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Fitness to Practise Committee Substantive order review hearing 15 February 2018 Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE

Name of registrant: Susan Anne Beevers

NMC PIN: 77A0283E

Part(s) of the register: Registered Nurse – Sub Part 1

Adult Nursing – April 1980

Registered Midwife – August 1981

Area of registered address: Yorkshire

Type of case: Misconduct

Panel Members: Jane Davis (Chair – Registrant member)

Linda Tapson (Registrant member)

Trevor Spires (Lay member)

Legal Assessor: Paul Hester

Panel Secretary: Anita Abell

Ms Beevers: Present and represented by Andrew

Bousfield, Counsel instructed by

Thompsons Solicitors

Nursing and Midwifery Council: Represented by Daniel Walker, Case

Presenter

Order to be reviewed: Suspension order for 12 months

Outcome: Conditions of practice order for 18

months to take effect from end of 29 March

2018 under Article 31 of the Nursing and

Midwifery Order 2001

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Decision and Reasons:

The panel determined that your fitness to practise remains impaired. The panel

decided to impose a conditions of practice order for a period of 18 months to take

effect from end of 29 March 2018.

This hearing was the first review of a twelve month suspension order imposed on

your registration by a panel of the Conduct and Competence Committee on 24

February 2017. The order expires on 29 March 2018.

Substantive hearing 23-24 February 2017 At the substantive hearing held between 23-24 February 2017 the following charges

were admitted and found proved:

Charges

That you, a registered midwife and whilst employed as a Band 6 Midwife on the

Delivery Suite at St James' University Hospital:

1. On 7 April 2015 and in relation to Patient A:

1.1. At or around 07.47 and after categorising the cardiotocography ("CTG")

trace as 'suspicious' failed to request a review from an obstetrician

1.2. At or around 08.15 incorrectly categorised the CTG trace as 'normal'

when the CTG trace was 'suspicious'

1.3. Incorrectly increased the dose of syntocinon at or around one or more of

the following times:

1.3.1. 08.41

1.3.2. 09.24

1.3.3. 10.02

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1.4. Between 10.17 and 11.36 failed to record a categorisation of the CTG

1.5. Between 10.24 and 11.22 failed to identify that the CTG trace was

pathological

1.6. At or after 11.26 failed to record your reasons for performing an

episiotomy

1.7. At or around 16.20 recorded that you had given fluids at one or more of

the following times, when you had not been responsible for Patient A's

care:

1.7.1. 02.19

1.7.2. 04.20

1.7.3. 07.00

2. On 19 April 2015 and in relation to Patient B:

2.1. Failed to record your reason for not undertaking a vaginal examination

within one hour prior to commencing syntocinon at 00:44

2.2. Failed to take, and/or failed to record that you had taken, blood pressure

readings every five minutes for one or more of the following 15 minute

periods:

2.2.1. 02.10 – 02.25

2.2.2. 03.06 – 03.21

2.3. At or around 04.43 failed to record your reason for catheterising the

patient

2.4. At or around 06.48:

2.4.1 failed to escalate a foetal bradycardia that had lasted for more

than three minutes and/or

2.4.2 failed to discontinue syntocinon

2.5. Failed to record why you amended your categorisation of the CTG at

06.57 from 'suspicious' to 'pathological'

That you, a registered midwife:

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3. On 27 February 2016 stole a number of products from Boots the Chemist;

4. On 19 March 2016 stole a number of products from Boots the Chemist.

In light of the above your fitness to practise is impaired by reason of your

misconduct.

Extract from Panel Reasons February 2017:

Agreed Facts

The panel was provided with the following statement of facts which was agreed by

both parties:

It is agreed between the parties that the facts are as follows:

1. “On 18 August 2015, the NMC received a complaint about Mrs Beevers with

regards to her practice in April 2015.

2. Mrs Beevers was employed as a midwife at the Leeds Teaching Hospital NHS

Trust (“the Trust”) since December 2014. Mrs Beevers initially worked in the

delivery suite (“the Ward”) at St James’ University Hospital (“the Hospital”) but in

April 2015 was transferred to the post-natal ward following concerns raised in

relation to two incidents which occurred on 7 and 18/19 April 2015. Mrs Beevers

was subsequently suspended whilst an investigation was commenced into the

incidents,

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3. The Trust’s investigation was conducted by Ms 1, Delivery Suite Manager.

Additionally, a Local Supervisory Authority (“LSA”) supervisory investigation was

also conducted by Ms 2, Supervisor of Midwives.

March 2015

4. In or around March 2015, Mrs Beevers was responsible for the care of a diabetic

patient whose baby was born with low blood glucose levels. Mrs Beevers

conducted a blood sugar test with a result of 0.0mmol/l. Mrs Beevers did not

request a review from the doctor and instead decided to cup feed the baby. The

baby subsequently became unwell so Mrs Beevers took the baby out of the room

and out to the corridor. Another midwife, Ms 3, took the baby from Mrs Beevers

and went back into the room where the baby was resuscitated. Ms 3 also called

the doctor to review the baby and the baby was subsequently transferred to the

critical care unit for observation. There was no harm to the baby and no action

was taken in relation to this incident.

