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Conduct and Competence Committee

Substantive Hearing

3-5 July 2017

Nursing and Midwifery Council, 2 Stratford Place, Montfichet Road, London, E20 1EJ

Name of Registrant Nurse: Miss Kirsty Frangos

NMC PIN: 11D0219E

Part of the register: Registered Adult Nurse - Sub part 1

Area of Registered Address: England

Type of Case: Misconduct

Panel Members: Andrew Gell (Chair, Lay member)

Susan Greenwood (Registrant member)

Eileen Skinner (Lay member)

Legal Assessor: Nigel Parry

Panel Secretary: Aoife Kennedy

Miss Frangos: Present and not represented

Nursing and Midwifery Council: Represented by Katherine Higgins, counsel,

NMC Regulatory Legal Team.

Facts proved: 5, 6

Facts proved by admission: 1a, 1b, 2, 3a, 3b, 3c, 3d, 3e, 4a, 4b

Facts not proved: None

Fitness to practise: Impaired

Sanction: Conditions of practice order (18 months)

Interim Order: Interim conditions of practise order (18 months)

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Details of charge:

That you, a registered nurse, whilst working as a Community Nurse at Great Western

Hospitals Foundation NHS Trust:

1. On 19 April 2015 in respect of Patient C’s community visit:

a. Failed to attend when you were scheduled to do so;

b. Failed to administer insulin as prescribed to the patient.

2. Failed to complete an IR1 incident form in relation to the medication error in

respect of Patient C.

3. On 3 July 2015, following a visit to Patient A:

a. Failed to record your visit;

b. Failed to complete and/or update the patient’s records;

c. Failed to record any clinical assessment made in relation to this patient;

d. Failed to hand over care of this patient to the team and/or arrange any follow

up visits;

e. Failed to complete an ‘e-pex’ entry after your visit.

4. On 18 September 2015 in respect of Patient B’s community visit:

a. Failed to attend when you were scheduled to do so;

b. Failed to administer insulin as prescribed to the patient.

5. Failed to complete an IR1 incident form in relation to the medication error in

respect of Patient B.

6. On 18 September 2015 did not inform your supervisor of your concerns

regarding your own fitness to practise in that you were suffering from a burn to

your leg, the pain from which was causing you to become distracted from your

duties.

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AND in light of the above, your fitness to practise is impaired by reason of your

misconduct.

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Decision and Reasons on application under Rule 19

At the outset of the hearing the panel decided it was necessary to hear certain parts of

the case in private on the basis that proper exploration of your case involves matters

relating to your health.

Ms Higgins indicated that she supported the application to the extent that any reference

to your health should be heard in private.

The legal assessor reminded the panel that while Rule 19 (1) provides, as a starting

point, that hearings shall be conducted in public, Rule 19 (3) states that the panel may

hold hearings partly or wholly in private if it is satisfied that this is justified by the

interests of any party or by the public interest.

Having heard that there will be reference to your health, the panel determined to hold

such parts of the hearing in private. The panel determined to rule on whether or not to

go into private session in connection with your health as and when such issues are

raised.

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Background

You were employed by Great Western Hospital Foundation Trust (the Trust) as a

Community Nurse from 2 April 2013 until 6 November 2015. In your role you were part

of a team but also worked on your own and with colleagues undertaking community

visits.

You were referred by the Trust on 24 November 2015 for allegations surrounding three

events in April, July and September 2015.

It is alleged that, on 19 April 2015, you failed to attend to Patient A and administer a

dose of insulin. You also failed to complete an IR1 incident form in relation to this

incident. You were given a final written warning for this by way of a meeting, followed by

a letter dated 23 June 2015.

It is alleged that on 3 July 2015 you attended a community visit to Patient A and failed to

record the visit, complete and/or update any patient documentation either written or

electronic. It is further alleged that you failed to arrange any follow-up visit for the patient

which meant that he was at risk of not receiving ongoing clinical care. The patient’s next

of kin made contact with the community team on 6 July 2015 asking when there would

be a visit. As a consequence, a community nurse attended on 7 July and discovered

that the wound had broken down. This led to the patient being admitted to hospital for

treatment.

