Nursing and Midwifery Council Fitness to Practise ... · 7/5/2019 · Ms Lorna Deborah Pinder: Not present, written representations submitted Day 4 and 5 – represented by Marc

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Nursing and Midwifery Council

Fitness to Practise Committee

Substantive Hearing

1 July – 5 July 2019

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

Name of registrant: Lorna Deborah Pinder NMC Pin: 06B0445E Part(s) of the register: Registered Nurse – Sub Part 1 Adult Nursing – May 2006 Area of registered address: England Type of Case: Misconduct Panel Members: Anne Booth (Chair, Lay member)

John McGrath (Registrant member) Jacqueline Nicholson (Registrant member)

Legal Assessor: John Bromley-Davenport QC Panel Secretary: Charlie Russell Ms Lorna Deborah Pinder: Not present, written representations submitted

Day 4 and 5 – represented by Marc Walker, WhatRights

Nursing and Midwifery Council: Represented by Katie Mustard, Case

Presenter Facts proved: 12.5, 13, 14, 17, 22 Facts proved by admission:

1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12.1, 12.2, 12.3,

12.4, 15, 16.1, 16.2.1, 16.2.2, 16.3, 16.4, 19,

20, 21.1, 21.2, 21.2, 21.3, 21.4, 24.1.1, 24.1.2,

24.1.3, 25.1.1, 25.1.2, 25.1.3, 26.1, 26.2, 27,

28, 29.2, 29.3.1, 29.3.2, 29.4, 30.1.1, 30.1.2,

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30.1.3, 30.2, 30.4, 30.5, 32.1.1, 32.1.2 and

32.1.3.

Facts not proved: 23, 24.2, 24.3, 29.1, 29.5, 30.3, 31, 32.2 Fitness to practise: Impaired Sanction: Caution order (3 years)

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Admissions

At the outset of this hearing, Ms Mustard informed the panel that Ms Pinder and her

named representative have been in contact with the NMC, and have confirmed in

writing admissions to the following charges:

1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12.1, 12.2, 12.3, 12.4, 15, 16.1, 16.2.1, 16.2.2, 16.3, 16.4,

19, 20, 21.1, 21.2, 21.2, 21.3, 21.4, 24.1.1, 24.1.2, 24.1.3, 25.1.1, 25.1.2, 25.1.3, 26.1,

26.2, 27, 28, 29.2, 29.3.1, 29.3.2, 29.4, 30.1.1, 30.1.2, 30.1.3, 30.2, 30.4, 30.5, 32.1.1,

32.1.2 and 32.1.3.

The panel therefore found the above charges proved by way of admission.

Details of charge (before amendments)

“That you a registered nurse, whilst employed as a community staff nurse at the

Rotherham NHS Foundation Trust;

1) On 26 December 2016 incorrectly loaded patient A’s syringe driver with water

as a diluent. (Proved by way of admission)

2) On 26 December 2016 incorrectly loaded Haloperidol 2.5mg as regular

medication to Patient A’s syringe driver. (Proved by way of admission)

3) On 26 December 2016 incorrectly administered Ondansetron 8mg to Patient

A instead of 12mg as required by Patient A’s care plan. (Proved by way of

admission)

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4) On 26 December 2016 incorrectly documented “to introduce Buscopan

(Hyoscine) into driver tomorrow” on Patient A’s patient records. (Proved by way

of admission)

5) On 26 December 2016 incorrectly documented that you had administered

8mg/2ml of Ondansetron to Patient A when only 4gm/2ml doses were available.

(Proved by way of admission)

6) On 26 December 2016 did not document batch numbers and expiry dates of

medication for Patient A’s syringe driver. (Proved by way of admission)

7) On 20 January 2017 at 07.21 you created a syringe driver care plan for Patient

B. (Proved by way of admission)

8) On 20 January 2017 you incorrectly administered Midazalom 2.5mg to Patient


9) On 20 January 2017 you incorrectly administered Haliperidol 2.5mg to Patient


10) On 23 January 2017 you applied a syringe driver to Patient B. (Proved by

way of admission)

11) On 23 January 2017 you did not document a clear rationale to clinically justify

the use of syringe driver for Patient B. (Proved by way of admission)

12) On 23 January 2017 you administered the following medication through

Patient B‘s syringe driver, namely;

12.1 Diamorhpine 10mg (Proved by way of admission)

12.2 Midazolam 10mg (Proved by way of admission)

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12.3 Haloperidol 5mg (Proved by way of admission)

12.4 Hyoscine 600mcg (Proved by way of admission)

12.5 Cyclizine 50mg (Found proved)

13) On 23 January 2017 you did not administer Cyclizine through a sub-

cutaneous injection. (Found proved)


loading Patient B’s syringe driver with 5 different medications. (Found proved)


administering Cyclizine through the wrong route to Patient B. (Proved by way of

admission)

16) On 10 September 2016;

16.1 You did not administer diamorphine to Patient C, as was prescribed.


16. 2 You did not document a clear rationale in Patient C’s records to clinically

justify the administration of;

16.2.1 Midazolan 10mg (Proved by way of admission)

16.2.2 Haloperidol 5mg (Proved by way of admission)

16.3 You did not document a clear rationale to clinically justify the use of a

syringe driver for Patient C. (Proved by way of admission)

16.4 You did not document a clear rationale to clinically justify the administration

of diamorphine 10mg via subcutaneous injection for Patient C. (Proved by way

of admission)

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17) On 22 October 2016 you created a care plan for a syringe driver prior to

assessing Patient D. (Found proved)

18) On 25 October 2016;

18.1 You did not seek guidance/reassurance from a General

Practitioner/Specialist Palliative Care service before administering Patient D via

cannula with;

18.1.1 Midazolam 2.5mg (Found NOT proved)

18.1.2 Haloperidol 1.25mg (Found NOT proved)

18.1.3 Diamorphine 2.5mg (Found NOT proved)

19) You did not document that there were any secretions requiring management

before administering Hyoscine 1200mcg to Patient D. (Proved by way of

admission)

20 You did not document a clear rationale to clinically justify the use of a syringe

drive for Patient D. (Proved by way of admission)

21. You administered the following medication through Patient D‘s syringe driver,

namely;

21.1 Diamorphine 10mg (Proved by way of admission)




22) You did not seek guidance/reassurance from a General

Practitioner/Specialist Palliative Care service before commencing the syringe

driver for Patient D. (Found proved)

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23) On 26 October 2016 you did not document Patient D’s presentation. (Found

NOT proved)

24) On 31 August 2016;

24.1 You administered the following medication through Patient E‘s syringe

driver, namely;

24.1.1 Diamorphine 10mg (Proved by way of admission)

24.1.2 Midazolam 10mg (Proved by way of admission)

24.1.3 Hyoscine 1200mcg (Proved by way of admission)


syringe driver for Patient E. (Found NOT proved)



driver for Patient E. (Found NOT proved)


25.1 You reloaded Patient E’s syringe driver to administer medication, namely;






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26) On 29 August 2016;

26.1 You increased Patient F’s dose of Oxycodone from 25mg to 30mg. (Proved

by way of admission)

26.2 You did not document a clear rationale to clinically justify increasing Patient

F’s dose of Oxycodone. (Proved by way of admission)

27) On 7 June 2016 you created a care plan for a syringe driver prior to

assessing Patient G. (Proved by way of admission)

28) On 10 July 2016 you did not document a clear rationale to clinically justify

why further pain relief was not appropriate for Patient G. (Proved by way of

admission)

29) On 3 October 2015;