7 April 2015

5. On 7 April 2015, Patient A, a low risk primigravida was admitted to the Ward on 7

April 2015 in spontaneous labour. At 06:45, Patient A was prescribed syntocinon

to augment her labour. Syntocinon is a synthetic oxytocin that helps to increase

the rate of a woman’s contractions. The dose needed to be increased every 30

minutes in line with the Trust’s guidelines Oxytocin for the Induction and/or Augmentation of Labour in Pregnant Women. The syntocinon regime was

correctly commenced at 07:00 with an initial dose of 1.00ml/hr.

6. Mrs Beevers took over Patient A’s care at 07:24. At 07:32 she increased the

dose of syntocinon to 2.00ml/hr. At 07:47, Mrs Beevers categorised the

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cardiotocography (“CTG”) scan for Patient A as “suspicious” due to the presence

on non-reassuring feature, being that the fetal heart rate had dropped to 100 bpm

for a period of 90 seconds. Due to the fact that Patient A was receiving

syntoconin the Delivery Suite Coordinator should have been informed that the

CTG was suspicious and the Obstetrician should have been asked to review

Patient A. This is because the use of syntocinon can cause a decrease in the

fetal heart rate. Mrs Beevers did not request a review and instead made a plan

to observe Patient A for a further 30 minutes then reassess the CTG. Mrs

Beevers did not change the syntocinon regime.

7. At 08:04, Mrs Beevers increased the dose of syntocinon to 4.0ml/hr. At 08:15,

Mrs Beevers categorised that CTG scan as “normal”. At 08:17, Ms 3 reviewed

the CTG scan and disagreed with Mrs Beevers categorisation: she categorised

the CTG as ‘suspicious’ due to the presence of decelerations, a non-reassuring

feature.

8. Mrs Beevers increased the dose of syntocinon to 6.00 ml/hr at 08:41, to 8.00

ml/hr at 09:24 and then to 12.00 ml/hr at 10:02. This was not in line with the

Trust’s guidelines, which provide that the dose should have been increased to

8.00 ml/hr, then to 12.00 ml/hr and finally to 18.00 ml/hr.

9. AT 10:07, Mrs Beevers documented her review of the CTG, stating that the CTG

was “NORMAL FOR 2ND STAGE”. This is not a recognised way of categorising

a CTG. Mrs Beevers did not ensure that this assessment was checked by a

‘buddy’, When in line with the Trust’s Guidelines in relation to fetal monitoring

which advises that the CTG should be ‘buddied’ by another midwife hourly or at

least every two hours as a minimum. The CTG had been buddied at 08:17 and

09:19.

10. At or around 10:40, Mrs Beevers buzzed for a second midwife to attend. Ms 4, a

midwife, answered the call and entered Patient A’s room. Ms 4 remained in the

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room with Patient A from 10:41 until 10:57. When Ms 4 entered the room Mrs

Beevers was poised to deliver Patient A’s baby. The vertex was on the perineum

and delivery appeared to be imminent. After a few minutes the baby had not

been delivered and Mrs Beevers asked Ms 4 to remain the room while she went

for a bathroom break. The baby was not born during Mrs Beevers absence and

when she returned. Ms 4 left Patient A’s room to go back to her own patient. At

this time, the vertex remained on the perineum but was not advancing and Ms 4

advised Mrs Beevers to call for assistance again when required.

11. Mrs Beevers recorded in Patient A’s notes that she called for a second midwife at

11:21. Ms 4 states that she returned to Patient A’s room of her own accord,

without being called, at approximately 10:24. The CTG trace showed that there

was atypical deep decelerations of the fetal heart with more than half of Patient

A’s contractions and the baseline had become tachycardic.

12. When Ms 4 entered the room she saw that Mrs Beevers was performing an

episiotomy. The episiotomy was recorded as being performed at 11:26. Mrs

Beevers’s record in respect of the episiotomy was not made until 17:58 and

provided no explanation as to why the episiotomy was required.

13. Ms 4 asked Mrs Beevers whether she had reviewed the CTG since she had last

been in the room and Mrs Beevers said that she had not. Ms 4 waited for Patient

A's next contraction and the vertex did not deliver. Ms 4 therefore opened the

door and notified Ms 3 that assistance was required by way of immediate medical

review. At 11:27, Mrs Beevers recorded in the notes “PUSHING ENCOURAGED

VX POSSIBLY OP POSITION ASSISTANCE FROM DR REQUESTED BUSY IN

THEATRE AT PRESENT WILL COME”. Ms 4 states that shortly after she had

informed Ms 3 of the need for medical review, she then requested a review from

Dr 2, Registrar. Ms 3 states that she requested the review from Dr 1.