It is alleged that, on 17 September 2015, you suffered a burn to your leg, causing pain

which was severe enough to affect your ability to fulfil your duties as a nurse. The

allegation is that you went on duty on 18 September and did not inform your supervisor

of your concerns regarding the burn on your leg and your own fitness to practise

because of the pain it caused.

It is alleged that, on 18 September 2015, you failed to visit Patient B and administer

insulin, which could have been potentially life threatening to the patient who required

insulin injections twice daily. You failed to complete an IR1 incident form about this

omission.

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Decision on the findings on facts and reasons

In reaching its decisions on the facts, the panel considered all the evidence adduced in

this case together with the submissions made by Ms Higgins, on behalf of the NMC and

those made by you.

The panel heard and accepted the advice of the legal assessor.

The panel was aware that the burden of proof rests on the NMC, and that the standard

of proof is the civil standard, namely the balance of probabilities. This means that the

facts will be proved if the panel is satisfied that it is more likely than not that the

incidents occurred as alleged.

The panel took into account all the oral and documentary evidence in this case. The

panel heard oral evidence from two witnesses called on behalf of the NMC:

Ms 1, Community Nurse Band 6 at the Trust

Ms 1 held an investigation into the alleged incidents of 3 July and 18 September 2015.

She gave evidence outlining your duties and details of the investigation carried out and

its findings.

The panel considered Ms 1 was a credible witness. It noted that her recollection of

events had been impacted by the passage of time.

Mrs 2, Deputy Head of Locality for SARUM

Mrs 2 was your line manager at the time of the alleged incidents. In her evidence she

outlined her communications with you. She provided an overview of relevant interviews

and efforts made to assist you in your practice through a Conduct Improvement Plan

commenced on 20 July 2015.

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The panel found that Ms 2 was a credible and reliable witness. She answered the

panel’s questions to the best of her knowledge.

The panel also heard evidence from you under oath. The panel found your evidence to

be confused at times, although it considered that this was due to the passage of time

affecting your recall of events. The panel is satisfied that you are credible and were not

attempting to deliberately mislead it. However, it did find some of your evidence

unreliable.

At the start of this hearing you admitted the following charges;

That you, a registered nurse, whilst working as a Community Nurse at Great

Western Hospitals Foundation NHS Trust:

1. On 19 April 2015 in respect of Patient C’s community visit:

a. Failed to attend when you were scheduled to do so;

b. Failed to administer insulin as prescribed to the patient.

2. Failed to complete an IR1 incident form in relation to the medication error in

respect of Patient C.

3. On 3 July 2015, following a visit to Patient A:

a. Failed to record your visit;

b. Failed to complete and/or update the patient’s records;

c. Failed to record any clinical assessment made in relation to this patient;

d. Failed to hand over care of this patient to the team and/or arrange any

follow up visits;

e. Failed to complete an ‘e-pex’ entry after your visit.

4. On 18 September 2015 in respect of Patient B’s community visit:

a. Failed to attend when you were scheduled to do so;

b. Failed to administer insulin as prescribed to the patient.

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The panel therefore found those charges proved by admission.

The panel next proceeded to consider the contested charges, directing its attention to

the available evidence, and made the following findings on the balance of probabilities:

Charge 5:

Failed to complete an IR1 incident form in relation to the medication error in respect

of Patient B.

You accepted that you had a duty to complete an incident form and that you did not fulfil

that duty. The panel noted your evidence during this hearing in which you stated that

you did not complete the form because you did not have time. The panel considered

that the form should have been completed on 22 September 2015 when you realised

the error or, failing that, on 23 September when you were also at your work premises.

The panel found that, on the balance of probabilities, you did have a duty to complete

an IR1 incident form in relation to the medication error, and that you did not carry out

that duty.

Accordingly, the panel found charge 5 PROVED.

Charge 6:

On 18 September 2015 did not inform your supervisor of your concerns regarding

your own fitness to practise in that you were suffering from a burn to your leg, the

pain from which was causing you to become distracted from your duties.

In your oral evidence you stated that you were not distracted by the pain from your burn,

but rather by your colleague who was demonstrating bullying behaviour towards you.