29.1 You requested care home staff obtain a prescription for a syringe driver for

patient H, despite a General Practitioner’s decision that a syringe driver was not

needed. (Found NOT proved)

29.2 You did not document a clear rationale to clinically justify the purpose of a

syringe driver for Patient H. (Proved by way of admission)

29.3 You administered medication to Patient H, namely;


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29.4 You did not document a clear rationale to clinically justify the high doses of

Diamorphine and Midazolam administered to Patient H. (Proved by way of

admission)

29.5 You obtained a prescription for a syringe driver at 18:29, despite a General

Practitioner’s decisions that syringe driver was not needed. (Found NOT

proved)

30) On 4 October 2015:

30.1 You administered the following medication through Patient H‘s syringe

driver, namely;


30.1.2 Cyclizine 50mg (Proved by way of admission)

30.1.3 Buscopan 20mg (Proved by way of admission)





driver for Patient H. (Found NOT proved)

30.4 You did not document a clear rationale to clinically justify administering

Cyclizine through the wrong route to Patient H. (Proved by way of admission)


Buscopan through the wrong route to Patient H. (Proved by way of admission)

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31) On 23 May 2015 you created care plan for a syringe driver for Patient I,

despite the General Practitioner deciding that a syringe driver was not necessary.

(Found NOT proved)

32) On 28 May 2015

32.1 You administered the following medication through Patient I‘s syringe driver,

namely;



32.1.3 Hyoscine 1.2mg (Proved by way of admission)


syringe driver for Patient I. (Found NOT proved)

And in light of the above your fitness to practice is impaired by reason your misconduct.”

Service of Notice of Hearing

The panel was informed that Ms Pinder was not in attendance and that written notice of

this hearing had been sent to her registered address by recorded delivery and by first

class post on 31 May 2019. Royal Mail’s Track and Trace delivery service confirms that

notice of this hearing was delivered to Ms Pinder’s registered address on 3 June 2019.

It was signed for under the name ‘PINDER’.

The panel took into account that the notice letter provided details of the allegations, the

time, dates and venue of the hearing and, amongst other things, information about Ms

Pinder’s right to attend, be represented and call evidence, as well as the panel’s power

to proceed in her absence.

Ms Mustard submitted the NMC had complied with the requirements of Rules 11 and 34

of the Nursing and Midwifery Council (Fitness to Practise) Rules 2004, as amended

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(“the Rules”). She informed the panel that notice had been served in excess of the

standard 28 day requirement.

The panel accepted the advice of the Legal Assessor.

In the light of all of the information available, the panel was satisfied that Ms Pinder has

been served with notice of this hearing in accordance with the requirements of Rules 11

and 34.

Proceeding in the absence of Ms Pinder

The panel next considered whether it should proceed in the absence of Ms Pinder.

The panel had regard to Rule 21 (2) states:

(2) Where the registrant fails to attend and is not represented at the hearing, the

Committee

(a) shall require the presenter to adduce evidence that all reasonable

efforts have been made, in accordance with these Rules, to serve the

notice of hearing on the registrant;

(b) may, where the Committee is satisfied that the notice of hearing has

been duly served, direct that the allegation should be heard and

determined notwithstanding the absence of the registrant; or

(c) may adjourn the hearing and issue directions.

Ms Mustard informed the panel that both Ms Pinder and her representative have

indicated that they will attend this hearing at a later stage, namely the impairment stage.

She submitted that written representations have been provided on behalf of Ms Pinder

which the panel will be able to take into account. Ms Mustard informed the panel that

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Ms Pinder’s representative has acknowledged receipt of the NMC hearing bundle

documents and has approved its content.

Ms Mustard invited the panel to proceed in the absence of Ms Pinder. She submitted

that there is evidence to suggest that Ms Pinder and her representative have planned

for the hearing to be effective. Further, Ms Mustard submitted that Ms Pinder has clearly

indicated an acceptance for the panel to proceed in her absence and therefore a

postponement would serve no purpose. Ms Mustard reminded the panel that the case

concerns a number of charges and the public would expect the regulator to proceed in

the absence of Ms Pinder as it has responsibilities for public protection and the

expeditious disposal of the case. She also advised that witnesses had been warned and

were in attendance and that it would be in the public interest to proceed.


The panel noted that its discretionary power to proceed in the absence of a registrant

under the provisions of Rule 21 is not absolute and is one that should be exercised “with

the utmost care and caution” as referred to in the case of R. v Jones (Anthony William),

(No.2) [2002] UKHL 5. The panel further noted the case of General Medical Council v

Adeogba; General Medical Council v Visvardis [2016] EWCA Civ 162.

The panel has decided to proceed in the absence of Ms Pinder. In reaching this

decision, the panel has considered the submissions of the case presenter, and the

advice of the Legal Assessor. It has had particular regard to the factors set out in the

decision of Jones. It has had regard to the overall interests of justice and fairness to all

parties. It noted that:

Ms Pinder and her representative have both indicated that they wish to engage in

the hearing of Ms Pinder’s case at a later stage, namely the impairment stage;

written representations have been provided to the panel on behalf of Ms Pinder;

no application for an adjournment has been made by Ms Pinder;

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there is no reason to suppose that adjourning would secure her attendance at

some future date;

two witnesses have attended today to give live evidence, others are due to

attend;

not proceeding may inconvenience the witnesses, their employer(s) and, for

those involved in clinical practice, the clients who need their professional

services;

the charges relate to events that occurred between 2015 and 2017;

further delay may have an adverse effect on the ability of witnesses accurately to

recall events;

there is a strong public interest in the expeditious disposal of the case.

The panel considered that Ms Pinder has clearly indicated that she is happy for the

hearing of her case to proceed in her absence, and that she wishes to attend at a later

stage. The panel concluded that Ms Pinder has made a conscious decision to

voluntarily absent herself from the facts stage of this hearing. It was satisfied that it

could take account of written representations submitted in Ms Pinder’s absence when

determining facts.

In these circumstances, the panel has decided that it is fair, appropriate and

proportionate to proceed in the absence of Ms Pinder. The panel will draw no adverse

inference from Ms Pinder’s non-attendance in its findings of fact.

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Application to amend the charge

The panel heard an application made by Ms Mustard, on behalf of the NMC, to amend

the wording of charges 13 and 29.5.


cutaneous injection.


Practitioner’s decisions that syringe driver was not needed.

The proposed amendments were to specify that charge 13 relates to Patient B, and in

charge 29.5, to remove the time given as ‘at 18:29’. It was submitted by Ms Mustard

that the proposed amendments would provide clarity and more accurately reflect the

evidence.

The panel further identified some spelling mistakes in relation to incorrect medication

names, namely in charges 8, 9, 12.1, and 16.2.1. The panel identified that charge 8

‘Midazalom’ should be corrected to ‘Midazolam’; charge 9 ‘Haliperidol’ should be

corrected to ‘Haloperidol’; charge 12.1 ‘Diamorhpine’ should be corrected to

‘Diamorphine’ and charge 16.2.1 ‘Midazolan’ should be corrected to ‘Midazolam’.

The panel accepted the advice of the Legal Assessor that Rule 28 of the Rules states:

28. (1) At any stage before making its findings of fact, in accordance with rule

24(5) or (11), the Investigating Committee (where the allegation relates to a

fraudulent or incorrect entry in the register) or the Fitness to Practise Committee,

may amend

(a) the charge set out in the notice of hearing; or

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(b) the facts set out in the charge, on which the allegation is based,

unless, having regard to the merits of the case and the fairness of the

proceedings, the required amendment cannot be made without injustice.