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14. Ms 4 began preparing Patient A for an instrumental delivery. Dr 1 entered Patient

A's room within 60 to 90 seconds of being called. Shortly after she entered the

room, at 11:36, Patient A gave birth by kiwi ventouse delivery. Following the birth

the baby ("Baby A") required inflation breaths. Ms 4 assisted with the

resuscitation and Baby A's respiratory effort and heart rate improved. Within two

minutes of birth the heart rate was regular and Baby A was crying. Baby A

remained under observation on the resuscitaire and was returned to Patient A at

11 minutes of age. Between 10:17 and the birth at 11:36 Mrs Beevers had not

recorded any review of the CTG.

15. The Ward operates a computer records system 'K2'. Midwives are expected to

record their actions on the computer as they go, rather than handwriting notes.

Mrs Beevers made multiple retrospective entries on the patient notes for Patient

A. Amongst the retrospective entries made by Mrs Beevers were records

indicating that fluids were given to Patient A at 02:19, 04:20 and 07:00 on 7 April

2015. Mrs Beevers did not take over Patient A's care until 07:24 and could

therefore not have administered fluids at the times stated. Next to each of the

records on the K2 notes a time stamp indicating the time of the entry appears.

Each of the previously mentioned records was made by Mrs Beevers between

16:20 and 16:21 on 7 April 2015.

16. Mrs Beevers made further retrospective entries for the actions that she took

immediately prior to Patient A giving birth, including:

a. 10.51 Fetal Heart Rate – 160bpm (Recorded by Mrs Beevers at 13:11)

b. 11:00 Fetal Heart Rate - 160bpm (Recorded by Mrs Beevers at 13:11)

c. 11:11 Maternal Temperature - 37.1oC (Recorded by Mrs Beevers at

13:17)

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d. 11:11 Maternal Pulse - 89bpm (Recorded by Mrs Beevers at 13:17)

e. 11:11 Blood Pressure – 139mmHg/86 mmHg, calculated Mean Arterial

Pressure (MAP) 103 mmHg (Recorded by Mrs Beevers at 13:17)

f. 11:11 Maternal SpO2 - 98% (Recorded by Mrs Beevers at 13:17)

g. 11:11 Respiratory Rate - 16 breaths/min (Recorded by Mrs Beevers at

13:17)

h. 11:11 Neuro Response - Alert (Recorded by Mrs Beevers at 13:17)

i. 11:11 2nd Stage Maternal Status - Effective Pushing – Yes; Head

Descent – Yes; Maternal Position Checked – Yes; Bladder Care

Checked – No; Emotional Needs Considered - Yes (Recorded by Mrs

Beevers at 13:18)

j. 11:15 Fetal Heart Rate - 100bpm (Recorded by Mrs Beevers at 13:15)

k. 11:20 Note: Infiltration Lidocaine 1% 5mls with consent for Episiotomy

(Recorded by Mrs Beevers at 17:56)

l. 11:20 Fetal Heart Rate – 165bpm (Recorded by Mrs Beevers at 13:15)

m. 11:21 Note: 2nd Midwife called for (Recorded by Mrs Beevers at 13:22)

n. 11:25 Fetal Heart Rate – 165bpm (Recorded by Mrs Beevers at 13:16)

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o. 11:26 Note: Episiotomy performed with consent (Recorded by Mrs

Beevers at 17:58)

p. 11:27 Note: Pushing encouraged vx [vertex] advancing possibly op

[occipital posterior] position assistance from Dr requested busy in

theatre at present will come (Recorded by Mrs Beevers at 13:23

q. 11:30 Fetal Heart Rate – 143bpm (Recorded by Mrs Beevers at 13:16)

18/19 April 2015

17. On the night shift of 18/19 April 2015, Mrs Beevers was responsible for the care

of Patient B, who was admitted to the Ward for induction of labour. Mrs Beevers

took over Patient B's care at 23.10. The Coordinator for the shift was Ms 5.

18. The Trust's guidelines on Oxytocin for the Induction and/or Augmentation of Labour in Pregnant Women state that “an abdominal palpation and vaginal

examination should have taken place within the last hour prior to commencement

of oxytocin”. Patient B was commenced on a syntocinon regime at 00:44 on 19

April 2015. Mrs Beevers had performed a vaginal examination of Patient B at

23:14 on 18 April 2015, which was not within the hour prior to commencement of

syntocinon. No reason for the failure to perform the vaginal examination was

recorded in the notes. During interview with Ms 2, Mrs Beevers stated that she

had not performed another vaginal examination prior to commencing syntocinon

because Patient B's membranes had ruptured and performing another

examination within a short amount of time could pose an infection risk. Ms 2 felt

that Mrs Beevers’s decision not to perform the examination was appropriate in

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the circumstances, but the reason for this should have been recorded in Patient

B's notes.

19. At 02:10, Mrs Beevers recorded “TOP UP DOSE GIVEN AS FEELING

CONTRACTIONS” and “Epidural Catheter Top-Up Dose” at 02:11. The Trust's

guidelines on Regional Anaesthesia for Pain Relief in Labour provide two

different procedures following the administration of a top up epidural. The first is

that after each top up the mother's blood pressure should be measured “every

five minutes for 20 minutes”. The second is that the blood pressure should be

recorded “every five minutes for 15 minutes”. Mrs Beevers recorded taking

Patient B's blood pressure at 02:12, 02:19, 02:31 and 02:38. This is not in line

with either guideline.