You told the panel that you had specifically asked Mrs 2 not to allocate you to the same

shift as this colleague as she had been bullying you for some time. Despite this, you

were put on a shift with her on 18 September 2015. During the shift she criticised your

work and told you, “it would be better for you to go on benefits as you are not a good

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nurse”. While you accepted that your burn was causing you pain, you told the panel that

it had not distracted you from your work. You stated that it was your colleague’s bullying

behaviour that had distracted you.

In your statement to the NMC received on 10 December 2015 you stated:

“I have gone over that evening in my head so many times and I still do. I myself

cannot understand why I missed the call. The only explanation I have is that the

pain I was in following the burn to my left leg the previous evening distracted me

from my work and I wish I had not attended work that day. I tried to explain the

situation to my line manager.”

The panel considered that your explanation in your statement to the NMC, which was

given about two and a half months after the incident occurred, was more reliable than

the explanation you gave to the panel at this hearing nearly two years later. In your

evidence you accepted that you had not mentioned anything about your burn to your

supervisor at the time, even though you met with her on 18 September 2015.

Accordingly, the panel found charge 6 PROVED.

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Decision on misconduct and impairment:

Having announced its finding on all the facts, the panel then moved on to consider

whether the facts found proved amount to misconduct and, if so, whether your fitness to

practise is currently impaired by reason of that misconduct. The NMC has defined

fitness to practise as a registrant’s suitability to remain on the register without restriction.

The panel had regard to the submissions of Ms Higgins on behalf of the NMC and from

you. The panel also had regard to your reflective statements and your oral evidence.

The panel accepted the advice of the legal assessor.

In determining whether your fitness to practise is currently impaired, the panel has

borne in mind that this is a two stage process. It first considered whether the facts found

proved in this case amount to misconduct and, if so, whether as a result of that

misconduct, your fitness to practise is currently impaired.

The panel acknowledged that there is no burden or standard of proof at this stage of the

proceedings and that the issues of misconduct and impairment remain matters for the

independent judgment of the panel.

In reaching its decision the panel bore in mind its duty to protect the public, to maintain

public confidence in the profession and the regulatory process, and to declare and

uphold proper standards of behaviour and conduct.

The panel considered first whether the facts giving rise to the charges amounted to

misconduct on your part. This case involves your failure to administer drugs, attend

community visits, complete IR1 incident forms, and communicate effectively verbally or

by record keeping, as well as your attending work when not fit to do so. All of these

placed your patients at a real risk of harm.

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The panel took into account your personal circumstances at the time of the events.

[PRIVATE]. The panel considered that these were significant factors in your failures.

However, it recognised that your failures were multiple and that some were repeated.

The panel considered that your actions breached the 2015 Code (The code:

Professional Standards of Practice and Behaviour for nurses and midwives) (“the

Code”). It considered that the following paragraphs of the Code had been breached:

Practice effectively

8 Work cooperatively

8.2 maintain effective communication with colleagues

8.3 keep colleagues informed when you are sharing the care of individuals with

other healthcare professionals and staff

…

10 Keep clear and accurate records relevant to your practice

This includes but is not limited to patient records. It includes all records that are

relevant to your scope of practice.

…

Preserve safety

16.1 raise and, if necessary, escalate any concerns you may have about patient or

public safety, or the level of care people are receiving in your workplace or any

other healthcare setting and use the channels available to you in line with our

guidance and your local working practices

…

Promote professionalism and trust

20.1 keep to and uphold the standards and values set out in the Code

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The panel was aware that not every act 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. However, the Code clearly establishes the

basic rules and standards ordinarily required to be followed by a registered nurse. In all

the circumstances, the panel found that the facts found proved were sufficiently serious

to constitute misconduct.

The panel then went on to consider whether by reason of your misconduct your fitness

to practise is currently impaired. The panel reminded itself that it should consider not

only the risk that a registrant poses to members of the public, but also the public interest

in upholding proper professional standards and public confidence in the NMC as a

regulator, and whether those aims would be undermined if a finding of impairment were

not made in the circumstances.

