Embed Size (px)
Citation preview
1
Nursing and Midwifery Council Fitness to Practise Committee
Substantive Order Review Hearing
9 February 2018
Nursing and Midwifery Council, 61 Aldwych, London WC2B 4AE
Name of registrant: Grace Arkoh-Ankrah NMC PIN: 99J1120O Part(s) of the register: Registered Nurse – Sub part 1 Adult Nursing – October 1999 Mental Health Nursing – February 2008 Area of Registered Address: England Type of Case: Lack of Competence Panel Members: Anne Asher (Chair, registrant member)
Elizabeth Burnley (Lay member) John Vellacott (Lay member)
Legal Assessor: Nicholas Wilcox Panel Secretary: Virginia Sardeli Registrant: Not present and not represented in absence Nursing and Midwifery Council: Represented by Bryony Dongray, Case
Presenter. Order being reviewed: Conditions of practice order – 24 months Outcome: Conditions of practice order extended – 8
months, to come into effect at the end of 24 March 2018 in accordance with Article 30 (1)
2
Service of Notice of Hearing The panel was informed at the start of this hearing that Ms Arkoh-Ankrah was not in
attendance, nor was she represented in her absence.
The panel was informed that notice of this hearing was sent to Ms Arkoh-Ankrah on 10
January 2018 by recorded delivery and first class post to her registered address. The
panel was also informed that the Royal Mail ‘Track and Trace’ system showed that the
notice had been delivered on 12 January 2018 and signed for in the name of ‘ANKRAH’.
Further, the panel noted that notice of this hearing was also sent to Ms Arkoh-Ankrah’s
representative, Thomas Montford, on 10 January 2018.
The panel accepted the advice of the legal assessor.
In the light of the information available, the panel was satisfied that notice had been
served in accordance with Rules 11 and 34 of The Nursing and Midwifery Council
(Fitness to Practise) Rules Order of Council 2004 (as amended February 2012) (the
Rules).
Proceeding in absence The panel then considered proceeding in the absence of Ms Arkoh-Ankrah. The panel
was mindful that the discretion to proceed in absence is one which must be exercised
with the utmost care and caution.
The panel considered all of the information before it, together with the submissions
made by Ms Dongray, on behalf of the Nursing and Midwifery Council (NMC), who
referred to the case of R. v Jones (Anthony William), (No.2) [2002] UKHL 5.
Ms Dongray referred the panel to the letter dated 7 February 2018 from Ms Arkoh-
Ankrah’s representative, explaining that she would not be attending the hearing and her
reasons for this. Ms Dongray invited the panel to proceed in Ms Arkoh-Ankrah’s
3
absence. She submitted that it would be in the public interest and of limited prejudice to
Ms Arkoh-Ankrah for this hearing to go forward.
The panel heard and accepted the advice of the legal assessor. It noted Ms Arkoh-
Ankrah’s engagement throughout the history of these proceedings and accepted the
reasons for her non-attendance put forward via her representative’s letter dated 7
February 2018 (stated in full later in this determination).
The panel further accepted Ms Dongray’s submission that there would be limited
prejudice to Ms Arkoh-Ankrah by this hearing going forward, given the detailed
submissions from her representative.
The panel was satisfied that Ms Arkoh-Ankrah was aware of today’s hearing and it was
of the view that she had chosen voluntarily to absent herself. It further decided that, in
light of the submissions on her behalf, an adjournment would be of little use. Having
weighed the interests of Ms Arkoh-Ankrah with those of the NMC and the public interest
in an expeditious disposal of this hearing, the panel determined to proceed in Ms Arkoh-
Ankrah’s absence.
Decision and reasons on review of the current order The panel decided to extend the current conditions of practice order by a further 8
months. This order will come into effect at the end of 24 March 2018 in accordance with
Article 30 (1) of the Nursing and Midwifery Order 2001 (as amended) (the Order).