20. Mrs Beevers gave a further epidural top-up to Patient B at 03:06. Mrs Beevers

then recorded taking Patient B's blood pressure at 03:08 and 03:12. There are no

further records of Patient B's blood before a further epidural top up was given to

Patient B at 03:48.

21. At 04:43 Mrs Beevers recorded that she had inserted a catheter for Patient B with

consent. Mrs Beevers did not document the reason for inserting the catheter.

22. At approximately 07:00 Ms 5 looked at the central monitor, which is located at the

central area of the Ward, and reviewed the CTG for each of the patients on the

Ward at that time. When Ms 5 looked at the CTG for Patient B she noticed that

the CTG showed a fetal bradycardia, which is a prolonged deceleration of the

fetal heartbeat. Ms 2, Ms 1 and Ms 5 all provide evidence in relation to the CTG

trace for this period. Ms 2 states that the fetal decelerations were apparent

between 06:46 and approximately 06:52. Ms 1 states that there was a significant

drop in the fetal heartrate from 06:45 until 06:53. Ms 5 states that the bradycardia

had been ongoing from around 06:50 and was recovering when she entered

Patient B's room at around 07:00. The baseline for the fetal heartrate was

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approximately 130bpm, but dropped to around 80bpm. There was no harm to the

baby as a result of the bradycardia.

23. A bradycardia lasting for three minutes or longer should be escalated to a doctor.

Mrs Beevers did not take any action to escalate the bradycardia despite the fact

that it lasted for a period of at least eight minutes. At around 07:00, Dr 2 entered

Patient B's room, together with Ms 5. By this time the fetal heartrate had

recovered. Mrs Beevers made a recorded in Patient B's notes at 06:53 “Dr called”

but no record of the doctor's review was made until 07:00.

24. Mrs Beevers summarised her review of the CTG for Patient B at 06:57, in which

she categorised the CTG as suspicious. Mrs Beevers also recorded the following,

“BRADYCARDIA FOLLOWING VE FSE APPLIED TURNED LEFT LAT

RECOVERED TO BASELINE”. At approximately 07:13, Mrs Beevers deleted

these records and made an update entry stating that the CTG was pathological.

Mrs Beevers recorded “FSE APPLIED PT ON BACK BRADY DOWN TO 80PM

TURNED TO L LAT FLUIDS INCREASED”. During Mrs Beevers’s interview with

Ms 2 she stated that she had initially thought the CTG was suspicious, but

updated this after the doctor had reviewed Patient B and found that the CTG had

been pathological.

Outcome of the LSA & Trust Investigations

25. Ms 2 completed her investigation for the LSA on 30 June 2015 and drafted two

separate investigation reports for the incidents of 7 April and 18/19 April 2015.

Ms 2 found that Mrs Beevers had not demonstrated competence in relation to the

following areas of practice:

7 April 2015:

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a. Following clinical guidelines in relation to fetal monitoring

b. Recognising fetal compromise and escalating appropriately

c. Following protocol in relation to the syntocinon regime as per Trust

guideline

d. Accurately documenting reasons for altering an entry in the medical

records

e. Documenting an indication for undertaking an episiotomy

18/19 April 2015:

a. Following clinical guidelines in relation to fetal monitoring

b. Recognising fetal compromise and escalating appropriately

c. Following guidelines relating to post epidural anaesthesia observations

d. Accurately documenting care in relation to intravenous fluids and

bladder care

e. Failing to accurately document reasons for altered entry in the medical

records

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26. Ms 1 completed her investigation for the Trust and produced an investigation

report. During the course of the investigation Mrs Beevers raised mitigating

factors, including that she was feeling ill during the incident on 7 April 2015 and

felt that she was having a hypoglycaemic episode. Ms 1 found that the following

allegations were substantiated.

a. Negligence in duty that compromised the safety of patients;

b. Breach of the NMC code of Conduct; and

c. Failure to follow Trust Guidelines and Protocols in relation to fetal

monitoring.

27. Ms 1 recommended that the matter be taken to a disciplinary hearing. The

disciplinary hearing took place on 18 November 2015 and Ms 1 presented the

management case. The outcome of the hearing was that a final written warning

was placed on the Mrs Beevers’s file. Mrs Beevers is no longer employed by the

Trust and plans to take early retirement. She does however plan to undertake

work through an Agency.”

Misconduct and impairment

The panel was of the view that your actions amounted to the following breaches of

the The Code: Professional standards of practice and behaviour for nurses and

midwives 2015 (the Code):

1 Treat people as individuals and uphold their dignity

To achieve this, you must:

1.2 make sure you deliver the fundamentals of care effectively

6 Always practise in line with the best available evidence

To achieve this, you must:

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6.2 maintain the knowledge and skills you need for safe and effective practice.