The panel reminded itself of the guidance of Mrs Justice Cox in Council for Healthcare

Regulatory Excellence v. NMC and Paula Grant [2011] EWHC 927 (Admin), adopting

the test proposed by Dame Janet Smith in the Shipman enquiry:

“Do our findings of fact in respect of the doctor’s [nurse’s] misconduct, deficient

professional performance, adverse health, conviction, caution or determination show

that his/her fitness to practise is impaired in the sense that s/he:

a) Has in the past acted and/or is liable to act in the future 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 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 profession; and/or.

d) …”

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The panel found that the first three limbs are engaged in relation to the charges

admitted and found proved. You accepted this in your submissions.

The panel had regard to whether your misconduct was easily remediable, whether it

had been remedied and whether it is likely to be repeated. The panel found that your

misconduct is capable of remediation. You have been open and honest and have

acknowledged your failings from the beginning of proceedings. You have not been

working as a nurse since your referral, although the panel noted that you had personal

issues which prevented you from doing so. The panel found that you have accepted

personal responsibility, as shown in the evidence you gave at this hearing and in your

detailed reflections submitted to the NMC and received on 10 December 2015, and 1

March 2017.

The panel considered that you have shown full insight into your failings and have

demonstrated an understanding of the potential impact your actions could have had

upon your patients, your colleagues, and the wider reputation of the nursing profession.

The panel considered that you have shown clear evidence of remorse for your actions.

It also considered that you have shown insight into how you might manage your own

behaviour and seek support should you face similar challenges in the future.

The panel noted that you have developed different coping strategies to address any

issues that arise from your health and work environment, such as being subject to

bullying behaviour. However, the panel noted that you have not yet had the opportunity

to put these strategies into effect in a nursing environment, and that a risk of repetition

therefore remains. [PRIVATE]. In all of these circumstances, the panel found that your

fitness to practise is currently impaired on the grounds of public protection.

The panel decided that your misconduct was serious and undermined the trust and

confidence the public has in the profession. For all the reasons thus far, the panel

further determined that the need to uphold proper professional standards and public

confidence in the profession would be undermined if a finding of current impairment was

not also made.

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Accordingly the panel determined that your current fitness to practise is impaired by

reason of your misconduct.

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Determination on sanction:

Having determined that your fitness to practise is impaired, the panel has considered

what sanction, if any, it should impose. In reaching its decision, the panel has

considered all the evidence provided, together with Ms Higgins’ oral submissions.

The panel accepted the advice of the legal assessor.

The panel has considered this case very carefully and has decided to make a conditions

of practice order for 18 months. The effect of this order is that your name on the NMC

register will show that you are subject to a conditions of practice order and anyone who

enquires about your registration will be informed of this order.

The panel has borne in mind that any sanction imposed must be appropriate and

proportionate and, although not intended to be punitive in its effect, may have such

consequences. The panel had careful regard to the Indicative Sanctions Guidance

(“ISG”) published by the NMC. It had regard to the need to protect the public as well as

the wider public interest. It recognised that the decision on sanction is a matter for the

panel, exercising its own independent judgement.

Before making its decision on the appropriate sanction, the panel established the

aggravating and mitigating features in your case.

The panel considered the aggravating features to be:

The repeated nature of your failures

The uniqueness of the community setting in which you were working

The potential for serious harm to patients

The panel considered the mitigating features to be:

[PRIVATE]

The environment in the workplace at the time of events

You have demonstrated full insight

Your admissions to charges 1 to 4

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Your previous unblemished record

You have attended and engaged fully during this hearing

The panel first considered whether to take no action but concluded that this would be

inappropriate in view of the seriousness of the case. The panel decided that it would be

neither proportionate nor in the public interest to take no further action.

Next, in considering whether a caution order would be appropriate in the circumstances,

the panel took into account the ISG, which states that a caution order 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.’ The panel considered that your misconduct was not at the lower end

of the spectrum and that a caution order would be inappropriate in view of the

seriousness of the case and the continuing risk identified. The panel decided that it

would be neither proportionate nor in the public interest to impose a caution order.

