view that there is a public interest in retaining the services of a committed and competent nurse. The panel therefore determined that a caution order would be the appropriate and proportionate sanction. The panel considered that a conditions of practice order would be disproportionate in the particular circumstances of Ms Settle s case, owing to the steps she has taken to remedy the deficiencies in her practice. With the agreement of both parties, the panel has decided to vary the terms of the provisional agreement and impose a caution order for a period of two years, rather than the proposed three years, in order to proportionately reflect the significant remediation and insight demonstrated by Ms Settle. The panel determined that a caution order will not only mark the importance of maintaining public confidence in the profession, but will also send to the public and the profession a clear message about the standards required of a registered nurse. For the next two years, Ms Settle s employer or any prospective employer will be on notice that her fitness to practise was found to be impaired and that her practice is subject to a caution order. At the end of this period the note on Ms Settle s entry in the register will be removed. However, the NMC will keep a record of the panel s finding that her fitness to practise had been found to be impaired. In the event that the NMC receives a further allegation that Ms Settle s fitness to practise is impaired, the record of this panel s finding and its determination will be made available to any practice committee which considers the new allegation. This decision will be confirmed to Ms Settle in writing. That concludes this determination. Page 7 of 7