The Director of Proceedings (the Director) laid a charge of professional misconduct against Mr Paul Jury, a registered nurse of Hastings (the Nurse) relating to an incident which occurred on 24 November 2010. The Director alleged that while caring for his patient the Nurse:
- While attempting to remove the Patient's upper clothing applied unreasonable force to his patients:
(a) arm; and/or
- Failed to treat his Patient with dignity and respect in that while she was sitting in the bath of water he:
(a) removed the bath plug (flannel) and left her there while, and/or after the water drained out; and/or
(b) made derogatory comments about her.
- While transferring his Patient he applied unreasonable force by propelling her forward with the application of his leg to her body, including transfer:
(a) from the bathroom to the bedroom; and/or
(b) from the bedroom to the seclusion room.
- Failed to adequately document the care he provided to his patient.
The Tribunal found Particulars 2 to 4 established and when considered cumulatively amounted to professional misconduct.
The events which were the subject of the charge, centre on the Mental Health Inpatient Unit at Hastings Hospital. The Unit is comprised of a ward with two areas: a 19 bed sub-acute area, the East Wing, and an immediately adjacent five bed secure area, the Intensive Psychiatric Care Unit (IPCU). The nursing resources were shared between both clinical areas and were acuity based.
The Patient was a 76 year old woman with the diagnosis of Paranoid Schizophrenia and had been receiving treatment for her mental illness for many years. Although she lived and was treated in the community in the early course of her illness, she had over forty-four admissions for inpatient treament. In recent years (the better part of the last decade) she had essentially lived as a patient on the mental health inpatient unit.
Her illness was characterised by paranoid delusions, periods of agitation and distress and depression. The Patient could be aggressive, hitting staff, throwing food and glasses of water etc. In the past when unwell in the community she had severly assaulted her elderly neighbour.
Treatment of her mental illness was complicated by deterioration in her physical health. She had required transfer to the Emergency Department 18 times since the end of January 2010 and had been diagnosed with recurrent Neuroleptic Malignant Syndrome which can be life threatening. This necessitated discontinuation of her antipsychotic medication. The Patient's mental state subsequently deteriorated requiring transfer to IPCU for several weeks including periods of seclusion. At the time of the events giving rise to the charge, medication had gradually been reintroduced with some improvement in the Patient's mental state. She was being managed on the open ward but at times she was agitated, disruptive, shouting out and refusing or spitting out her medication. In terms of her day to day functioning she required a lot of assistance.
Between 1600 and 1645 hours on 24 November 2010, the Patient became agitated when requested by RN Clarke to smoke in the designated smoking area. She rammed Ms Clarke with her walker. The Patient was given an extra 1mg of Lorazepam along with her regluar 1700 medications. Later she was discovered near her room coming up the hallway pushing her walker with faeces on her arms, on the front of her top, her sleeves, arms, hands, skirt front and back and her socks. She came to the lounge, and was asked to go to her room. She became agitated and would not co-operate, so she was informed that she would have to to to IPCU.
She was escorted to IPCU for a bath where there were difficulties removing her soiled clothing. She was placed in the bath. In anticipation of her being taken to a nearby bedroom for an IM injection of Lorazepam, the bath was drained and she sat in it without water for at time. Then she was escorted to the bedroom for the IM medication, and was restrained by 4 staff members whilst it was administered. Following this she was escorted under restarint to a seclusion room within IPCU.
Reason for Finding
The Tribunal considered the facts of the case and was satisfied that the Nurse found this situation challenging and unpleasant, but the Tribunal was not saisfied that there was a deliberate application of inappropriate force. The Patient had soiled clothing on which needed to be romoved. She was described as being agitated, delusional and confused, and was not able to assist in the removal of her clothing; indeed she was resistant.
The situation was not straightforward, and there was a priority to remove her clothing. The Tribunal found that the situation was borderline as the amount of force that was used, but the circumstances the Tribunal was not satisfied the particular was made out.
The Tribunal accepted that the Patient was in the bath for at least five minutes, without water and that she became cold. Another nurse wanted to place a towel over the patient to keep her warm before a third nurse returned, but the Nurse would not let her.
The Tribunal are satisfied that the Nurse made remarks which were derogatory within the hearing of the Patient. The Tribunal considered that unfortunately by this stage in the process, the Nurse was beginning to exhibit some frustration at the Patient.
The Tribunal was satisfied that this particular was established.
The Tribunal found:
The Nurse gave varying accounts as to where in the transfer sequence he was bringing his thigh into contact with the Patient. His more contemporaneous accounts described this as happening in the transfer from the bathroom to the bedroom.
This was inconsistent with the evidence of two witnesses, one of whom in particular was well placed to observe what occurred. From a distance of three to four metres she saw the Nurse raise his knee to the small of the Patient's back after they left the bedroom. Both witnesses observed a physical reaction to this manoeuvre. The Tribunal accepted this evidence.
The Nurse accepted that he used an unapproved form of restraint, and said he regetted using it.
The expert evidence was that the use of an alternative unapproved technique in itself amounted to a moderate departure from accepted standards and that if force had been applied into the small of the back of the Patient that would amount to an excessive use of force, which would amount to a severe departure from acceptable standards.
The Tribunal concluded that Particular 3(b) was established and Particular 3(a) was not.
Following this incident, the Nurse prepared a clinical note and an incident report. The Nurse agreed that his notes could have been more detailed, but said that in the circumstances he needed to document the incident and get back to other patients as well.
The Expert gave evidence that he considered that there were two areas which should in the circumstances have been the subject of a proper record. One was the removal of the clothing in the bathroom area, and the other was the unorthodox transfer of the Patient. He though this was unnecessary, because both had features which were "....beyond the normal range of usual experience a nurse would undertake."
The Tribunal agreed that a record of these aspects of the matter would have ensured other staff were alert to the possibility of any physical and/or mental consequences of the incident. The Tribunal was satisfied that particular 4 was made out.
The Tribunal was required to consider the four Particulars separately or cumulatively, to determine whether there is professional misconduct. It elected to consider the established Particulars (2 to 4) cumulatively.
The Tribunal found that the multiple breaches which occurred showed a significant disregard for the Patient's best interests, even allowing for the challenges which she presented. Of particular concern was the unorthodox application of force, when the Nurse placed his knee in the small of the Patient's back.
The Tribunal concluded there were significant departures from acceptable practice, warranting a disciplinary sanction to maintain professional standards, protect the public and punish the practitioner. The charge of professional misconduct was made out.
The Tribunal ordered that the following conditions be placed on the Nurse:
- The Nurse undertake a course in managing challenging situations, calming and de-escalation before returning to practice. The course is to be approved by the Nursing Council and be taken at such time as the Nursing Council sees fit. If there is a cost involved the Nurse is to meet it.
- The Nurse remain under supervision for six months upon return to practice and the supervisor meet monthly with the Nurse and then report to the Nursing Council, for the period of supervision. The supervisor is to be appointed by the Nursing Council and if there is a cost involved the Nurse is to meet it. Any other necessary terms and conditions are to be stipulated by the Nursing Council.
The Tribunal further ordered that the Nurse be censured, pay costs of $2,500.00 and that the decision be published.