Reasons for the substantive hearing of the Conduct and Competence

Committee panel
held at
77 Oxford Street, London, W1D 2ES
On
1st & 2nd June 09

Name: Derek Green

PIN: 87C0558E
Part (s) of register: Adult

Facts proved: Charge 1, 2, 3 and 4

Fitness to practise: Impaired
Sanction: Striking Off
Interim Order: Interim suspension order imposed for 18 months

Reason for not proceeding in the absence of the registrant:

Having heard submissions from the case presenter and the advice given by the legal
assessor the panel has decided that this case should proceed today for the following
reasons:
1. The panel is satisfied that the registrant is aware of these proceedings and
that he had indicated that he does not intend to appear or be represented in
these proceedings
2. The events that gave rise to this case occurred over two years ago. It is in the
interests of justice that this matter precedes as soon as possible, in the light
of the fact that witnesses’ memories inevitably fade with time.
3. Whilst fairness to the registrant is of prime importance, fairness to the council
and the council’s witnesses is also relevant. We have been told that there are
eight witnesses present today ready to give evidence in the case.
4. Although the panel has heard no evidence as yet, the charges on their face
appear to be serious. In those circumstances issues of public safety are
clearly relevant.

In all the circumstances, the case should be dealt with as expeditiously as possible.

Charges read as follows:

That you, whilst working as a Registered Nurse at the Rossall Rehabilitation Hospital
on the night of 10th/11th April 2007:

1. Contrary to Trust Policy and Procedure, did not record any observations for
Patient A when you were notified of a change in her breathing by Healthcare
Assistant Yvonne Wright on the evening of 10th April 2007;

2. Contrary to Trust Policy and Procedure, did not record a full set of
observations for Patient A at around 03.00 hours and/or 03.30 hours on the
morning of 11th April 2007 in that you did not record:

a. Patient A’s pulse;

b. Patient A’s heart rate;
c. Patient A’s temperature;
d. Patient A’s blood pressure;
e. An Early Warning Score for Patient A.
 3. Did not contact the on-call doctor or seek a medical review of Patient A when
her condition deteriorated;

4. Your conduct at 3 above was contrary to the Trust’s Medical Algorithm Early
Warning Score.

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

Reason for the finding of facts

The registrant has admitted charges 3 and 4 in this case. When considering charges
1 and 2, the panel has taken no account of those admissions and has considered
charges 1 and 2 on the basis of the evidence presented. The registrant denies both
of these charges.

Charges 1 and 2 read as follows;

1. Contrary to Trust Policy and Procedure, did not record any observations for
Patient A when you were notified of a change in her breathing by Healthcare
Assistant Yvonne Wright on the evening of 10th April 2007;

2. Contrary to Trust Policy and Procedure, did not record a full set of
observations for Patient A at around 03:00 hours and/or 03:30 hours on the
morning of 11th April 2007 in that you did not record:

a) Patients A’s pulse;

b) Patient A’s heart rate;
c) Patient A’s temperature;
d) Patient A’s blood pressure;
e) An Early Warning Score for Patient A

Under cover of a letter dated 16th May 2008, the registrant provided a statement
dealing with the events of the night of 10th/11th April 2007. In that statement, he
conceded that he made an assessment of Patient A at about the time referred to in
charge 1, following a request from healthcare assistant Wright. He also conceded
that he carried out a further assessment of the patient at about the time referred to in
charge 2, again following concerns expressed by healthcare assistant Wright. The
registrant has not attended this hearing but it is understood that he contends that on
the evening and the morning of the dates in question he commenced a new chart for
observations on patient A. The panel finds that this is inherently unlikely for the
following reasons;

a) All of Patient A’s records were collected up before she was transferred to the
Royal Victoria Hospital but this document is the only one that appears to be
missing.

b) On the morning of the 11th April 2007, patient A was assessed by Nurse
Connolly who recorded her findings on the observation chart which had been
in use for 8th and 10th April day shifts. Had the registrant created a new
observation chart we would have expected Nurse Connolly to have recorded
her findings on the new chart. Further whilst there is an entry in the nursing
notes, made by Nurse Green during this shift, there was no indication that a
new chart had been commenced, as good practice would have required.

c) At 03:00 hours on 11th April 2007, the registrant recorded his assessment of
Patient A in the nurses’ notes. It is his case that he would have also recorded
 those findings in the new observation chart which he created. After he was
warned about Patient A’s deteriorating condition at about 22:00 hours the
previous evening, there is no similar entry in the nurse’s notes. In the
absence of any record of this intervention, it seems inherently unlikely that
observations would have been recorded elsewhere.

d) Had the registrant recorded a proper assessment of Patient A at 03:00 on the

11th April in the observation chart, with proper scoring on the EWS, it is most
unlikely that he would not have called for immediate medical assistance from
a doctor.

