Conduct and Competence Committee
Substantive Hearing
Consensual Panel Determination
Wednesday 17 May 2017
Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE
Name of Registrant Nurse:
Paula Ellen Hewitt
NMC PIN:
06F0203E
Part(s) of the register:
Registered Nurse (sub part 1) Adult
Area of Registered Address:
England
Panel Members:
Robert Barnwell (chair, lay member)
Catherine Askey (registrant member)
Kitty Lamb (registrant member)
Legal Assessor:
Robert Frazer
Panel Secretary:
Sam Hughes
Miss Barber:
Not present and not represented
Nursing and Midwifery Council:
Represented by Helen Fleck, counsel,
instructed by NMC Regulatory Legal Team.
Facts proved by admission:
All
Facts not proved:
n/a
Fitness to practise:
Impaired
Sanction:
Two year conditions of practice order
Interim Order:
18 month interim conditions of practice order
Determination on the service of notice
Mrs Hewitt was neither present nor represented. The notice was sent to Mrs Hewitt’s
address on the Register on 12 April 2017 by first class post and recorded delivery and
delivered and signed for on 13 April 2017.
In all the circumstances, and having taken advice of the legal assessor, the panel found
that there had been good service in this case.
Determination on proceeding in the absence of Mrs Hewitt
The panel next considered whether it would be fair to proceed in Mrs Hewitt’s absence.
The panel weighed any disadvantage to Mrs Hewitt in not being present against the
public interest in hearing these matters expeditiously. Mrs Hewitt and her UNISON
representative have been engaging with the NMC throughout the process. In an email
to the NMC on 11 May 2017 Mrs Hewitt’s UNISON representative stated that she had
intended on coming to the hearing but could no longer do so. She stated that if she
needs to be contacted she is available on the phone. Mrs Hewitt has admitted the
charge and has agreed that the matter may be dealt with by way of Consensual Panel
Determination (‘CPD’).
The CPD Provisional Agreement (‘the Agreement’) contains sufficient information and
the panel considered that Mrs Hewitt’s attendance would serve no useful purpose given
that she agrees with the proposed CPD. In all the circumstances, and balancing the
factors set out above, the panel has decided that it is fair, in the public interest and in
the interests of justice to proceed in her absence.
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Consensual panel determination: provisional agreement
The Nursing and Midwifery Council and Mrs Paula Hewitt, PIN: 06F0203E (“the
parties”) agree as follows:
Charges
1. Mrs Paula Hewitt (“the Registrant”) admits the following charges:
That you a registered nurse:
1. On 27 June 2015:
1.1 Between 10:50 and 16:30 failed to conduct and/or record any observations for
patient A;
1.2 From 13:00 failed to monitor Patient A’s urine output on a fluid balance chart;
1.3 At 10:50 and/or 16:30, incorrectly scored Patient A’s PAR score:
1.4 Upon reaching a PAR score of 3, did not escalate Patient A’s care to the
outreach team and/or nurse in charge;
2. On 28 June 2015:
2.1 Between 07:00 and 11:40 failed to conduct and/or record any observations for
Patient A;
2.2 Between 07:00 and 12:00 failed to monitor Patient A’s urine output on a fluid
balance chart;
2.3 At 11:40 incorrectly scored Patient A’s PAR score as 6;
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2.4 Upon recording a PAR score of 6 or above for Patient A at 11:40, 12:30, and/or
12:40, failed to immediately escalate Patient A’s care to the Medical Emergency
Team (MET);
3. Failed to review the plan of care drafted by a doctor at 13:44 on 27 June 2015;
AND, in light of the above, your fitness to practise is impaired by reason of your
misconduct
Background/Facts
The agreed facts are as follows:
1. The NMC received a referral with regard to Paula Hewitt on 22 October 2015
from the Head of Midwifery (the Referrer) at Dartford and Gravesham NHS Trust
(‘the Trust’.) At the material time Mrs Hewitt was employed as a band 5
registered nurse on Beech Ward (‘the Ward’) at Darent Valley Hospital (‘the
Hospital’).