8 Work cooperatively

To achieve this, you must:

8.3 keep colleagues informed when you are sharing the care of

individuals with other healthcare professionals and staff

8.4 work with colleagues to evaluate the quality of your work and that of

the team

8.5 work with colleagues to preserve the safety of those receiving care

8.6 share information to identify and reduce risk,

10 Keep clear and accurate records relevant to your practice

To achieve this, you must:

10.1 complete all records at the time or as soon as possible after an

event, recording if the notes are written some time after the event

10.2 identify any risks or problems that have arisen and the steps taken to

deal with them, so that colleagues who use the records have all the

information they need

10.3 complete all records accurately and without any falsification, taking

immediate and appropriate action if you become aware that

someone has not kept to these requirements

13 Recognise and work within the limits of your competence

To achieve this, you must:

13.1 accurately assess signs of normal or worsening physical and mental

health in the person receiving care

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13.2 make a timely and appropriate referral to another practitioner when it

is in the best interests of the individual needing any action, care or

treatment

13.3 ask for help from a suitably qualified and experienced healthcare

professional to carry out any action or procedure that is beyond the

limits of your competence

16 Act without delay if you believe that there is a risk to patient safety or public protection

To achieve this, you must:

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

20 Uphold the reputation of your profession at all times

To achieve this, you must:

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

20.2 act with honesty and integrity at all times, treating people fairly and

without discrimination, bullying or harassment

20.4 keep to the laws of the country in which you are practising

The panel accepted that breaches of the Code do not automatically result in a finding

of misconduct. However, the panel was of the view that your actions fell far below

the standards expected of a registered midwife. The panel found that your conduct

was a serious departure from the Code in relation to the standards of integrity

fundamental to the requirements of being a registered midwife and to upholding the

reputation of the profession.

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The panel considered that your behaviour was sufficiently serious to amount to

misconduct.

Decision on impairment

In addressing impairment, the panel bore in mind that its concern was with the

current position, looking forwards, not backwards. However, past events could assist

it in making judgments about what is likely to happen in the future. It took account of

the test set out in the Fifth Shipman Report and quoted with approval by Mrs Justice

Cox in the case of Council for Healthcare Regulatory Excellence v (1) Nursing and

Midwifery Council (2) Grant [2011] EWHC 927 (Admin).

“Do our findings of fact in respect of [the registrant’s] misconduct show that her

fitness to practise is impaired in the sense that she:

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 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;

d. has in the past acted dishonestly and/or is liable to act dishonestly in the

future.”

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The panel was satisfied that you have in the past acted so as to put patients at

unwarranted risk of harm. Although there was no evidence of actual patient harm,

your record keeping errors and in particular failure to escalate a number of concerns

including a foetal bradycardia involved potential harm to patients. Your failure to

provide good care put mothers and their babies at risk of suffering harm. The panel

considered that the facts found proved are serious in nature, multiple, and wide-

ranging, and cover specific concerns relating to basic clinical practise.

The panel also found that your actions had in the past brought the professions into

disrepute. The panel also found that your actions had in the past breached the

fundamental tenets of the nursing profession both in your clinical practice and your

dishonest conduct.

The panel next considered whether you would be liable in the future to act in such a

way as to exhibit current impairment as set out in the Fifth Shipman Report. It took

into account any evidence of your insight and remediation. The panel acknowledged

that you have made early admissions to the charges and made efforts to

demonstrate insight. The panel found that in oral evidence, you have been open and

honest with the panel. You also provided evidence that you have taken steps to

remedy your failings. Further you have reflected on the incidents in question as

evidenced in your reflective pieces. You have some understanding into the events

and circumstances surrounding your misconduct. You told the panel about the

difficult personal and family circumstances and the significant stress you were under.

You have also shown remorse for your actions and made apologies. You assured

the panel that you have developed coping mechanisms and have the relevant

support if faced with a similar situation to enable you to act differently.

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However, the panel found your oral evidence at times to be confusing, unclear and

somewhat contradictory particularly in relation to the issues of impairment and

remediation. The panel did not find that you had a clear understanding of what you

meant by accepting that your fitness to practise was impaired and during the course

of questioning on occasions you recognised you were impaired whilst on other

occasions you considered yourself safe to practise with no risk of repetition.

In relation to remediation, the panel acknowledged your efforts: you have provided

several examples of completed relevant training courses and provided evidence of

study and references. Nevertheless, the panel found that you have not been able to

remediate the clinical deficiencies in your practice which relate to a number of basic

nursing and midwifery skills including record keeping and escalation. In addition the

panel considered that the issue of dishonesty is particularly difficult to remediate.

The panel therefore concluded it cannot discount the risk of repetition of similar

behaviour and it therefore finds that you are liable in the future to act so as to put a

patient or patients at unwarranted risk of harm and thereby breach fundamental

tenets of the nursing and midwifery profession and bring the professions into

disrepute.

The panel therefore concluded that your fitness to practise is currently impaired.