This is the third review of a substantive order originally imposed by a panel of the
Conduct and Competence Committee on 19 February 2015 for 12 months. That panel
imposed a suspension order for 12 months, which was replaced by a 24-month
conditions of practice order following a review on 18 March 2016. A further review,
which concluded on 10 August 2017, took place in order to address issues with the
current conditions of practice order. No new order was made at that review.
The current order is due to expire on 24 March 2018.
4
The panel is reviewing the order pursuant to Article 30(1) of the Order.
The charges found proved which resulted in the imposition of the substantive order
were as follows:
“That you, whilst employed by the Warrington and Halton Hospitals NHS Trust as
a staff Nurse, and whilst subject to an action plan / formal capability procedure
between 18 February 2011 and 4 June 2012 failed to demonstrate the standards,
knowledge, skills and judgement required to practise as a Staff Nurse in that you:
Whilst working on Ward A8 between 18 February 2011 and 13 November 2011:
1. ..:
a. …
2. On or around 2 March 2011:
a. Failed to provide Patient 6 with a drink
b. …
c. …
3. On or around 2 June 2011:
a. Failed to handover Patient 10's "nil by mouth" status at the end of
your shift
4. On or around 11 August 2011:
5
a. Gave a very brief handover to Ms 1 during which you used
abbreviations which you did not understand
b. Failed to request clarification of abbreviations you did not
understand when patients were handed over to you at the start of
your shift
c. Communicated with staff in a manner which appeared abrupt
and/or aggressive
d. Communicated with patients in a manner which appeared abrupt
and/or aggressive
5. On or around 2 September 2011:
a. Reported that Patient 12's mouth was "just a bit red" or words to
that effect when Patient 12 had a thrush infection and swollen
ulcers
b. Failed to show empathy for Patient 12's condition
6. On or around 7 September 2011:
a. Failed to gain the consent of Patient 13's family before transferring
Patient 13 to a rehabilitation unit
7. On an unknown date between June and October 2011:
a. Failed to check Patient 1's blood sugar levels
b. Failed to re-dress Patient 1's leg sores
6
c. Did not know that you should not commence suction on the chest
drain for Patient 2 before the doctor had specified the correct
pressure to be used
d. Failed to ensure that Patient 3's pressure sores were covered
e. Failed to notify the doctor that the prescription in respect of Patient
5 needed to be altered
8. Between 22 and 28 September 2011
a. Failed to complete fluid balance charts for Patient 20
b. In the absence of an accurate record of urine output for patient 20,
scored zero on this aspect of the Modified Early Warning Score
(MEWS)
Whilst working on Ward A7 between 14 November 2011 and 4 June 2012:
9. On or around 8 December 2011:
a. Requested a one:one for Patient 15 without taking steps to find out
the reason for the change in his condition
b. Failed to request a medical review for Patient 15 for a period of
around 45 minutes
c. Failed to check how frequently the sedative prescribed to Patient
15 could be administered
d. Did not know the steps you should take pre-administration and
post-administration of Patient 15’s sedative.
7
10. …:
a. …
11. On or around 1 January 2012:
a. Failed to attend Patient 21 when he indicated that he was about to
suffer a hypoglycaemic episode
b. Failed to demonstrate an adequate understanding of diabetic care
12. On or around 9 January 2012:
a. Did not know how Patient 22, who had a pneumothorax with chest
drain in-situ, should be cared for
13. On or around 18 January 2012:
a. Failed to administer a prescribed dose of calcium resonium to
Patient 23
b. Did not know the potential consequences of raised potassium
levels
14. On or around 9 February 2012:
a. Did not know if any of Patient 24's medications had been altered
b. Did not know if Patient 24 had been administered any analgesia
15. On or around 10 February 2012:
8
a. Failed to complete a pain score in respect of Patient 25
b. Failed to complete a bowel chart in respect of Patient 25
c. Did not know the correct steps to take on recording a Modified
Early Warning Score of two for Patient 25
d. Failed to record the appearance of Patient 27’s pressure sores
16. On or around 14 February 2012:
a. Inadequately completed documentation in respect of Patient 28's
chest drain
17. On or around 15 February 2012:
a. Caused Patient 33 to be brought up to Ward A7 when there was no
bed for Patient 33
b. Failed to handover that Patient 30 was not for resuscitation
c. Did not wash your hands prior to taking Patient 31’s blood sugar
d. Used poor technique to take Patient 31s blood sugar, resulting in
contamination of the test
e. Failed to update the careplans of the patients in your care
18. On or around 16 February 2012 you failed the medication competency
assessment.