2. On 2 July 2015 the matron of the ward was informed via a datix form that on 28
June 2015 a Medical Emergency Team (“MET”) call was made in relation to
Patient A. The reason for the call was due to low blood pressure and no urine
output. It was further noted that the Patient A had been hypotensive for over 12
hours. As a result of concerns raised an investigation was started as to who was
responsible for the care of Patient A.
3. The Registrant was responsible for the care of the patient on 27 and 28 June
2015. The evidence demonstrates and the registrant accepts that she failed to
escalate the deterioration of patient A’s health as per the trust policy and
process.
4. Patient A had been hypotensive for 12 hours. This means that Patient A had low
blood pressure for over 12 hours. In this situation the registrant should have
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increased observations as per the trust policy with urine output being monitored
every 4 hours. When a patient has low blood pressure a nurse is expected to
carry out observations every hour; this would include a check of a patient’s
conscious levels, their respiration rate, their heart rate, blood pressure, urine
output and oxygen saturation levels. All of these are combined to give a Patient
At Risk (“PAR”) score that guides a nurse when to escalate care.
5. On 27 June 2015 the Registrant failed to carry out observations as set out in the
charges. When the Registrant did carry out observations she failed to score the
urine output correctly. Furthermore when observations were recorded the PAR
score was incorrect and care was not escalated appropriately.
6. Had the registrant PAR scored the observations correctly on the initial date on 27
June 2015 those scores would have triggered escalating of care, urgent doctor
review within one hour and referral to the outreach team.
7. The Registrant failed to follow the care plan provided by the doctor in which he
clearly states what should be done to monitor Patient A. The plan documented a
cross match for bloods. The Registrant carried out this cross match but failed to
carry out the rest of the observations as set out in the care plan.
8. During the night shift of 27/28 June, the night nurse was concerned about Patient
A and called the on call registrar. Patient A was assessed, it was noted that his
renal function was deteriorating and that his haemoglobin was low. As a result of
this he was to be under close observation.
9. On 28 June the Registrant started her shift at 07:00 but failed to carry out any
observations on Patient A until 11:40. It had been handed over to her that the
patient was hypotensive and therefore further observations should have been
conducted.
10. An observation was done by the Registrant at 11:40. She incorrectly scored the
patient with PAR score of 6, although this was incorrect it was still a score which
should have triggered immediate action of the emergency team and put a MET
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call out. The Trust guidance for PAR scoring states that if a patient has a PAR
score of 5-6 that the Medical Emergency Team (‘MET’) should be called. This
was not done by the registrant. The registrant did further observations between
11:45 and 12:40 but failed to put a MET call out until 12:48.
11. Patient A’s condition deteriorated and he was transferred to ITU that day and
died on 4 July 2015. The patient was extremely ill with multiple comorbidities.
While Patient A’s failures did not contribute to death her actions did contribute to
a lack of timely emergency care being given to Patient A.
12. At the time of the incident the Registrant was being performance managed due to
previous concerns. Of note she was given a formal warning on 3 November 2015
while on the Ebony ward as a result of which she was moved to the Laurel Ward,
a high dependency ward. Whilst on the Laurel ward she was closely monitored
and no concerns were identified. She joined the Beech Ward on a capability plan.
13. Mrs Hewitt is not currently working in her capacity as a registered nurse as she is
subject to an Interim Suspension Order (‘ISO’) imposed by the NMC; Mrs Hewitt
is employed as a Senior Carer at Rosewood Care Home (‘the Home’) which is a
residential home caring for residents with dementia.
14. Mrs Hewitt has engaged with the NMC; her submissions and reflections are set
out in Appendices 1 and 2. References from her current employer are set out in
Appendix 3.