(2) Before making any amendment under paragraph (1), the Committee shall

consider any representations from the parties on this issue.

The panel was of the view that such amendments, as identified and applied for, were in

the interests of justice. The panel was satisfied that there would be no prejudice to Ms

Pinder and no injustice would be caused to either party by the proposed amendments

being allowed. It was therefore appropriate to allow the amendments, as identified and

applied for, to ensure clarity and accuracy.

Details of charge (after amendments)

That you a registered nurse, whilst employed as a community staff nurse at the

Rotherham NHS Foundation Trust;

1) On 26 December 2016 incorrectly loaded patient A’s syringe driver with water

as a diluent. (Proved by way of admission)

2) On 26 December 2016 incorrectly loaded Haloperidol 2.5mg as regular

medication to Patient A’s syringe driver. (Proved by way of admission)

3) On 26 December 2016 incorrectly administered Ondansetron 8mg to Patient

A instead of 12mg as required by Patient A’s care plan. (Proved by way of

admission)

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4) On 26 December 2016 incorrectly documented “to introduce Buscopan

(Hyoscine) into driver tomorrow” on Patient A’s patient records. (Proved by way

of admission)

5) On 26 December 2016 incorrectly documented that you had administered

8mg/2ml of Ondansetron to Patient A when only 4gm/2ml doses were available.


6) On 26 December 2016 did not document batch numbers and expiry dates of

medication for Patient A’s syringe driver. (Proved by way of admission)

7) On 20 January 2017 at 07.21 you created a syringe driver care plan for Patient


8) On 20 January 2017 you incorrectly administered Midazolam 2.5mg to Patient


9) On 20 January 2017 you incorrectly administered Haloperidol 2.5mg to Patient


10) On 23 January 2017 you applied a syringe driver to Patient B. (Proved by

way of admission)


the use of syringe driver for Patient B. (Proved by way of admission)





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12.5 Cyclizine 50mg (Found proved)


cutaneous injection to Patient B. (Found proved)


loading Patient B’s syringe driver with 5 different medications. (Found proved)


administering Cyclizine through the wrong route to Patient B. (Proved by way of

admission)


16.1 You did not administer diamorphine to Patient C, as was prescribed.


16. 2 You did not document a clear rationale in Patient C’s records to clinically

justify the administration of;


16.2.2 Haloperidol 5mg (Proved by way of admission)


syringe driver for Patient C. (Proved by way of admission)

16.4 You did not document a clear rationale to clinically justify the administration

of diamorphine 10mg via subcutaneous injection for Patient C. (Proved by way

of admission)

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assessing Patient D. (Found proved)

18) On 25 October 2016;



cannula with;

18.1.1 Midazolam 2.5mg (Found NOT proved)

18.1.2 Haloperidol 1.25mg (Found NOT proved)

18.1.3 Diamorphine 2.5mg (Found NOT proved)

19) You did not document that there were any secretions requiring management

before administering Hyoscine 1200mcg to Patient D. (Proved by way of

admission)

20 You did not document a clear rationale to clinically justify the use of a syringe

drive for Patient D. (Proved by way of admission)

21. You administered the following medication through Patient D‘s syringe driver,

namely;







driver for Patient D. (Found proved)

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23) On 26 October 2016 you did not document Patient D’s presentation. (Found

NOT proved)

24) On 31 August 2016;

24.1 You administered the following medication through Patient E‘s syringe

driver, namely;










25.1 You reloaded Patient E’s syringe driver to administer medication, namely;






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26) On 29 August 2016;

26.1 You increased Patient F’s dose of Oxycodone from 25mg to 30mg. (Proved

by way of admission)

26.2 You did not document a clear rationale to clinically justify increasing Patient

F’s dose of Oxycodone. (Proved by way of admission)

27) On 7 June 2016 you created a care plan for a syringe driver prior to

assessing Patient G. (Proved by way of admission)

28) On 10 July 2016 you did not document a clear rationale to clinically justify

why further pain relief was not appropriate for Patient G. (Proved by way of

admission)

29) On 3 October 2015;



needed. (Found NOT proved)



29.3 You administered medication to Patient H, namely;


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29.4 You did not document a clear rationale to clinically justify the high doses of

Diamorphine and Midazolam administered to Patient H. (Proved by way of

admission)


Practitioner’s decisions that syringe driver was not needed. (Found NOT

proved)

30) On 4 October 2015:

30.1 You administered the following medication through Patient H‘s syringe

driver, namely;


30.1.2 Cyclizine 50mg (Proved by way of admission)

30.1.3 Buscopan 20mg (Proved by way of admission)





driver for Patient H. (Found NOT proved)


Cyclizine through the wrong route to Patient H. (Proved by way of admission)


Buscopan through the wrong route to Patient H. (Proved by way of admission)

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(Found NOT proved)

32) On 28 May 2015

32.1 You administered the following medication through Patient I‘s syringe driver,

namely;



32.1.3 Hyoscine 1.2mg (Proved by way of admission)


syringe driver for Patient I. (Found NOT proved)

And in light of the above your fitness to practice is impaired by reason your misconduct.

Background

The NMC received a referral from Rotherham NHS Foundation Trust (the Trust) on 15

March 2017. Ms Pinder commenced employment at the Trust in September 2006 as a

staff nurse. She became a community staff nurse in April 2013.

On 23 January 2017 Ms Pinder visited a patient’s home. The patient was receiving end

of life care and had pre-emptive medications written up by a General Practitioner which

were available in the patient’s own home. Whilst at the patient’s home Ms Pinder set up

a syringe driver and allegedly incorrectly added Cyclazine, Diamorphine, Haloperidol,

Midazolam and Hyoscine. It is unusual to infuse more than three medications at once

via syringe driver, even though more medications may have been prescribed by a GP.

To administer five different medications via syringe driver is highly unusual, and against

the Trust’s policy to have more than three medications in one syringe driver.

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Documentation did not indicate why the combination and volume of medication was

selected. Medication should only be given if the patient is presenting symptoms

requiring treatment and this is clearly documented.

The Trust conducted a review of previous patient records which Ms Pinder was involved

in that concerned end of life care. 30 sets of clinical records were reviewed relating to

the period 2015/2016. The review identified that nine patients could have been involved

in similar incidents regarding use of syringe drivers in end of life care. The Trust

identified that six of the records were of concern, allegedly involving syringe driver

medication being administered with no rationale recorded in the patient’s notes.

Ms Pinder was dismissed by the Trust on 31 August 2017 for gross misconduct. The

matter was referred to the police but the police had since confirmed that no further

action is to be taken by them.

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Findings on facts

In reaching its decisions on the facts, the panel considered the submissions made by

Ms Mustard, on behalf of the NMC, and written representations on Ms Pinder’s behalf. It

also considered the evidence before it, both documentary and oral.


The burden of proof rests upon the NMC and Ms Pinder does not have to prove or

disprove anything. The standard of proof is the civil standard, namely the balance of

probabilities. This means that, for a fact to be found proved, the NMC must satisfy the

panel that what is alleged to have happened is more likely than not to have occurred. In

determining the facts, the panel is entitled to draw common-sense inferences but not to

speculate.

The panel has drawn no adverse inference from the non-attendance of Ms Pinder.

The panel heard oral evidence from two witnesses tendered on behalf of the NMC.

Witnesses called on behalf of the NMC were:

Ms 1 – Lead Nurse in Palliative Care/Investigating Officer;

Ms 2 – Student Nurse.