The panel bore in mind that its primary function is to protect patients and the wider

public interest, which includes maintaining confidence in the nursing and midwifery

profession and upholding proper standards and behaviour. The panel considered

that the facts found proved are serious and involve dishonest behaviour leading to a

conviction for theft. The panel has also determined that, the need to uphold proper

professional standards and public confidence in the profession would be undermined

if a finding of impairment was not made in the circumstances of this case.

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For the reasons set out above, the panel finds that your fitness to practise is

currently impaired by reason of your misconduct.

Determination on sanction

The panel accepted the advice of the legal assessor.

The panel has borne in mind that any sanction imposed must be reasonable,

appropriate and proportionate. Under Article 29 of the Nursing and Midwifery Council

Order 2001, the panel can take the following actions in ascending order: no action;

make a caution order for one to five years; make a conditions of practice order for no

more than three years; make a suspension order for a maximum of one year; or

make a striking-off order. The sanction should be the least restrictive that protects

patients and the wider public interest.

The panel was mindful that the purpose of sanctions is not to be punitive but to

protect patients and the wider public interest, although a sanction may have a

punitive effect.

The panel had careful regard to the Indicative Sanctions Guidance (“ISG”) published

by the NMC. It recognised that the decision on sanction is a matter for the panel

exercising its own independent judgment.

In considering the aggravating factors of this case, the panel took into account the

following: There were two incidents of dishonesty and two shifts during which serious

and wide ranging clinical failings occurred that had the potential to cause significant

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harm to a to a mother and her baby. Further, the panel found that there is a risk of

repetition both in respect of your clinical failings and dishonest conduct.

The mitigating factors include your efforts to remediate your failings, your personal

circumstances, your positive testimonials, your early admissions and your full

engagement. Further you have shown remorse and some insight.

In determining which sanction, if any, to impose the panel has first considered

whether it would be appropriate to take no action. It has concluded that the

seriousness of the facts found proved was such that it could not justify such a

decision. It determined that the public interest requires the imposition of a sanction

and that taking no action would not address the public interest.

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. The panel

considered that your misconduct was not at the lower end of the spectrum and that a

caution order would not be appropriate in view of the seriousness of the case. Some

of the charges against you relate to dishonesty and the panel decided that it would

be neither proportionate nor appropriately guard the public interest. Further, the

panel bore in mind that such an order would not restrict your practice rights, and

would therefore be insufficient to protect the public.

The panel next considered a conditions of practice order. The panel was mindful that

any conditions imposed must be proportionate, measurable and workable. It noted

the factors set out in paragraphs 62 to 64 of the ISG which indicate when such an

order may be appropriate. The panel concluded that it could not formulate

appropriate, workable and measurable conditions which would address the issue of

dishonesty, protect the public and maintain the public’s trust and confidence in the

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profession and in the NMC as a regulator. Furthermore, the panel took the view that

the public interest would not be satisfied by the imposition of a conditions of practice

order, particularly given the dishonesty found proved in this case.

The panel then went on to consider whether a suspension order would be an

appropriate sanction. Paragraph 67 of the ISG indicates that a suspension order may

be appropriate where the misconduct is not fundamentally incompatible with

continuing to be a registered nurse or midwife in that the public interest can be

satisfied by a less severe outcome than permanent removal from the register. This is

more likely to be the case when some or all of the following factors are apparent:

67.1 A single instance of misconduct but where a lesser sanction is not

sufficient.

67.2 No evidence of harmful deep-seated personality or attitudinal

problems.

67.3 No evidence of repetition of behaviour since the incident.

The panel was of the view that whilst the personal circumstances in which your acts

of dishonesty took place may provide mitigation, they cannot excuse or fully explain

your actions. The panel was not satisfied that your dishonest behaviour was directly

attributable to a health condition. The panel had no evidence before it that you had

repeated your dishonest behaviour. While your dishonest behaviour was not a single

incident, it did not take place over an extended period of time and could therefore not

be considered persistent, nor was it covered up.

The panel noted that you have made admissions and you have expressed remorse.

The panel considered that there is a risk of repetition in this case and, while you

presently do not have full insight , this is developing. There is no evidence of deep-

seated attitudinal issues and your health issues appear to have been partly

addressed. Taking all this into account the panel considered that your misconduct

was not fundamentally incompatible with remaining on the Register and the panel

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determined that a suspension order was the appropriate order in this case. Such an

order will address both public protection issues and the wider public interest.

The panel also considered whether a striking-off order was necessary in your case.

Taking account of all the information before it, including the mitigation, the panel

concluded that it was not necessary and would be disproportionate at this time and

in the specific circumstances of this case.

Balancing all of these factors the panel has concluded that a suspension order would

be the appropriate and proportionate sanction.

The panel noted the hardship such an order may cause you. However, this is

outweighed by the public interest in this case. The panel considered that this order is

necessary to protect the public, mark the importance of maintaining public

confidence in the profession and to send to the public and the profession a clear

message about the standard of behaviour required of a registered nurse/midwife.