Misconduct
15. The Registrant admits that the facts set out above amount to misconduct
because her actions fell well short of what would be expected of a registered
nurse in the particular circumstances and that this failing was serious relying on
Roylance v GMC (No.2) [2000] 1 AC 311) in which it was stated:
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“Misconduct is a word of general effect, involving some act or omission
which falls short of what would be proper in the circumstances. The
standard of propriety may often be found by reference to the rules and
standards ordinarily required to be followed by a medical practitioner in the
particular circumstances.”
16. The Registrant accepts that her failings namely (i) failing to conduct observations
(ii) when observations were taken failing to record the correct score, (iii) failing to
monitor urine output (iv) failing to escalate and (v) failing to review a plan of care,
amounted to serious professional misconduct of a kind that colleagues, and the
wider public, would reasonably regard as being deplorable.
17. The Registrant accepts that her failings represents a serious departure from the
following standards set out in the NMC 2015 Code “professional standards of
practice and behaviour for nurses and midwives” (“the Code”) in particular:
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Always practise in line with best available evidence
6.2
maintain the knowledge and skills you need for safe and
effective practice.
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Work cooperatively
8.2
maintain effective communication with colleagues
8.5
work with colleagues to preserve the safety of those receiving
care
8.6
share information to identify and reduce risk
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Keep clear and accurate records relevant to your practice
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Recognise and work within the limits of your competence
13.1
accurately assess signs of normal or worsening physical and
mental health in the person receiving care
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.
20
Uphold the reputation of the profession at all times
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Impairment
18. The registrant admits that her fitness to practise is impaired by reason of her
misconduct according to the principles laid down in Council for Healthcare
Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011]
EWHC 927 (Admin). In particular, according to the set of principles laid down by
Dame Janet Smith in the fifth report to the Shipman Inquiry, the Registrant
accepts 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;
b) Has in the past brought and/or is liable in the future to bring the profession
into disrepute; and
c) Has in the past breached and/or is liable in the future to breach one of the
fundamental tenets of the professions;
19. In particular it is accepted by the registrant that she placed patient A at risk of harm
in failing to take timely observations, failing to monitor urine output, failing to
conclude correct PAR scores and failing to escalate as appropriate. Patient A was
an extremely ill individual who required close observation. The registrant accepts
that he did not get the emergency care he required due to her failures.
20. In relation to bringing the profession into disrepute, the registrant accepts that in
failures to complete observations and the direct consequences that followed, she
damaged the reputation of the profession. Record keeping and observations are
basic tenants of nursing.
21. As to the present position, the registrant has provided 2 reflective pieces that show
insight in relation to her actions. In addition she has submitted training certificates
one of which goes to record keeping and another to communication. No remediation
as to observations and PAR scores has been evidenced. The parties agree that the
failings in the Registrant’s practice have not been fully remediated.
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22. The Registrant acknowledges that public confidence in the profession would be
undermined if no finding of impairment were made, given the seriousness of her
misconduct in terms of observation failures and record keeping.
Sanction
23. It is agreed between the parties that the appropriate sanction in this case is a 24
month Conditions Of Practice Order in order to protect the public, to maintain
public confidence in the profession, the NMC as a regulator and to declare and
uphold proper standards of conduct and behaviour.
24. In arriving at an appropriate sanction the parties have taken into account all the
circumstances of the case including the Registrant’s response. The following
aggravating factors exist:
a) The misconduct was serious and involved failures in basic nursing from an
experienced nurse.
b) conduct that went over two shifts with the same repeated failures
c) the patient was extremely ill and therefore the risk of harm was high
25. The following mitigating factors exist:
a) The Registrant has engaged with both the local investigation and with the
NMC process throughout;
b) The Registrant has made admissions and has apologised.
c) The Registrant has demonstrated both remorse and insight into the wider
implications of aspects of her conduct as set out in her reflective piece (see
Appendices 1 & 2 to the CPD agreement)
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26. Starting with the least restrictive sanction of taking no further action it is accepted
by the parties that this is not a case with exceptional circumstances that would
warrant such a sanction. It would provide no element of public protection and would
not be sufficient to satisfy public interest considerations.