The panel first considered the overall credibility and reliability of all of the witnesses it

had heard from. The panel also read the NMC bundle of documents, and the bundle of

documents submitted on behalf of Ms Pinder.

The panel found Ms 1 to be a reliable and helpful witness. She had a good and clear

knowledge of the procedures and working environment at the Trust. Ms 1 informed the

panel that she didn’t question Ms Pinder about allegations in relation to Patients C to I,

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during the investigation interview. Nonetheless, the panel found Ms 1 to be well

balanced, consistent and credible.

The panel found Ms 2 to be straightforward and tried her best to assist the panel. While

the panel noted that Ms 2 was a direct eye witness to events concerning Patient B, Ms 2

accepted that her recollection was in some areas somewhat vague. Nonetheless, the

panel had no reason to doubt her integrity.

The panel then considered the remaining charges against Ms Pinder which were:



12.5 Cyclizine 50mg

The panel drew reference to the Trust’s investigation meeting notes. When asked to

explain why Ms Pinder had put Cyclizine into the syringe driver, she said:

“I know now that I didn’t need to do this…The patient was making a loud noise so

I stopped what I was doing…then I came back and drew up the Cyclizine.”

In an email dated 20 March 2017, Ms Pinder asserted that the Cyclizine had actually

spilt on this occasion, and she had not administered it and so there was no error. She

states:

“the cyclizine had spilt that was being prepared stat which the student nurse I

was with witnessed…I accidentally wrote the cyclizine on as well.”

The panel bore in mind Ms 2’s assertion that no spillages occurred on the day in

question. Ms 2 told the panel that she was making notes of the visit, and therefore

would have recorded this. Ms 2 told the panel that she was ‘100%’ sure no medication

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was spilt and as this would have been an unusual event she was sure she would have

remembered it. Further in her NMC written statement, Ms 2 states that ‘no drug

ampules were broken or spilled during the visit’, and that if there had been then this

would have been recorded and reported. The panel did not accept Ms Pinder’s account

that she had spilled the Cyclizine, and accepted the evidence of Ms 2 that nothing had

been spilt.

Further, the panel noted Ms Pinder’s acceptance that she should not have used

Cyclizine in the syringe driver. Weighing up all of the evidence the panel concluded that

it was more likely than not that Ms Pinder did administer Cyclizine via syringe driver to

Patient B as recorded in Patient B’s computerised clinical record.

The panel therefore found this charge proved.


cutaneous injection to Patient B.

The panel took into account Ms 1’s oral evidence. Ms 1 was clear in her evidence of the

steps she would expect all nurses to follow when administering medications.

Ms 2 told the panel she witnessed Ms Pinder give one medication via sub-cutaneous

injection. Ms Pinder’s notes record that she administered 2.5mg of Diamorphine sub-

cutaneously as Patient B was complaining of abdominal pain. The panel accepted Ms

2’s evidence that there was one sub-cutaneous injection and concluded that Ms Pinder

did not administer Cyclizine via sub-cutaneous injection.

The panel concluded that Ms Pinder’s computerised clinical record for Patient B was

accurate that she loaded the syringe driver with

‘Diamorphine…Midazolam…Haloperidol and Cyclizine.’ The panel saw no evidence to

suggest that Ms Pinder administered Cyclizine via sub-cutaneous injection prior to

commencement of the syringe driver.

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The panel concluded that the only medication Ms Pinder administered via sub-

cutaneous injection was Diamorphine.



loading Patient B’s syringe driver with 5 different medications.

Ms 1 told the panel that Ms Pinder’s documentation was unclear, insufficient and did not

clinically justify loading the selection of medication loaded into Patient B’s syringe driver.

Ms 1 stated that due to the volume of medication produced by five drugs, this would be

inappropriate to load into one syringe driver.

The panel also accepted the evidence of Ms 2. Ms 2 accompanied Ms Pinder during

Patient B’s home visit on 23 January 2017. She asserted that she saw Ms Pinder load

the syringe driver with five different medications, although she could not comment on

what they were. When questioned, Ms 2 confirmed for the panel that handwritten notes

could be found in Patient B’s home. However, the panel saw no requisite documentation

to explain the clinical rationale Ms Pinder had in loading Patient B’s syringe driver with

five different medications and any rationale should have been recorded in the

computerised clinical record.



assessing Patient D.

The panel noted that on the Trust’s computer record system, on 22 October 2016 at

09:26, following a telephone referral, listed as from her office, Ms Pinder created a

detailed syringe driver care plan for Patient D. This was prior to seeing Patient D to

carry out an assessment. The panel bore in mind Ms 1’s oral evidence that it would not

have been possible for Ms Pinder to know what Patient D’s symptoms were and

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whether Patient D would require drugs to be administered via a syringe driver prior to

assessment.

Ms Pinder maintained in the investigation interview that she did not create a syringe

driver care plan. The panel do not accept this as the plan clearly records what type of

device is to be used, namely McKinley T34 syringe driver, that the cannula sight has to

be checked and that the practitioner needs to ensure that the syringe driver is placed

within the lockbox. The panel accepted Ms 1’s evidence that this computerised clinical

record could not be mistaken for anything other than a syringe driver care plan.

Weighing up all of the evidence the panel concluded that it was more likely than not that

Ms Pinder created a care plan for syringe driver use prior to assessing Patient D.


18) On 25 October 2016;



cannula with;

18.1.1 Midazolam 2.5mg

18.1.2 Haloperidol 1.25mg

18.1.3 Diamorphine 2.5mg

The panel noted that Ms Pinder did not need to seek guidance/reassurance in

administering the above drugs via cannula as these drugs were pre-emptively

prescribed to Patient D for administration via this route. Ms Pinder recorded that she

had received a call that Patient D was ‘distressed’ and ‘agitated’. Upon arrival Ms Pinder

reported that Patient D was ‘crying in pain’. She was informed by staff that Patient D

had been crying out for most of the night. Ms Pinder accordingly administered STAT

29

doses of the prescribed Midazolam, Haloperidol and Diamorphine drugs according to

her clinical judgement.

The panel concluded that there was no need for Ms Pinder to seek

guidance/reassurance when administering the above drugs sub-cutaneously.

The panel therefore found this charge NOT proved.



driver for Patient D.

The panel noted that Patient D was assessed on 22 October 2016 by a GP, who

advised that if Patient D becomes agitated or distressed to consider the syringe driver.

However, there was no information before the panel to indicate that any discussion took

place about the deterioration in Patient D with a member of the multidisciplinary team

prior to administering medications via syringe driver on 25 October. The visit to Patient

D’s care home was recorded as ‘60 minute’s total contact’. Ms 1 told the panel that it is

‘not normal’ practice to commence the use of a syringe driver within such a short period

of time of sub-cutaneous injection. She stated that a period of time should be allowed

after administration to monitor the symptoms each of the drugs were administered for.

Upon reviewing Patient D’s notes, the panel saw no evaluation in relation to the

effectiveness of sub-cutaneous injection prior to commencing the syringe driver.

Ms 1 informed the panel of the various points of contact available to Ms Pinder at the

Trust regarding end of life treatment including her line manager, Patient D’s GP and the

24 hour Palliative Care team. She also confirmed that it was normal practice to seek

guidance before commencing a syringe driver. The panel was satisfied that Ms Pinder

had ample opportunity to seek guidance/reassurance from various points of contact,

which she did not utilise.


30

23) On 26 October 2016 you did not document Patient D’s presentation.

