Transcript Supervisory Investigation Workshop

Supervisory Investigation
Workshop
TONI MARTIN
LSA WEST MIDLANDS
2012
Expected outcomes from the day
 Exploration of any issues of concern for you and
your team
 How to investigate an area of concern in midwifery
practice
 Preparing for and conducting an investigatory
interview
 Summing up your findings for the report
 Making recommendations to the LSA
 Creating and managing a supervised practice
programme
The Legislation
 The Nursing and Midwifery Order (2001) requires
the Nursing and Midwifery council (NMC) to set
rules and standards (Midwives rules and standards
2004) for the function of statutory supervision of
midwives
 Midwives Rules & Standards 2004 sets out
responsibilities of LSA, SOM and midwife
Future Legislation
 Changes to Midwives Rules
 Changes to the NMC
 The impact on SOMs and Midwives
Standards for the preparation of SOMs
 Section 5 (2) - Competencies for a SOM
 Understand the supervisor’s role in the investigatory
process by demonstrating ability to:
◦
◦
undertake an investigation of any serious untoward
incident concerning midwifery practice or of an individual
midwife’s alleged impairment to practise
prepare a supervisory report of the investigation’s
outcomes and recommendations and inform the LSAMO
in cases where supervised practice is recommended, set
agreed learning objectives for the midwife, with a
midwifery educationalist, and monitor progress support a
midwife involved in the investigatory process
Standards for the supervised practice of
midwives (NMC 2007)
 All incidents that cause serious concern relating to
midwifery care or practice should be notified to the
LSA (Rule 15)
 This includes an untoward incident or circumstances
indicating lack of competence
 The investigation should be led by a SOM, notified to
the LSA and completed within a 20 day timeline and
be independent of management investigations
Standards for the supervised practice of
midwives (NMC 2007)
 It must be fair, transparent, fully documented and follow






Guideline L
The named SOM should not usually conduct the
investigation
Midwives have a responsibility to co-operate with
investigations (Code, NMC 2008)
The SOM recommends the appropriate action and the LSA
agrees it
The report should include system failures
The midwife is entitled to a copy of her section of the
investigation report
A summary report should be provided to the HOM
How is fitness to practise impaired?
 Misconduct
 Lack of Competence
 A Conviction or Caution
 Physical or mental Ill Health
 A fraudulent or incorrect entry in the NMC register
 Concerns raised n the workplace
Concerns in the workplace
 Low standard of work, for example, frequent mistakes, not
following a task through, inability to cope with instructions
given
 An inability to handle a reasonable volume of work to a
required standard
 Unacceptable attitudes to work of colleagues, for example,
unco-operative behaviour, poor communication, inability to
acknowledge the contribution of others poor team work,
lack of commitment or drive
A Clinical Incident
 Complaint letter from parents about attitude of a
midwife
 Manager brings it to you asking your opinion
 What will you do?
First Steps/Key Learning









Look at letter/notes
Identify immediate areas of concern
Talk to midwife?
Talk to named SOM/HOM?
Have rules or code been breached?
Is there evidence of misconduct or lack of competence?
Do you have time to wait for RCA (if relevant)
Consider where midwife should now work (if relevant)
Make decision about supervisory investigation and notify
LSA
 Decided to investigate?
 Now what?
 What is the process?
 Who do you involve?
 How do you tell the midwife?
 How can you prepare?
 What resources do you have?
 What happens in a joint investigation?
Supervisory Investigation




Start a diary of events – (save copies of everything)
Use template letters - why use these?
Send Guideline L and statement writing guidance to midwife
Inform midwife - in writing
 Who you are
 What you are doing
 Which supervisor the midwife to go to for support
 Confidentiality of investigation
 Why you are doing this
 What will happen in the investigation process
 When do you hope to complete this
 How will midwife (s) be involved – will be invited to be interviewed
and will be able to bring someone as support (union rep, SoM, friend
or colleague)
 What happens at the end of the process - outcomes
Supervisory Investigation
 Inform manager if employed - meeting
Check to see if clinical risk or managerial investigation is
going to take place
 Negotiate time out from clinical duties to ensure timely
investigation
 How long do you give for return of statements?
 What to do if they are late?
 Refusal to co-operate?
 When do you start the report?
 Should you keep the midwife informed?
 Can you keep the manager informed?

Investigation - fact finding
 Gather information
 Maternal notes
 Relevant policies & guidelines
 Gather statements if you feel it is relevant
 Staff rotas
 Training records
 Equipment involved
 Interview
 Everyone that had involvement in the case or collect
statements
 The mother (and partner) if you feel it is appropriate
The Interview
 How do you prepare?
 What resources do you need?
 Worries, fears, concerns
 Who should be present?
 What questions should you ask?
Interviewing the midwife
 This is the midwife’s opportunity to explain his or her actions
 A record of the interview should be maintained with a witness present
(e.g. another SoM). Take time to take accurate notes. Pause the
interview so that you have time to take notes.
 Support for the midwife
 Questions you may have

Did the midwife have





A thorough induction to work area
Training and supervision where necessary
Preceptorship and mentoring
Ongoing access to professional development
Supervisory annual review
Interview (cont’d)
 Ask her to give her account of what happened, her actions and her
reason for those actions
 Ask how did she feel
 Go through each area where you allege that she failed/omitted to act
and thus breached the rule or code of conduct and listen to responses
 Ask about any mitigating circumstances- what is this?