27. The parties also agree that a caution order in this matter would neither be
appropriate nor proportionate. It would not adequately address any risk of harm that
may still exist or adequately address the wider public interest.
28. A conditions of practice order is normally appropriate where there are definable
areas of a nurse or midwife’s practice in need of assessment and/or retraining. It is
agreed in this case that there are workable conditions that could be formulated
which could adequately safeguard patients against the risk of any future harm.
29. Accordingly the parties agree that a conditions of practice order for a duration of 24
months would be the appropriate and proportionate sanction in this case. It allows
supervised and monitored practice, safeguarding the public from harm. It is
submitted that it adequately marks the extent to which the registrant departed from
the standards of behaviour and conduct expected of a registered nurse. It satisfies
the wider public interest considerations in allowing an otherwise good nurse to return
to practice safely, thereby balancing the public interest with the registrant’s right to
practice in her chosen profession acknowledging the registrant’s level of insight,
remediation and remorse at this stage.
30. The parties agree that the appropriate conditions in this case are as follows:
1. At any time that you are employed or otherwise providing nursing or midwifery
services, you must place yourself and remain under the indirect 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 floor and/or
unit as another registered nurse.
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2. You must work with your line manager, mentor or supervisor (or their
nominated deputy) to formulate a Personal Development Plan specifically
designed to address making and recording accurate observations, which
must include PAR score calculations, record keeping and escalating a
deteriorating patient.
3. You must meet with your line manager, mentor or supervisor (or their
nominated deputy) at least fortnightly 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
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.
5. You must send a report from your line manager, mentor or supervisor (or their
nominated deputy) setting out the standard of your performance and your
progress towards achieving the aims set out in your Personal Development
Plan to the NMC every six months and at least 14 days before any NMC
review hearing or meeting.
6. 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.
7. 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
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involved in your retraining and supervision with any employer, prospective
employer, and at any educational establishment.
8. You must notify the NMC within seven 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.
9. You must inform the NMC of any professional investigation started against
you and/or any professional disciplinary proceedings taken against you within
seven days of you receiving notice of them.
10. You must immediately inform the following parties that 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 (9) above, to them:
a. Any organisation or person employing, contracting with, or using you to
undertake nursing or midwifery work
b. Any agency you are registered with or apply to be registered with (at
the time of application)
c. Any prospective employer (at the time of application)
d. Any educational establishment at which you are undertaking a course
of study connected with nursing or midwifery, or any such
establishment to which you apply to take such a course (at the time of
application).
31. The period of 24 months is appropriate as it will allow Mrs Hewitt sufficient time to
achieve a measurable and effective level of improvement in the areas of her practice
that give cause for concern. As the failings relate to basic and fundamental nursing
any shorter period may be insufficient. As the order will be subject to a review before
its expiry this period is sufficient to protect the public and uphold the public interest.
32. A suspension order would be disproportionate in this case because the Registrant’s
failings are capable of remediation, she has admitted her failings and that her fitness
to practise is currently impaired by reason of misconduct and is willing to work under
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the terms of conditions of practice order to improve her practice and to protect
patients. Indirect supervision and development under the terms of the proposed
conditions of practice order are sufficient to protect the public. A conditions of
practice order for a period of 24 months also declares and upholds proper standards
and performance and so is also sufficient to address the public interest in this
matter. A more restrictive sanction would serve only to punish the Registrant, which
is not the purpose of a sanction.
33. For the same reasons a striking off order is not appropriate or proportionate. In any
event, the Registrant’s failings are not fundamentally incompatible with continuing
registration
Interim Order
34. The parties also agree that it is also necessary for the protection of the public and
otherwise in the public interest for there to be an interim conditions of practice order
for 18 months to cover the appeal period. The interim conditions of practice should
be in the same terms as the substantive order.