The panel noted that on 26 October 2016, Ms Pinder had documented Patient D’s

presentation as ‘very comfortable and peaceful and pain free’. Further, Ms Pinder

produces detailed notes in relation to Patient D’s pressure sores, in four separate

entries. The panel was satisfied that Ms Pinder did produce detailed documentation in

relation to Patient D’s presentation on 26 October 2016.


24) On 31 August 2016;


syringe driver for Patient E.

On 31 August 2016, at 14:00, Ms Pinder recorded that she visited Patient E as she was

discharged from a hospital. Ms Pinder documented various drugs being administered

and that that the syringe driver was ‘battery 80% and infusing at time of visit’. The panel

considered that this was indicative that the syringe driver was already in place and in

use at the time of assessment. The panel was not satisfied that there was sufficient

evidence to prove that Ms Pinder had commenced the syringe driver for Patient E.

Rather, there is evidence to suggest that the hospital had commenced the syringe driver

for Patient E prior to discharge.




driver for Patient E.

Taking its earlier finding in relation to charge 24.2 into account, the panel determined

that there was therefore no requirement for Ms Pinder to seek guidance/reassurance on

this matter as she did not commence the syringe driver.

31




needed.

The panel noted from Patient H’s computerised records, on 2 October 2015 that Patient

H was reviewed by a GP. Patient H’s notes state at 05:45 on 3 October that she was

now becoming restless and less responsive, and further STAT doses of medication

were given.

During Ms Pinder’s home visit on 3 October at 16:20, Ms Pinder noted that Patient H

was ‘comfortable’. She was informed that the GP had reviewed Patient H overnight and

had stated that she was for sub-cutaneous medication, not a syringe driver. Ms Pinder

requested a fax be sent by care home staff to the GP and was later informed by the

senior carer on duty that the GP had refused to complete a syringe driver ‘pink sheet’.

Ms Pinder then documented ‘to review patient H tomorrow and if no improvement

involve palliative care for advice’.

On 3 October 2015, at 18:23, Ms Pinder revisited Patient H. It is reported that Patient H

was now ‘agitated’ and so Ms Pinder administered medication via cannula in her left leg.

Further, it is recorded that the GP arrived and prescribed for a syringe driver, which was

‘left in the home should this be required’. Ms Pinder recorded a general nursing

assessment of Patient H that she had been reviewed by the GP and was to be kept

‘comfortable’ as she was ‘approaching end of life care’.

The panel saw no evidence that Ms Pinder had challenged the GP’s advice, but

responded to the changing needs of Patient H.


29.5 You obtained a prescription for a syringe driver, despite a General

Practitioner’s decisions that syringe driver was not needed.

32

The panel noted that the GP had reviewed Patient H on 3 October 2015. The GP had

initially confirmed that a 24 hour syringe driver was not required as Patient H was

‘comfortable’. However, as Patient H’s condition began to deteriorate, the GP

prescribed for the use of a syringe driver, to be used ‘if required’. The panel was

satisfied that Ms Pinder adhered to the Trust’s policy, and followed the normal

procedure in obtaining pre-emptive medication.




driver for Patient H.

The panel saw evidence to suggest that Ms Pinder had followed the normal procedure

in administering medication via sub-cutaneous injection the night before. It considered

that Patient H’s condition had deteriorated. Ms Pinder commenced the use of a syringe

driver for medications prescribed by the GP, with the advice that Patient H should be

kept ‘comfortable’. Ms Pinder noted that Patient H now appeared ‘distressed’. The panel

was satisfied that Ms Pinder had used her own clinical judgement in determining

whether a syringe driver would be required to administer the prescribed medication. The

panel was satisfied that Ms Pinder had acted on appropriate guidance/reassurance from

the GP given the night before, and based on this and using her own clinical judgement

had commenced the use of the syringe driver.




The panel referred to the care plan produced by Ms Pinder on 23 May 2015, at 12:15

during a home visit. The panel noted that Ms Pinder had received a telephone call from

33

a GP, who confirmed that Patient I was ‘confused and coming towards end of life care

and has unresolved pneumonia’. Ms Pinder recorded:

“the gp feels she is not currently at the point of requiring a driver and is currently

comfortable and pain free. Driver to commence should Patient I deteriorate.”

The panel considered that Ms Pinder had a clear discussion with the GP, and sought

advice in relation to the commencement of the administration of prescribed medication

via a syringe driver. The GP directed for the use of the driver when necessary to keep

Patient I ‘comfortable’. Ms Pinder noted that she would visit Patient I daily to monitor her

symptoms, and assess whether prescribed medication should be administered via the

syringe driver.

In light of the above, the panel saw no evidence to suggest that Ms Pinder went against

the advice from a GP, and that she instead followed correct procedure and monitored

Patient I’s presentation.



syringe driver for Patient I.

The panel referred to its earlier finding in relation to charge 31. It bore in mind that Ms

Pinder had a detailed discussion with a GP about the introduction of medication via a

syringe driver for Patient I. At the point of Ms Pinder’s visit, it was advised that Patient I

did not require the syringe driver. However, pre-emptive medications were in place,

should her condition deteriorate. The panel noted that Patient I had ‘unresolved

pneumonia’ and her condition was deteriorating. After daily visits to assess Patient I’s

condition, it is noted on 28 May at 08:30, that Ms Pinder collected a ‘pink card’ from

Highthorne Surgery, Swinton. She then ‘returned and commenced syringe driver as

discussed with gp.’ The panel determined that Ms Pinder had provided sufficient

34

documentation to clinically justify the commencement of a syringe driver for Patient I,

over several daily visits.


Submissions 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 Ms Pinder’s

fitness to practise is currently impaired. There is no statutory definition of fitness to

practise. However, the NMC has defined fitness to practise as a registrant’s suitability to

remain on the register unrestricted.

Ms Mustard provided the panel with a written copy of her submissions. She submitted

that the comments of Lord Clyde in Roylance v General Medical Council [1999] UKPC

16 would provide assistance to the panel when seeking to define misconduct:

‘[331B-E] 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 [nursing] practitioner in the particular circumstances’.

She submitted that the panel may further be assisted by the comments of Elias LJ in R

(on the application of Remedy UK Ltd) v General Medical Council [2010] EWHC 1245

(Admin) who stated that misconduct must be ‘sufficiently serious that it can properly be

described as misconduct going to fitness to practise’.

35

Ms Mustard invited the panel to take the view that Ms Pinder’s actions amount to a

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

midwives (2015) (“the Code”). She directed the panel to specific paragraphs and

identified where, in the NMC’s view, Ms Pinder’s actions amounted to misconduct. The

specific paragraphs are as follows:

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

2 Listen to people and respond to their preferences and concerns


2.1 work in partnership with people to make sure you deliver care effectively

3 Make sure that people’s physical, social and psychological needs are

assessed and responded to


3.1 pay special attention to promoting wellbeing, preventing ill health and

meeting the changing health and care needs of people during all life stages

8 Work cooperatively


8.1 respect the skills, expertise and contributions of your colleagues, referring

matters to them when appropriate

36

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

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.


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

13 Recognise and work within the limits of your competence


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 act

18 Advise on, prescribe, supply, dispense or administer medicines within

the limits of your training and competence, the law, our guidance and

other relevant policies, guidance and regulations


18.3 make sure that the care or treatment you advise on, prescribe, supply,

dispense or administer for each person is compatible with any other care or

37

treatment they are receiving, including (where possible) over-the-counter

medicines

20 Uphold the reputation of your profession at all times


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

20.8 act as a role model of professional behaviour for students and newly

qualified nurses and midwives to aspire to

Regarding the issue of impairment, Ms Mustard addressed the panel on the need to

have regard to protecting the public and the wider public interest. This includes the need

to declare and maintain proper standards and maintain public confidence in the

profession and in the NMC as a regulatory body. Ms Mustard referred the panel to the

cases of Cohen, and also Zgymunt v General Medical Council [2008] EWHC 2643

(Admin).