For these reasons, we find that on the balance of probabilities, no new observation
chart was ever created.

We now turn to the two charges, specifically. With regard to charge (1), it was the
policy and procedure at the time that patients should have at least one complete set
of basic observations in each 24 hour period. The observations which the registrant
has admitted making should have been recorded in writing. For the reasons set out
above, the panel finds that, on the balance of probabilities, these observations were
not recorded by the registrant at 22.00.

With regard to charge 2, it is clear that a record was made in the nurses’ notes in
relation to the assessment carried out at 03:00 hours on the 11th April 2007 but the
record failed to show the necessary particulars as required by the hospital’s policy as
set out in exhibit 8. In particular, it failed to record an early warning score. The panel,
therefore, finds, on the balance of probabilities that the facts set out in charge 2 is
proved.

Reason for the finding of impairment

The registrant has admitted the facts in charges 3 and 4 and the panel have found
the facts in charges 1 and 2 proved. We therefore turn to the issue of misconduct.

Charges 1 and 2 relate to record keeping and we have already found that the
registrant did not record his observations of patient A on the evening of 10th April
2007 and the early morning of 11th April 2007. Paragraph 4.4 of the NMC Code of
Professional Conduct 2004, sets out a nurse’s obligation with regard to record
keeping. The paragraph reads as follows “Health care records are a tool of
communication within the team. You must ensure that the health care record of a
patient is an accurate account of treatment, care planning and delivery. It should be
consecutive, written with the involvement of the patient whenever practicable and
completed as soon as possible after an event has occurred. It should provide clear
evidence of the care planned, the decisions made, the care delivered and the
information shared”. In the panel’s judgement, the registrant’s failures as set out in
charges 1 and 2 constitute clear breaches of paragraph 4.4. Further it is the
judgement of the panel that these failures amounted to serious misconduct.

We now to turn to charges 3 and 4. Patient A was an elderly woman suffering from
thyroid problems. She was an in-patient at the Rossall Hospital for the purpose of
rehabilitation. The evidence was that she could expect to receive active treatment at
all times to manage any condition that arose. On the evening of the 10th April 2007
and the morning of 11th April the registrant was informed twice of the patient’s
deteriorating condition. The registrant assessed the patient himself and was fully
aware of the need for interventions and could have calculated a EWS that would
have raised concern. It appears from his statement, attached to his letter addressed
to the council, dated 16th May 2008 that he took the conscious decision not to call for
medical help, even though this patient was for active management and resuscitation
if necessary. The registrant acted in this way, despite the fact that he considered the
situation serious enough to contact the patient’s relatives in the middle of the night to
attend the hospital immediately. The failure to take appropriate action was in clear
breach of paragraphs 1.2 & 1.4 of the Code. He was accountable for such behaviour
by virtue of paragraph 4.5 of the NMC Code. It is the panel’s judgement that the
failures as set out in charges 3 and 4 also amount to serious professional
misconduct.

In those circumstances, we now consider the question of impairment. The panel

concluded that the failures as set out in the four charges are so serious, both
individually and cumulatively; that they have no doubt that the registrant’s fitness to
practice was impaired by reason of his misconduct at the time of these events.

As we have stated before, the registrant did not attend these proceedings and we
have no information as to what he has been doing since these events, save that we
have been informed that he is presently not working as a registered nurse. In view of
that lack of information, the panel finds that the registrant’s fitness to practice is and
remains impaired.

Reason for the sanctions

The panel first considered taking no further action but came to the conclusion that the
case was far too serious for this to be an appropriate response.

A caution order was next considered but again the panel concluded that this sanction
was inappropriate. As far as the panel is aware the registrant has a previous good
history lasting some twenty years. Nevertheless the registrant’s behaviour in this
case delayed treatment for patient A when she was in a serious condition.
Furthermore, the panel has already found that the registrant’s inaction in this case
was deliberate. Neither statements made by the registrant demonstrated sufficient
insight into the importance of following policies and procedures to promote good
quality care and ensure patient safety.

The panel then considered conditions of practice but felt that it would be
impracticable to provide sufficient safeguard for patients.

A suspension order was then considered. The panel has already found at the
impairment stage that the misconduct in this case was of a very serious nature. The
registrant was an experienced nurse in charge of a number of patients that night. The
panel is of the view that the misconduct in this case is not fundamentally compatible
with the registrant remaining on the professional register.

In those circumstances, the only sanction available to the panel is a striking off order.
The panel considered this to be a proportionate sanction balancing the interest of the
registrant against those of the public which requires protection, maintaining
confidence in the profession and the upholding of proper standards.

Reason for the interim order

In all the circumstances of this case, the panel came to the clear conclusion that such
an order is necessary for the protection of the public and is otherwise in the public
interest.