The panel determined that a suspension order for the maximum period of 12 months

would be necessary to mark the seriousness of the misconduct in this case and

would give you sufficient opportunity to further reflect and develop your insight.

Before the end of the period of suspension, another panel will review the order. At

the review hearing the panel may extend, vary, revoke or replace the order with any

order the panel could have made today. A future reviewing panel may be assisted by

the following:

• Any evidence of how you have further developed your insight

• Up to date references from employers and colleagues, either in the health

profession or otherwise

• Your ongoing engagement with the NMC and attendance at a future hearing

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Substantive order review hearing 15 February 2018

Application under Rule 19 for part of the hearing to be held in private

Mr Bousfield stated that he would need to refer to health matters and applied for

those parts of the hearing which relate to health matters to be held in private.

Mr Walker did not object to this application.

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

The panel agreed to hear those parts of the hearing that refer to health in private, but

that all other parts of the hearing will be held in public.

Reasons

Mr Walker, on behalf of the NMC, summarised the situation. He submitted that the

main concern of the substantive panel had been the issue of remediation of your

clinical failings and of your dishonesty. He reminded the panel of the suggestions

made by the substantive panel as to the material that might assist the reviewing

panel today in reaching its decisions. He submitted that whether your fitness to

practise remains impaired was a matter for the panel’s judgment

Mr Bousfield, on your behalf, agreed that impairment was a matter for the panel. He

reminded the panel that you had attempted to remediate the issues of concern. He

submitted that, in these circumstances if your fitness to practise was found to be

currently impaired it would be possible to impose restrictions on your practice that

would safeguard the public and the uphold the public interest. He submitted that a

suspension order was not necessary.

You gave evidence to the panel. You told the panel that you had a long career as a

nurse and midwife and that you were keen to return to practise. You have officially

retired from the NHS and you envisaged working a few shifts a week, possibly as a

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bank or agency midwife or nurse. You told the panel of some difficult family

circumstances which put you under stress and which, you claimed, affected your

practice and judgment. You told the panel of how you have addressed these issues

with your GP and through other means of help, including hypnotherapy, mindfulness

and yoga. You told the panel that you considered that the change of workplace and

the use of computer-based as opposed to paper records had contributed to the

incidents at St James University Hospital. You stated that you now realised the

importance of escalation.

You informed the panel that you have completed some on-line training and read a

number of articles. Your financial circumstances have prevented you from doing any

face to face training.

You expressed remorse for the shoplifting.

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

When reaching its decision on impairment the panel took into account all of the

evidence before it, and the submissions made by Mr Walker and Mr Bousfield. The

evidence includes your oral evidence today, the NMC bundle which contains the

determination of the substantive panel, a lengthy on-table document submitted by

you which contained an updated reflection, details of relevant on-line training and

reading you have undertaken since the substantive panel hearing, and updated

references.

The panel noted that your failings encompassed two discrete areas of your practice

as a registered professional. Your failings covered clinical shortcomings and

dishonesty which occurred outside of your workplace.

The panel firstly considered your clinical failings. Whilst these failings occurred on

two shifts, they were serious and wide-ranging. The panel carefully considered all of

the evidence and, in particular, gave regard to your sworn evidence. The panel

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reminded itself that it must consider evidence of your remediation and whether there

is a real risk of you repeating your clinical shortcomings.

The panel carefully considered the evidence of your remediation. It noted that you

have undertaken a significant amount of learning. The panel scrutinised the

relevance of this learning in respect of your clinical failings. Whilst some of the

learning was relevant and addressed your clinical deficiencies, the panel found that

the majority of the learning was not directly relevant. Given the serious and wide-

ranging extent of your clinical deficiencies the panel was concerned that your

learning was neither sufficient nor pertinent so as to address your shortcomings in

your practice.

The panel noted that you have not worked in a clinical setting since you retired and

have not had a full opportunity to practically remedy your deficiencies. Accordingly,

the panel is concerned about a lack of relevant of theoretical and practical

remediation.

The panel had careful regard to your oral evidence and your written reflective pieces.

Whilst you expressed genuine remorse the panel was concerned as to whether your

insight into your clinical failings is sufficient in terms of its development. In particular,

the panel was concerned that you did not fully recognise the significance of your

shortcomings and the work that is required to achieve full remediation. In your oral

evidence you stated that you could safely practise whilst being mentored rather than

by direct supervision. Given the nature and extent of the clinical findings against you

the panel determined that this was a significant shortfall in insight.

The panel reminded itself that the NMC has defined impairment as the suitability to

remain on the register without restriction. Given that your insight is not fully

developed and that you have not practically remediated your failings the panel

decided that there is a real risk of you repeating your clinical shortcomings. The

panel concluded that the lack of remediation is such as to engage the first three

limbs of the Shipman test approved in Grant. Namely, you are liable in the future to

act so as to put patients at unwarranted risk of harm and; bring the nursing

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profession inio disrepute; and; breach one of the fundamental tenets of the

professions.