Ms Mustard submitted that Ms Pinder’s actions have breached fundamental tenets of

the nursing profession through four key areas. She identified those areas as:

Medication administration errors;

Poor record-keeping;

Unnecessary/pre-emptive medication/care planning;

Not obtaining advice/guidance where necessary;

Ms Mustard submitted that whilst Ms Pinder made a number of admissions at the outset

of this hearing, there were still many features of this case which were disputed by her.

Ms Mustard submitted that Ms Pinder has failed to take full accountability for her actions

38

and her inability to take full accountability demonstrates a lack of insight. Consequently,

Ms Mustard suggested that any insight which can be established from the admissions

cannot be said to be more than limited.

In light of the above, Ms Mustard invited the panel to make a finding of impairment on

both public protection and public interest grounds. She submitted that Ms Pinder’s

actions are so serious that a finding of current impairment is required in order to

maintain public confidence in the professions and to uphold proper professional

standards.

Mr Walker, on Ms Pinder’s behalf, accepted that her actions amounted to misconduct.

However, he submitted that Ms Pinder’s fitness to practise is currently not impaired

because she has demonstrated safe and effective practice whilst unrestricted in ‘fresh

employment’ with Greenfield Care Home, since November 2017. Mr Walker stated that

the errors found proven were similar in nature and narrow in compass and could be

remedied in practice. Mr Walker addressed the two medication errors in 2018. He

submitted that remediation is a ‘journey’, and that such errors identified do not

undermine Ms Pinder’s clear evidence of remediation. Mr Walker submitted that the

positive testimonials provided to the panel are demonstrable of a nurse who has

‘developed markedly’, has reflected on her shortcomings and has developed clinical

competence in the areas of concern identified. Mr Walker told the panel that Ms Pinder

is now considered to be a ‘receptive and reflective practitioner’ and an ‘asset to the

home’, so much so that senior colleagues have encouraged her to take on more senior

roles. Mr Walker presented the panel with a list of the testimonials and references Ms

Pinder has received from her manager, senior clinical colleagues and a medical

colleague that describes evidence of clinical competence, improvements in record

keeping, the ability to work effectively in a team, advice being sought and learning

through feedback and clear communication, all developed positively between 2018 and

2019.

39

Mr Walker also submitted that Ms Pinder has engaged with the NMC, has instructed

counsel to appear on her behalf and has provided a large bundle of documents to the

panel. He invited the panel to consider the positive testimonials as to Ms Pinder’s

character and practice, and to take note of her successful completion on a number of

training courses. Furthermore, Mr Walker invited the panel to consider a previous

panel’s decision at an interim order hearing. Whilst he acknowledged that the previous

panel had a different role in identifying risk, rather than impairment, Mr Walker

submitted that such findings at that hearing are relevant to today’s panel. Mr Walker

informed this panel that findings at the interim stage concluded that Ms Pinder had

‘comprehensively addressed’ the deficiencies in her practice, and demonstrated

‘considerable insight’. Mr Walker submitted that there is evidence of remediation

through Ms Pinder’s workbook and supervision notes.

Mr Walker submitted that by seeking fresh employment, remaining open and honest

about her shortcomings, and through remedying her failings, Ms Pinder has

demonstrated considerable insight into the effect of her shortcomings. He also reminded

the panel that Ms Pinder made early admissions to a vast majority of the charges.

Mr Walker stated that Ms Pinder was going through personal health concerns at the

time of the incidents and that she has now recovered and this no longer impacts on her

professional practice. He argued that there is a public interest in allowing a good nurse

to practise.

The panel has accepted the advice of the legal assessor which included reference to a

number of judgments which are relevant, including: Roylance v General Medical Council

(No 2) [2000] 1 A.C. 311, and Council for Healthcare Regulatory Excellence v (1)

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

The panel adopted a two-stage process in its consideration, as advised. First, the panel

must determine whether the facts found proved amount to misconduct. Secondly, only if

the facts found proved amount to misconduct, the panel must decide whether, in all the

40

circumstances, Ms Pinder’s fitness to practise is currently impaired as a result of that

misconduct.

Decision on misconduct When determining whether the facts found proved amount to misconduct the panel had

regard to the terms of The Code: Professional standards of practice and behaviour for

nurses and midwives (2015)’ (“the Code”), as referred to by Ms Mustard in her

submissions.

The panel, in reaching its decision, had regard to the public interest and accepted that

there was no burden or standard of proof at this stage and exercised its own

professional judgement.

The panel referred to the four areas of concern identified by Ms Mustard. The panel

considered that Ms Pinder made admissions to a vast majority of medication

administration errors as set out in the charges. The panel accepted Ms Mustard’s

submission that such errors were inappropriate, and placed patients at a real risk of

harm. Further, these errors were not isolated, and involved nine vulnerable patients

whom Ms Pinder had a duty of care to.

The panel considered Ms Pinder’s record keeping to be extremely poor. It noted that on

multiple occasions, Ms Pinder’s assessment of patient symptoms and reasoning for the

use of a syringe driver was insufficient. Further, her notes were unhelpful to colleagues.

The panel considered that her record keeping was unreliable.

The panel found that Ms Pinder did produce unnecessary/pre-emptive medication/care

planning. It noted its earlier findings in relation to creating care plans prior to

assessment of patients, and in relation to administering medication via syringe driver,

shortly after sub-cutaneous injection. The panel noted information suggesting a genuine

41

misunderstanding from Ms Pinder about her duties and remit. Nonetheless, the panel

determined that Ms Pinder’s actions were inappropriate.

The panel noted that there were times when Ms Pinder did seek appropriate advice

from a GP/Specialist Palliative Care service, and other times when she did not. The

panel considered this to be very inconsistent.

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

of misconduct. However, taken individually, the panel was of the view that Ms Pinder’s

actions, which occurred over a two year period, fell seriously short of the conduct and

standards expected of a nurse and do amount to misconduct.

Decision on impairment

The panel next went on to decide if as a result of this misconduct, Ms Pinder’s fitness to

practise is currently impaired.

Nurses occupy a position of privilege and trust in society and are expected at all times

to be professional and to maintain professional boundaries. Patients and their families

must be able to trust nurses with their lives and the lives of their loved ones. To justify

that trust, nurses must…act with integrity. They must make sure that their conduct at all

times justifies both their patients’ and the public’s trust in the profession. In this regard

the panel considered the judgement of Mrs Justice Cox in the case of Council for

Healthcare Regulatory Excellence v (1) Nursing and Midwifery Council (2) Grant [2011]

EWHC 927 (Admin) in reaching its decision, in paragraph 74 she said:

In determining whether a practitioner’s fitness to practise is impaired by

reason of misconduct, the relevant panel should generally consider not

only whether the practitioner continues to present a risk to members of the

public in his or her current role, but also whether the need to uphold

proper professional standards and public confidence in the profession

42

would be undermined if a finding of impairment were not made in the

particular circumstances.

Mrs Justice Cox went on to say in Paragraph 76:

I would also add the following observations in this case having heard

submissions, principally from Ms McDonald, as to the helpful and

comprehensive approach to determining this issue formulated by

Dame Janet Smith in her Fifth Report from Shipman, referred to above.