19. On or around 24 February 2012:
9
a. …
b. Required prompting to complete a food chart for a patient
c. Required prompting to change a fluid bag for a patient
d. …
e. …
20. On or around 29 February 2012:
a. Required prompting to note down the necessary information at the
handover of shifts
b. Failed to record observations in respect of Patient 39 who had a
chest drain in-situ
c. Failed to speak with the relatives of Patient 40 who had attended
Ward A7 for this purpose
d. Gave handover to the late shift at 3.30pm when this should have
been done at 1.30pm
e. Failed to complete necessary documentation, including fluid
balance charts during the course of the shift
f. Failed to monitor Patient 43 who was on chest drain suction
g. Incorrectly attempted to take blood sugars for Patient 44, who was
not diabetic and did not require a blood sugar test at that time
h. …
10
21. On or around 4 March 2012:
a. Failed the medication competency assessment
b. Did not know that an anti-emetic could be omitted when a patient
was not feeling sick
c. …
d. …
22. On or around 3 March 2012:
a. Failed to complete the necessary blood card for Patient 45's blood
tests
23. On or around 15 March 2012:
a. Failed to handover to an oncoming member of staff that a patient
had a red buttock area
b. Failed to handover to an oncoming member of staff that a patient
had very low blood pressure and therefore required four-hourly
observations
c. Did not know whether or not Patient 46 had had an International
Ratio (INR) to test the consistency of his blood
d. …
e. …
11
f. Failed to check Patient 46A's feet, despite a note from the doctor
mentioning that Patient 46A's feet were discoloured
g. Did not know that Patient 46A had swollen and discoloured feet
h. Failed to chase referrals for patients, including Patient 47
i. Failed to attend to Patient 47 who had a dry and coated mouth
j. Required prompting to refer to Care Plans when writing up your
notes
k. Spent more than an hour writing up notes for the care given to your
patients
24. On or around the weekend of 24-25 March 2012:
a. Failed to offer Patient 48 alternative nutrition when he refused
breakfast
b. Failed to re-check Patient 48's blood sugars after his refusal to take
breakfast
c. Did not know the correct treatment for a patient with low blood
sugar levels
d. Required prompting to re-check Patient 48's blood sugar levels
after they had been recorded as below a normal level
e. Required prompting to re-check Patient 49's blood sugar after they
had been recorded as low.
f. Failed to administer a second dose of colyamicin to Patient 50
12
g. Failed to carry out risk assessments for Patient 50
25. On or around 7 April 2012:
a. Failed to complete observations of any patients for the first three
and a half hours of your shift
26. On or around 12 April 2012:
a. Failed to complete patient care plans
b. Failed to document wound care given to Patient 52 who had a
Grade 2 sacral sore
c. Failed to carry out an assessment of Patient 52's sacral sore
27. On or around 16 April 2012
a. Gave an inadequate handover of information to oncoming staff
b. Recorded Patient 53's respiration rate as 17, when it was in fact 22
28. On or around 18 April 2012:
a. Failed to hand over information which was required to enable to the
transfer of Patient 54 from Ward A7
29. On or around 19 April 2012:
a. Ordered blood for a non-urgent transfusion for Patient 55 for a time
when you would not be able to administer it
13
b. Asked a carer to give the blood to Ms 3 to deal with as you did not
have time to do so yourself
c. Asked a carer to put the blood in a fridge on Ward A7 when this
was not correct procedure
d. Failed to handover to Ms 4 that Patient 56 had a broken hip
e. Had to be asked three times by Patient 57 before you took down
the empty blood bag following Patient 57's transfusion
30. On or around 24 April 2012:
a. Used the incorrect nebuliser for Patient 59
31. On or around 26 April 2012:
a. Recorded in a patient's notes that the Medical Team had "no idea"
about the Home Oxygen Therapy required for the patient on
discharge, even though they had previously documented the
requirement in his notes.