The panel next considered the shoplifting and the resulting dishonesty. The panel

took into account your genuine remorse. The panel carefully considered the

mitigating circumstances in relation to your shoplifting. In this regard the panel

considered and accepted the significant personal background to you acting in a way

which was out of character. The panel noted that you have significantly addressed

some of those personal circumstances with the help of relevant professionals. Other

personal circumstances have been remedied over time. Accordingly, the panel

concluded that the risk of you repeating your dishonesty is low.

In respect of your dishonesty the panel noted that you have almost completed your

twelve month suspension order and in all the circumstance the panel concluded that

this is sufficient to satisfy the public interest in upholding standards of behaviour in

the professions and maintaining confidence in the professions and the NMC as

regulator.

The panel concluded that limb (d) (dishonesty) of the Shipman test in Grant is not

engaged and that you are no longer impaired on the grounds of the wider public

interest in respect of your dishonesty.

Sanction

Having found your fitness to practise currently impaired, the panel then considered

what, if any, sanction it should impose on your registration. The panel noted that its

powers are set out in Article 29 of the Order. The panel has also taken into account

the NMC’s Sanctions Guidance (SG) and has borne in mind that the purpose of a

sanction is not to be punitive, though any sanction imposed may have a punitive

effect.

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

inappropriate as it would allow you to practise without restriction, when the panel has

concluded that there is a risk of repetition of the clinical incidents.. Taking no further

action would not address the issue of public protection.

The panel then considered whether to replace the existing order with a caution order

but concluded that this would be inappropriate for the same reasons as taking no

further action

The panel next considered a conditions of practice order. The panel concluded that

there was no evidence of attitudinal issues and that there were identifiable areas of

your practice that needed to be addressed. As the incidents occurred in a relatively

short period in a long and varied career the panel concluded there was no evidence

of general incompetence. Further, you have already demonstrated a willingness to

undergo training. In such circumstances the panel concluded that a conditions of

practice order was appropriate and proportionate.

The panel has decided to impose the following conditions, which it considers to be

workable, practical and will provide sufficient public protection:

1. You must tell 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.

2. You must tell the NMC about any professional investigation started against you

and/or any professional disciplinary proceedings taken against you within 14 days of

you receiving notice of them.

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3. a) You must within 14 days of accepting any post or employment requiring

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

midwifery, provide the NMC with the name/contact details of the individual or

organisation offering the post, employment or course of study.

b) You must within 14 days of entering into any arrangements required by

these conditions of practice provide the NMC with the name and contact details of

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

4. a) At any time that you are employed or otherwise providing midwifery

services, you must place yourself and remain under the supervision of a workplace

line manager, mentor or supervisor nominated by your employer, such supervision to

consist of working at all times under the direct observation of a registered midwife of

band 6 or above.

b) At any time that you are employed or otherwise providing nursing services,

you must place yourself and remain under the supervision of a workplace line

manager, mentor or supervisor nominated by your employer, such supervision to

consist of: working at all times on the same shift as, but not necessarily under the

direct observation of, a registered nurse of band 6 or above who is physically present

in or on the same ward, unit, floor or home that you are working in or on.

5. When working either as a midwife or a nurse, you must work with your line

manager, mentor or supervisor (or their nominated deputy) to create a personal

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

your practice:

• Medication administration

• Record-keeping including electronic records

• Escalating concerns and identifying deteriorating patients

• Recognising the limits of your competence.

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6. You must meet with your line manager, mentor or supervisor (or their nominated

deputy) at least every 4 weeks to discuss the standard of your performance and your

progress towards achieving the aims set out in your personal development plan.

7. You must forward to the NMC a copy of your personal development plan within 28

days of the date on which these conditions become effective or the date on which

you take up an appointment, whichever is sooner.

8. 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 at

least 14 days before any NMC review hearing or meeting

9. 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.

10. 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 employers (at the time of

application) 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.

11. When working either as a midwife or a nurse, you must not carry out

unsupervised medication administration until such time as you have been assessed

both theoretically and practically as competent to do so.

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12. You must not care for women having continuous electronic fetal monitoring until

such time as you have been assessed and signed off by a Band 6 or above midwife,

both theoretically and practically, as competent to do so safely.

13. You must keep your nursing and midwifery commitments under review and

immediately limit your practice or stop practising in line with advice from your general

practitioner, or any other registered medical practitioner or therapist responsible for

your care.

14. 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 the conditions listed at (1) to (13) above, to them.

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

undertake nursing or midwifery work.

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

time of application) to provide nursing or midwifery services.

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

applying for any nursing or midwifery appointment.

4) 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).

The panel has concluded that this order should run for a period of 18 months. This

will give you sufficient time to find employment and to demonstrate that you have

addressed the shortcomings in your practice.

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The panel did consider whether the imposition of a further suspension order was

appropriate. However, it concluded that the public interest has been satisfied by the

period of suspension. The panel considered a further period of suspension would be

both disproportionate and would be punitive in that it would not afford you a proper

opportunity to fully remediate your clinical shortcomings.

That concludes this determination.