At paragraph 25.67 she identified the following as an appropriate test for

panels considering impairment of a doctor’s fitness to practise, but in my

view the test would be equally applicable to other practitioners governed

by different regulatory schemes.

Do our findings of fact in respect of the [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 in the future to act so as to

put a patient or patients at unwarranted risk of harm; and/or

b. has in the past brought and/or is liable in the future to bring the

medical profession into disrepute; and/or

c. has in the past breached and/or is liable in the future to breach

one of the fundamental tenets of the medical profession; and/or

d. …

The panel identified that limbs (a), (b), and (c) are engaged in this case.

43

The panel noted that Ms Pinder continues to engage with her regulator, has sought

legal representation and has submitted a large bundle of documents for consideration in

her absence. The panel noted that Ms Pinder was unable to attend today, due to

financial reasons.

The panel saw evidence to show that Ms Pinder has taken positive steps to remedy her

practice, training and supervision records, reflective pieces and testimonials. Based on

these, the panel is satisfied that she now has full insight into her shortfalls and how she

would do things differently.

On 12 May 2017, Ms Pinder wrote in a reflective piece, titled ‘Reducing medication

errors in nursing practice’:

“I made assumptions from previous discussion with the gp that upon review of

the pt the syringe driver could be commenced. Due to the high complexity of the

visit and poor connectivity in the area instead of commencing the driver a stat

dose should have been given to alleviate pain then return to the office to gain

further support from the Gp and palliative care team discuss with the dn before

commencing the driver.”

She also wrote:

“To remain objective and to not allow emotion to overtake rational thinking

processes. To move away from the situation to think clearly. Learning to

recognise stress and fatigue within myself and to not be afraid to ask for extra

support and help with syringe driver care in end of life.”

And:

44

“If a pt is nearng [sic] end of life and requires subcutaneous medicstions [sic]

then x2 staff present. Stat doses to be given over 24-48 hours to ensure the pt is

not sensitive to the medications. If the pt requires 8 doses or more over that

period then contact palluative [sic] care team and gp to inform of current situation

and for them to review the pt asap for a further plan of care jointly. The

medications will be px for stat and 24 hour medications but this does not mean

that they can be given until further advice is sought in the first instance.”

In her reflective account, dated 14 March 2019, Ms Pinder states:

“I now recognise my limitations and continually seek for support from my team

members and the multi-disciplinary team where I am currently employed.”

And:

“I took it upon a previous conversation from three days prior with the GP in which

I should’ve requested assistance as soon as possible. I feel I should have made

the patient safe and due to no connectivity I should’ve left and gone back to base

for help and support but took it upon myself which I am truly remorseful for.

Ms Pinder is supported by a number of professional references from those who have

directly monitored and evaluated her practice.

Ms 3, Home Manager at Greenside states:

“Lorna is an asset to the home and a pleasure to work with. She has built

professional relationships with both service users and staff and is fully committed

to her role.”

Dr 4, of Rotherham Hospice, stated on 23 February 2019:

45

“From my observations Lorna has a much better understanding of pre-emptive

medication and their indications. She appreciates when they should appropriately

be administered and that a combination in some circumstances might be needed

to treat symptoms.”

She goes on to say:

“I have always found Lorna to be engaged with myself and other members of the

hospice team. She will always ask for advice and guidance which includes

reassurance before making any decisions with regards to administering

medication…On the contrary, she discusses more frequently patient’s care,

which for me is more reassuring when I am not present with patients.”

Mr 5, Clinical Lead Nurse at Greenfield, stated on 27 March 2019:

“Currently Lorna is taking the lead within the unit in relation to React to

Red…Lorna does not currently require shadowing or the support of another

nurse on shift at this present time as her clinical competence does not require

such measures….In my clinical opinion Lorna has developed markedly over the

last 12 months and continues to grow and develop as a nurse.”

Ms 6, Senior Nurse at Greenside stated:

“Her record keeping around the End of Life care is very informative and very

detailed ensuring that she covers everything that has happened at that specific,

time and date including conversations that have taken place with relatives,

professionals and colleagues”

And:

46

“Lorna monitors her patients very closely and is outstanding at recognising when

a patient is starting to take a decline in their health, and the need to escalate to

the GP and or Palliative GP/consultant and when out of hours escalates to the

Hospice at Home team. This is done to ensure that the patient is in receipt of the

best possible care, comfortability and ultimately to ensure their dignity remains

intact. Lorna’s competency in manging a syringe driver is excellent”

The panel has made its own decision today. Although it was cognisant of the interim

order hearing decision, this panel is aware that the interim order panel was not fully

appraised of all the facts in this case. This panel noted that Ms Pinder has been subject

to an interim conditions of practice order, with which she fully complied. The panel was

satisfied that Ms Pinder benefited from the conditions on her practice, her current

employers support and her willingness to undertake training. This has enabled her to

fully reflect on her failings and remediate/improve her practice in her current

employment. The interim conditions of practice order was lifted at the end of March

2019 and she has maintained safe and effective practice since that time.

Taking all of the information provided to it into account, the panel was satisfied that Ms

Pinder no longer poses a risk to the public. The panel noted that it had been provided

with evidence suggesting that Ms Pinder demonstrates ‘excellent practice’, and has fully

addressed the specific areas of concern identified by her regulator, in medication

administration, record keeping, necessary pre-emptive medication and care planning

and obtaining advice/guidance where necessary. Evidence before the panel suggests

that Ms Pinder is being continually supported by her current employer, who has

encouraged her to take on additional responsibilities. The panel saw this as indicative

that she is no longer clinically impaired. The panel was satisfied that Ms Pinder

continues to take the necessary steps the NMC would expect a registered nurse to take

in maintaining safe and effective practice.

The panel determined that a finding of impairment on public protection grounds was not

necessary.

47

The panel bore in mind that the overarching objectives of the NMC are to protect,

promote and maintain the health safety and well-being of the public and patients, and to

uphold/protect the wider public interest, which includes promoting and maintaining

public confidence in the nursing and midwifery professions and upholding the proper

professional standards for members of those professions. The panel determined that, in

this case, a finding of impairment on public interest grounds was required, to mark the

serious misconduct found.

Whilst the panel noted that Ms Pinder has demonstrated an extended period of safe and

effective practice for some time now, it bore in mind that serious and multiple failings

occurred over a two year period, in relation to nine vulnerable patients. Ms Pinder had a

responsibility to provide the highest standard of care to a vulnerable group of patients.

Patient safety and trust in nurses are at the heart of the profession and the panel

considered that a fully informed member of the public would have their confidence in the

profession and the NMC as regulator seriously undermined if no finding of impairment

were to be made.

Having regard to all of the above, the panel was satisfied that Ms Pinder’s fitness to

practise is currently impaired, on public interest grounds alone.

48

Decision on sanction

The panel has considered this case very carefully and has decided to impose a caution

order for a period of three years. The effect of this order is that Ms Pinder’s name on the

NMC register will show that she is subject to a caution order and anyone who enquires

about her registration will be informed of this order.

In reaching this decision, the panel has had regard to all the evidence that has been

adduced in this case, together with the submissions of Ms Mustard on behalf of the

NMC and those of Mr Walker on Ms Pinder’s behalf.