32. On or around 8 May 2012:
a. Required prompting to give assistance to Patient 62 who was
unwell and short of breath
b. Failed to provide an adequate handover Patient 62's condition to
the nurse who took over the care of Patient 62 at the time the nurse
took over care
14
c. Failed to handover information relating to Patient 62's planned
transfer to the High dependency Unit
d. Failed to chase up test results for patients allocated to you
33. On or around 10 May 2012:
a. Failed to carry out instructions given to you by Ms 2 in respect of
Patient 63 and instead handed this patient over to another member
of staff
34. On or around 18 May 2012:
a. Requested that the ward clerk send a fax referring Patient 64 to the
district nursing team, when that fax did not contain:
i. Information as to medication dosages
ii. The time for the patient's discharge
iii. The weight of the patient upon discharge
b. Failed to provide Patient 64 with a sharps bin on discharge
AND in light of the above, your fitness to practise is impaired by reason of your
lack of competence.”
The reviewing panel of 18 March 2016 determined the following with regard to
impairment:
“The panel considered that although you had demonstrated a level of insight both
in your reflective statement and whilst giving oral evidence today, this insight was
limited.
15
The panel noted that you had reflected at length on your failings in dealing with
patients, patients’ families and your colleagues. However, the panel considered
you had failed to develop full insight as you sought to attribute some of your
failings to the pressure you felt you were under from colleagues who were
working with you to improve your performance. The panel was concerned that
you did not appear to accept that you may be in similar pressurised situations in
the future if you return to practise, when your competence may be scrutinised.
The panel considers that this might impact upon your ability to fully recognise
your limitations.
In its consideration of whether you have remedied your practice the panel took
into account the fact that you have undertaken a number of training courses. The
panel acknowledged that you have taken significant steps to address your
failings, however the panel noted that the courses you have undertaken are
theoretical. The panel considered that whilst you have made progress, you have
not fully remedied your failings as you have not been able to put into practice the
theoretical training that you have undertaken.
The panel is of the view that there is a risk of repetition based on the fact that you
have been unable to demonstrate practical remediation of your failings and you
do not have full insight into your failings. The panel therefore decided that a
finding of current impairment was necessary on the grounds of public protection.
The panel had borne in mind that its primary function was to protect patients and
the wider public interest which includes maintaining confidence in the nursing
profession and upholding the proper standards and behaviour. The panel
determined that, in this case, a finding of impairment on public interest grounds
was also required given the wide ranging nature of your failings and the lack of
opportunity you have had to remedy these. In these circumstances, an informed
member of the public exercising reasonable judgment would be concerned to
learn you had been allowed back into practice unrestricted.”
16
The reviewing panel of 18 March 2016 determined the following with regard to sanction:
“The panel considered substituting the current suspension order with a conditions
of practice order. Your failings were serious; however there has been evidence
produced to show that you have developed some insight, that you have
undertaken relevant theoretical training and that you wish to return to nursing.
Further the panel considered that it would be possible to formulate practicable
and workable conditions, that if complied with, may lead to your unrestricted
return to practice and would serve to protect the public and the reputation of the
profession in the meantime. The panel considered that a further period of
suspension would be disproportionate.
The panel decided that the public would be suitably protected as would the
reputation of the profession by the implementation of … conditions of practice”
Decision on current fitness to practise The panel has considered carefully whether Ms Arkoh-Ankrah’s fitness to practise
remains impaired. Whilst there is no statutory definition of fitness to practise, the NMC
has defined it as ‘a registrant’s suitability to remain on the register without restriction’. In
considering this case, the panel has carried out a comprehensive review of the order in
light of the current circumstances. It has noted the decision of the last panel. However, it
has exercised its own judgment as to current impairment.