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, provided that it would be relevant
and fair to do so.
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The panel’s decision and reasons
The panel sought the advice of the legal assessor. He told the panel that Mrs Hewitt has
made full admissions to the charge and the agreed facts from which it arises as well as
agreeing that her fitness to practise is currently impaired. Mrs Hewitt has signed the
Agreement. Accordingly the legal assessor advised that this matter is capable of being
dealt with by way of a CPD. The panel was advised that it is now a matter for its
judgment to determine whether the proposed Agreement is to be accepted or rejected.
The legal assessor reminded the panel that a sanction should protect the public,
maintain proper standards of practice and behaviour and uphold public trust confidence
in the profession and its regulator. The panel accepted the advice of the legal assessor.
Having regard to the facts set out in the Agreement and Mrs Hewitt’s admissions to the
charge the panel agreed the facts were proved and has proceeded to exercise its
judgment in relation to the matters that follow from the basis of those agreed facts.
The panel also had regard to Mrs Hewitt’s written submissions and reflections together
with certificates of further training. It also had before it a reference from Mrs Hewitt’s
current employer dated 8 February 2017 attesting to her good practice as a senior
carer.
The panel noted the correspondence from the referrer at Darent Valley Hospital dated
18 April 2017 which indicates that she agrees with the Agreement. She further stated, ‘I
agree with the sanctions imposed [proposed] although future employment might not
expose Nurse Hewitt to PAR score/deteriorating patients.’
The panel accepted that Mrs Hewitt’s actions, as agreed, fell below the standard to be
expected of a registered nurse. The panel was satisfied that Mrs Hewitt’s actions
amounted to breaches of the Code as set out in paragraph 17 of the Agreement.
In relation to impairment, the panel concurred with the conclusion in the Agreement that
Mrs Hewitt’s fitness to practise is currently impaired for the reason set out at paragraphs
18 to 22 of the Agreement. The panel concluded that, in the circumstances, a finding of
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no impairment would undermine public confidence in the profession and the NMC as its
regulator.
The panel agreed that taking no action would be wholly inappropriate in view of the
seriousness of the failings for the reasons set out at paragraph 26 of the Agreement.
The panel agreed that a caution order would be neither appropriate nor proportionate
for the reasons set out in paragraph 27 of the provisional Agreement.
The panel agreed that a conditions of practice order would be an appropriate sanction in
this case for the reasons set out in paragraph 28 of the provisional Agreement. The
panel was satisfied that the Agreed conditions of practice set out in paragraph 30 are
proportionate, measurable and workable. The panel agreed that they allow supervised
and monitored practice, safeguarding the public from harm. The panel also agrees that
such an order adequately marks the extent to which Mrs Hewitt departed from the
standards of behaviour and conduct expected of a registered nurse. It satisfies the
wider public interest considerations in allowing an otherwise good nurse to return to
practice safely, thereby balancing the public interest with the registrant’s right to practice
in her chosen profession acknowledging the registrant’s level of insight, remediation and
remorse at this stage.
Prior to reaching a final conclusion the panel considered a suspension order but agreed
with the reasons set out in paragraph 31 of the Agreement, that indirect supervision and
development under the terms of the proposed conditions of practice order are sufficient
to protect the public. In all the circumstances the panel agreed that a suspension order
was not appropriate or proportionate.
The panel also considered the imposition of a striking-off order however it determined
that Mrs Hewitt’s failings are not fundamentally incompatible with continuing registration.
The panel therefore approves the Agreement reached between the NMC and Mrs
Hewitt in all respects and accordingly determines that Mrs Hewitt is the subject of a
conditions of practice order for two years.
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The panel also agreed that it is necessary for the protection of the public and otherwise
in the public interest for there to be an interim conditions of practice order for 18 months
to cover the appeal period. The interim conditions of practice should be in the same
terms as the substantive order.
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