The panel next considered whether placing conditions of practice on your registration

would be a sufficient and appropriate response. The panel is mindful that any conditions

imposed must be proportionate, measurable and workable. The panel took into account

the Indicative Sanctions Guidance (‘ISG’), in particular:

64 This sanction may be appropriate when some or all of the following factors are

apparent (this list is not exhaustive):

64.1 No evidence of harmful deep-seated personality or attitudinal problems

64.2 Identifiable areas of nurse or midwife’s practice in need of assessment

and/or retraining

64.3 No evidence of general incompetence

64.4 Potential and willingness to respond positively to retraining

64.5 Nurse or midwife has insight into any health problems and is prepared to

agree to abide by conditions on medical condition, treatment and supervision

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64.6 Patients will not be put in danger either directly or indirectly as a result of

conditional registration

64.7 The conditions will protect patients during the period they are in force

64.8 It is possible to formulate conditions and to make provision as to how

conditions will be monitored

The panel determined that it would be possible to formulate appropriate and practical

conditions, as set out in paragraph 64 of the ISG, which would address the failings

highlighted in this case and be sufficient to protect the public. The panel noted that you

would be willing to comply with conditions of practice.

Balancing all of these factors and after having taken into account both the aggravating

and mitigating features of this case, the panel determined that the appropriate and

proportionate sanction is that of a conditions of practice order.

The panel was of the view that to impose a suspension order or a striking off order

would be wholly disproportionate and would not be a reasonable response in the

circumstances of your case.

The panel determined that the following conditions are appropriate and proportionate in

this case:

1. At any time that you are employed or otherwise providing nursing services, you

must place yourself and remain under the direct observation of a registered

nurse nominated by your employer, until such time as you have been assessed

by a registered nurse as competent to work unsupervised in all of the following

areas:

Record keeping

Caseload management

Risk management

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2. You must work with your line manager (or their nominated deputy) to create a

personal development plan designed to address the concerns about the areas of

your practice listed in condition 1.

3. You must meet with your line manager (or their nominated deputy) at least once

a month to discuss the standard of your performance and your progress towards

achieving the aims set out in your personal development plan.

4. You must forward to the NMC a copy of your personal development plan prior to

the review of this order.

5. 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 (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.

6. You must tell the NMC within 7 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 tell the NMC about any professional investigation started against you

and/or any professional disciplinary proceedings taken against you within 7 days

of you receiving notice of them.

8. a) You must within 7 days of accepting any post of employment requiring

registration with the NMC, or any course of study connected with nursing, provide

the NMC with the name/contact details of the individual or organisation offering

the post, employment or course of study.

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b) You must within 7 days of entering into any arrangements required by these

conditions of practise provide the NMC with the name and contact details of the

individual/organisation with whom you have entered into the arrangement.

9. [PRIVATE].

10. You must immediately tell the following parties that you are subject to a

conditions of practice order under the NMC’s fitness to practise procedures and

disclose to them the conditions listed at (1) to (9) above:

1. Any organisation or person employing, contracting with or using you to

undertake nursing work

2. Any agency you are registered with or apply to be registered with (at the

time of application) to provide nursing services

3. Any prospective employer (at the time of application) where you are

applying for any nursing appointment

4. Any educational establishment at which you are undertaking a course of

study connected with nursing, or any such establishment to which you

apply to take a course (at the time of application).

11. [PRIVATE]

12. [PRIVATE]

The period of this order is for 18 months. The period of 18 months will allow you

adequate time to demonstrate that you have addressed your shortcomings.

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 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 for another order.

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Decision on interim order and reasons:

The panel has considered the submission made by Ms Higgins, on behalf of the NMC,

that an interim conditions of practice for a period of 18 months should be made on the

grounds that it is necessary for the protection of the public and is otherwise in the public

interest.

The panel accepted the advice of the legal assessor.

The panel was satisfied that an interim order was necessary for the protection of the

public and was otherwise in the public interest. In reaching the decision to impose an

interim order, the panel had regard to the reasons set out in its decision for the

substantive order. The panel decided to impose an interim suspension order for the

same reasons as it imposed the substantive order. To do otherwise would be

incompatible with its earlier findings.

The period of this interim suspension order is for 18 months to allow for the possibility of

an appeal to be made and determined. If no appeal is made then the interim order will

be replaced by the substantive order 28 days after the decision of this hearing is sent to

you in writing.

That concludes this determination.

This decision will be confirmed to you in writing.