The panel has had regard to all of the documentation before it. It has taken account of
the submissions made by Ms Dongray on behalf of the NMC, and those made by Mr
Montford on Ms Arkoh-Ankrah’s behalf, in his letter dated 7 February 2018.
Ms Dongray provided the panel with a background to the proceedings. She referred to
the communications between the NMC and Ms Arkoh-Ankrah clearly showing that she
has not yet embarked on a return to practice course, as required by the current
conditions of practice order. Ms Arkoh-Ankrah has not worked as a registered nurse
since 2012, and in the circumstances, she has not been able to ameliorate the NMC’s
17
concerns, and is therefore still impaired. Ms Dongray noted that it is commendable that
Ms Arkoh-Ankrah is attempting to get accepted on a return to practice course and it
appears that she may well achieve this in the next 6 months.
Ms Dongray invited the panel to continue the current conditions of practice order, as it is
currently set out, for a period of 8 months, in order to enable Ms Arkoh-Ankrah to
undertake a return to practice course. She will then be in a position to provide more
information to a future reviewing panel regarding any progress she has made towards
her remediation.
The panel noted Mr Montford’s letter on your behalf, which stated:
“I spoke with the registrant as regards the forthcoming hearing at the beginning
of last week and also engaged her Course Leader at Liverpool John Moores
University on the last working day of that same week. I capture what came up in
the numbered paragraphs below:
1. Upon speaking with the registrant at the beginning of last week and a couple
of times before then, she led me to understand that she is always willing to
cooperate with council and attend all requested hearings and reviews as she has
done unfailingly in the past. She however noted that on this occasion there are
difficulties in the sense that whilst she thought her placement had been arranged,
it turns out that there are still some administrative issues to be ironed out, the
same emanate from the conditions of practice.
2. Owing to the difficulty captured as per the last sentence of the previous
paragraph, the registrant is of the considered opinion that she needs to be
available via telephone throughout the week. If she were to proceed to London to
attend the review, she would be unable to access her phone whilst driving to
London on Thursday and would also not be able to take calls whilst at the NMC
on Friday.
18
3. In addition to the aforesaid, the registrant also drew my attention to the fact
that she is not just expected to proceed on the placement but she is undertaking
various studies as regards placements, some of which are in her study folder,
with others being on line. She equally informed me that she has obtained some
academic articles as regards placements, which she had started reading and
was also accessing background information on YouTube, to enable her benefit
maximally from the provision. She made it clear that her studies around
placements would continue till the last minute.
4. I equally spoke with the registrant’s course leader at Liverpool John Moores
University, … who confirmed to me in a telephone conversation that the
registrant could either complete the course on 7 June 2018 or in
August/September 2018. [ She ] also confirmed that the registrant is expected to
undertake personal and university recommended study in relation to placements
at the run up to the commencement of the placement itself.
In view of the foregoing, the registrant has, with sadness, instructed me to inform
you that she would not be able to make it to the NMC organised review this time.
She would rather appeal to the NMC to extend the Conditions of Practice in their
current form till September 2018 and also push the forthcoming review till then.
That way, she would be able to attend in person and showcase all that she has
done on the course itself, the placement and privately to the respected panel.”
The panel heard and accepted the advice of the legal assessor.
In reaching its decision, the panel was mindful of the need to protect the public,
maintain public confidence in the profession and to declare and uphold proper
standards of conduct and performance.
The panel considered whether Ms Arkoh-Ankrah’s fitness to practise remains impaired.
It noted that, to date, she has not been able to complete a return to practice course.
There has therefore been no change as far as her remediation and she remains a risk.
19
The panel noted that the charges found proved related to a number of wide-ranging
issues, and that she has not worked as a registered nurse since 2012. It had no
information before it to show that Ms Arkoh-Ankrah had made any progress towards
addressing these, apart from applying to undertake a return to practice course. There
was also no new information before the panel in respect of any developments in Ms
Arkoh-Ankrah’s insight.
The panel again acknowledged Ms Arkoh-Ankrah’s continued engagement in these
proceedings and her continued efforts to gain a place on a return to practice course.