Ms Mustard addressed the panel on the aggravating and mitigating features of Ms

Pinder’s case and made submissions in relation to the approach the panel should take

at the sanction stage. She invited the panel to have regard to the NMC’s Sanctions

Guidance (SG). Ms Mustard submitted that in the light of the panel’s findings on facts

and that Ms Pinder’s fitness to practise is impaired solely on public interest grounds, the

NMC’s sanction bid was that of a long caution order at the upper end. She submitted

that should the panel think that the seriousness of the regulatory concerns warrant a

temporary removal from the register, there are a number of factors that show that this

case does fall within the relevant considerations for a suspension order. She added

however, that this is overall a matter for the panel’s professional judgement.

Mr Walker addressed the panel on the mitigating features of Ms Pinder’s case and

made submissions in relation to the panel imposing a short caution order to mark the

misconduct found. He reminded the panel of its earlier findings, in that, impairment has

been found solely on public interest grounds. Mr Walker submitted that there is

evidence before the panel to suggest that Ms Pinder has fully remediated her

misconduct, and that she has not only accepted her failings, but sought to rectify them

from the earliest opportunity. He added that to impose a short suspension order would

be ‘unduly severe’ in this case. Mr Walker submitted that a short caution order would be

the appropriate and proportionate outcome in the circumstances of Ms Pinder’s case.

49

The panel accepted the advice of the legal assessor. The panel bore in mind that any

sanction imposed must be reasonable, appropriate and proportionate and, although not

intended to be punitive in its effect, may have such consequences. The panel had

careful regard to the SG published by the NMC. It recognised that the decision on

sanction is a matter for the panel, exercising its own independent judgement.

The panel first considered the mitigating and aggravating factors in Ms Pinder’s case.

The panel identified the following as aggravating factors in Ms Pinder’s case:

Ms Pinder’s actions placed nine vulnerable patients at a real risk of harm;

There is a pattern of serious misconduct over a two year period concerning

failures in basic nursing.

The panel identified the following as mitigating factors in this case:

Ms Pinder demonstrated full insight and expressed genuine remorse;

Ms Pinder made admissions to the majority of the charges in these

proceedings;

Ms Pinder has continued support from her current employer;

Ms Pinder has undertaken relevant training and updated her skills and

knowledge, addressing the four areas of concern identified by her regulator;

There is medical evidence relating to Ms Pinder’s health at the time of incidents,

which may have impacted upon her practice over that period.

The panel then turned to the question of which sanction, if any, to impose. It considered

each available sanction in turn, starting with the least restrictive sanction and moving

upwards.

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

inappropriate. The panel decided that taking no further action would not adequately

mark the seriousness of the misconduct found and would do nothing to maintain public

50

confidence in the profession and the NMC as its regulator. To take no further action

would therefore not address the public interest considerations of Ms Pinder’s case.

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

the panel took into account the SG, which states:

“A caution order is only appropriate if the Fitness to Practise Committee

has decided there’s no risk to the public or to patients requiring the nurse

or midwife’s practice to be restricted, meaning the case is at the lower end

of the spectrum of impaired fitness to practise, however the Fitness to

Practise Committee wants to mark that the behaviour was unacceptable

and must not happen again.”

The panel took into account that Ms Pinder has demonstrated significant insight into her

misconduct and has expressed genuine remorse. The panel was satisfied that Ms

Pinder’s reflections were considered over a lengthy period of time and that she has

identified how she would do things differently, should she find herself in a similar

situation in the future. The panel noted that Ms Pinder made admissions from the outset

and took responsibility and accountability for her clinical shortcomings. Ms Pinder also

remains open and honest with her current employer, who continues to support and

commend her work.

The panel considered that it has found impairment solely on the grounds of the public

interest and that the risk of repetition in Ms Pinder’s case is minimal. She has engaged

fully and positively with the NMC process and fully remediated her practice since the

referral. The panel noted that whilst Ms Pinder’s misconduct arose from a pattern of

repeated poor practice, she has reflected on her practice and, at an early stage, started

her journey to remediation. After her dismissal form the Trust, Ms Pinder sought fresh

employment, undergoing relevant training and working with her current employer

towards returning to safe and effective practice. She has undertaken relevant learning

and been monitored and evaluated by senior staff addressing her failings, prioritising

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the safety of patients, in order to minimise the risk of repetition. Ms Pinder has

demonstrated that she is committed to best practice and engaging with the wider multi-

disciplinary team, receiving positive feedback form the Palliative Care team. The panel

was of the view that these regulatory proceedings, including the interim conditions of

practice order, have been a salutary lesson for Ms Pinder.

In all the circumstances, the panel determined that a sanction of a caution order was

sufficient to address the public interest in declaring and upholding proper standards and

confidence in the NMC as regulator. In the light of Ms Pinder’s remorse, insight,

remediation and the minimal risk of repetition, the panel concluded that a caution order

satisfies the public interest in marking her misconduct as unacceptable.

The panel considered whether it would be proportionate to impose a more restrictive

sanction and looked at conditions of practice. The panel determined that such a

sanction would not be appropriate as Ms Pinder has taken positive steps to remediate

and address her clinical failings. Further, Ms Pinder was subject to an interim conditions

of practice order for two years, with which she fully complied. As a result, that order was

revoked by a panel, in March 2019. This panel was reassured that although it was a risk

assessment of Ms Pinder by another panel, she has now demonstrated safe and

effective practice over a period of time which includes the period from March 2019,

when she has practised unrestricted. Further, Ms Pinder’s current employers have

encouraged her to take on additional responsibilities and seek promotional

opportunities. The panel was reassured that Ms Pinder has benefitted from the interim

conditions of practice order imposed previously, has taken any constructive criticism

from her current employer on board, and has demonstrated safe and effective practice

whilst unrestricted.

The panel then considered whether a suspension order would be proportionate. The

panel determined that, in light of its findings that Ms Pinder’s fitness to practise was

impaired solely on the public interest grounds, and taking into account her insight,

extensive remediation and the minimal risk of repetition, a suspension order would be

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disproportionate and punitive. The panel therefore concluded that removing Ms Pinder’s

name from the register, even for a limited period of time, was not necessary in order to

adequately satisfy the public interest. The panel also bore in mind the public interest in

retaining the skills of an otherwise safe registered nurse. It would remove a nurse

practising safely from her place of work and potentially cause disruption to her current

patients. Further, it noted that Ms Pinder has been described as an ‘outstanding’ and

‘excellent’ nurse by her current employer, who states she has developed ‘therapeutic

relationships’ with patients, their relatives, and her colleagues. It considered that such

relationships may be negatively impacted, should Ms Pinder be temporarily removed

from her role. Having considered the general principles above and looking at the totality

of the findings based on the evidence, the panel determined to impose a caution order

for a period of three years.

The panel has therefore decided that a caution order will adequately address the public

interest considerations of Ms Pinder’s case. For the next three years, her employer or

any prospective employer will be on notice that her fitness to practise was found to be

impaired and that her practice is subject to a caution order. Having considered all the

circumstances of her case, the panel has determined that to impose a caution order for

a period of three years is the appropriate and proportionate response. It marks not only

the importance of maintaining public confidence in the profession, but also sends the

public and the profession a clear message about the standards required of a registered

nurse.

At the end of this period the note on Ms Pinder’s entry in the register will be removed.

However, the NMC will keep a record of the panel’s finding that her fitness to practise

had been found impaired. If the NMC receives a further allegation that Ms Pinder’s

fitness to practise is impaired, the record of this panel’s finding and decision will be

made available to any practice committee that considers the further allegation.

This decision will be confirmed in writing.

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That concludes this determination.

Documents

Nursing and Midwifery Council Fitness to Practise ... · 7/5/2019 · Ms Lorna Deborah Pinder: Not present, written representations submitted Day 4 and 5 – represented by Marc