The outcome of these efforts will be of interest to a future reviewing panel.
The last panel determined that Ms Arkoh-Ankrah was liable to repeat matters of the kind
found proved. This panel has received no new information that would indicate
otherwise. In light of this, the panel determined that Ms Arkoh-Ankrah is liable to repeat
matters of the kind found proved, and that a finding of current impairment is necessary
on the grounds of public protection.
The panel bore in mind that its primary function was to protect patients and the wider
public interest which includes maintaining confidence in the nursing profession and
upholding proper standards of conduct and performance. The panel determined that, in
this case, a finding of current impairment on public interest grounds is required.
For these reasons, the panel finds that Ms Arkoh-Ankrah’s fitness to practise remains
currently impaired.
Determination on sanction Having found Ms Arkoh-Ankrah’s fitness to practise currently impaired, the panel then
considered what, if any, sanction it should impose in this case. The panel noted that its
powers are set out in Articles 29 and 30 of the Order. The panel has also taken into
account the NMC’s sanctions guidance and has borne in mind that the purpose of a
sanction is not to be punitive, though any sanction imposed may have a punitive effect.
20
The panel first considered whether to take no action, or to impose a caution order, but
concluded that either outcome would be inappropriate in view of the risk of repetition
identified by this panel and the consequent risk to the public if she were allowed to
practice unrestricted. The panel decided that these outcomes would be neither
proportionate, nor in the public interest.
The panel next considered the imposition of a conditions of practice order. The panel
was of the view that a conditions of practice order is sufficient to protect patients and the
wider public interest, noting that appropriate and proportionate conditions could be
formulated which would protect patients during the period they are in force. It further
took into account Ms Arkoh-Ankrah’s continued attempts to comply with the current
conditions of practice order, and the fact that she appears to be in the process of
undertaking a return to practice course in the near future.
Accordingly, the panel determined, pursuant to Article 30(1) of the Nursing and
Midwifery Order 2001, to extend the current conditions of practice order for a period of 8
months, in order to give Ms Arkoh-Ankrah the opportunity to complete the return to
practice course and possibly gain employment as a registered nurse. This order will
come into effect on the expiry of the current order.
The conditions remain as follows:
1. You must tell the NMC within 14 days of any nursing appointment (whether paid
or unpaid) you accept within the UK or elsewhere, and provide the NMC with
contact details of your employer.
2. You must tell the NMC about any professional investigation started against you
and/or any professional disciplinary proceedings taken against you within 14
days of you receiving notice of them.
3. a) You must within 14 days of accepting any post or employment requiring
registration with the NMC, or any course of study connected with nursing or
21
midwifery, provide the NMC with the name/contact details of the individual or
organisation offering the post, employment or course of study.
b) You must within 14 days of entering into any arrangements required by these
conditions of practice provide the NMC with the name and contact details of the
individual/organisation with whom you have entered into the arrangement.
4. Before returning to practice you must successfully complete and pass an NMC-
approved return to practice programme. The course should address the following
areas of competency and you must be assessed as competent in those areas;
a) Communication
b) Record Keeping
c) The assessment, planning, implementation and evaluation of care
d) Time management
e) Prioritisation of tasks
f) Compliance with procedures and policies
g) The ability to assess your own performance and limitations in performance.
5. You must immediately inform the following parties that you are subject to a
conditions of practice order under the NMC’s fitness to practise procedures, and
disclose the conditions listed at (1) to (4) above, to them:
a. Any organisation or person employing, contracting with, or using you to
undertake nursing 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); and
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).
A future reviewing panel may be assisted by the following:
22
- Ms Arkoh-Ankrah’s attendance at the review hearing
- A reflective piece focusing on the return to practice course outcomes and relating
to the problem areas identified at the substantive hearing.
- Any up-to-date testimonials from registered nursing colleagues who have worked
with Ms Arkoh-Ankrah during her return to practice course.
This decision will be confirmed to Ms Arkoh-Ankrah in writing.
That concludes this determination.