Absence of recognised supervision
Ill health affecting the midwife’s judgement, behaviour of intellectual
function
Denial of access to training opportunities
System failures (mostly)
Interview (cont’d)
 End the interview by stating that you will have to review all
the information available to you before you can make a
recommendation for the next course of action
 You can state what the possible outcomes are
 Be clear about when she should expect a transcript and
what you want from the midwife – agreement of the
content – what if she does not agree?
What’s wrong with a little ‘attitude’?
 Could be a sign of a strong independent mind, sure,




confident
When does assertiveness move to ‘attitude’, to ‘bad
attitude’?
Does the midwife know best- we have been trained
you know!
Advocacy versus patriarchy
‘Midwives must never practice in such a way that
assumes they know what is best for the people they
are caring for’ - NMC Advocacy & Autonomy Advice
sheet
What the NMC expects
 Professionals entering and remaining on the register




to be of good health and character
Honest and trustworthy
Assessment based on conduct and behaviour of the
registrant
Your character must be sufficiently good for you to
be capable of safe and effective midwifery practice
without supervision
The SOM to be able to handle conflict and achieve
consensus ensuring no party feels disadvantaged
Principles of report Writing
 Guide to report writing - www.npsa.nhs.uk
 Provides good overview and worth examining
 Purpose of the report
 To convey all necessary information about the incident, the
investigation process and the outcome of the investigation
 To present a culmination of all the work you have undertaken
 Provide a formal record of the process and is a means of
sharing learning
Principles of report Writing
 The report should explain
 What happened, a chronology of events and your investigation
 Who it happened to
 When
 Where
 How (what went wrong)
 Why (contributory factors
 Think of your audience – the midwife, the LSA, the
family, the NMC
Writing the investigation report
 Section 1 - should have sufficient detail to
understand what prompted the investigation. The
reader should be able to understand why you
decided to investigate. Use of decision tree?
This is a description of the incident and its
consequences
 Avoid emotional, judgemental language

 Section 2 – brief employment and supervisory
details of the midwife. Ensure dates are completed
Writing the investigation report
 Section 3 – Chronology - ESSENTIAL to begin as soon as
possible and keep up to date.




Put as much information as possible in this section as it shows
the methodology you followed; the reasons for delays; failure to
meet the deadline
This section should be continued to the end of the investigation
including dates report sent to the LSA; final report submission;
Details on when and how the midwife was informed of the
findings;
Date the summary report sent to the HOM and ideally date the
developmental support/supervised practice programme started
Writing the investigation report
 Section 4 –
 This should contain an analysis of all the information you have
seen and heard. It should be structured, analytical, balanced
and objective. The reader should have a full understanding of
the evidence you have found and what your analysis is based
upon
 It should come to a conclusion about what your opinion is in
relation to the investigation. Facts found or not. Evidence
seen or not.
 Mitigation – why did she practise in this way? Are
there system failures? Rare that there are no
mitigating factors
Investigation report- Recommendations
Currently under review
 Must always show a direct link to the conclusions
you have reached in the earlier section. Cannot
introduce something new



No action – rare
Local action – reflection with named SOM or similar work.
Should be documented by SOM in supervisory file
Developmental support – for minor, non-recurring mistakes.
Should have objectives and be time limited. Named SOM
undertakes support and notifies investigating SOM of
completion of actions
Investigation report- Recommendations
 Supervised practice –
 Should be used when there are serious concerns about the
midwife’s attitude or safety of their practice.
 Competence is in question as a result of serious or recurring
errors in practice, or a midwife lacks insight into her
shortcomings or fails to take action to improve skills and
knowledge.
 Not the same as intractable lack of competence or misconduct
 Referral to the NMC
Summary Report to the HOM/Telling the midwife
 Summary report
 Why not the full report?
 Who ‘owns’ the reports?
 Summary report should contain sufficient information that the
HOM can understand what happened, why it was investigated,
why it happened, and the rationale behind your
recommendations
 Telling the midwife:
 Full report, full explanation of her part in the
incident/investigation
Evidence to support allegations
Failure 1
I allege that MW Smith failed to recognise the role of patients
and clients as partners in their care and the contribution they
can make to it.
 Alleged breach of Code

.
Evidence
 Within the letter from the patient .....(Letter App 1)
 The transcript from the parents....(App 2)
 MW Smith’s statement of May 20th says that...... (Midwife Smith
statement App 3)
 MW Smith reiterates the above in her interview of 23 June and that her
usual practice is to ....... (Interview notes App 4)
Evidence to support allegations
 An audit of MW Smiths records from 10 other cases shows
that her usual practice appears to be .....(Records audit
summary App 5)
 Statements from other midwives/interviews show
that....(App 6)
 Midwife Smith’s understanding of her accountability as
demonstrated in the interview shows that....
 On the balance of probabilities, did it happen.......
Evidence to support allegations
Failure 2
I allege that MW Smith failed to provide an appropriate standard
of care in labour by not adequately monitoring fetal well
being.
 Alleged breach of Midwives Rules – Rule 6
 Relevant section of the Code
Evidence
 Within the notes the fetal heart was not recorded every 15 minutes ,
specifically at xx, xx and xx hours. (Labour notes App 1)
 The Trust policy dated xx states that NICE Guidance should be followed
regarding auscultation of the fetal heart. (Policy App 2)
 MW Smith’s statement of (Date) says that she did undertake further
observations but did not record them (Statement App 3)
Evidence to support allegations
 MW Smith reiterates the above in her interview of xx date
and that her usual practice is to take and record the fetal
heart according to trust guidelines (Interview notes App 4)
 An audit of MW Smiths records from 10 other cases shows
she does not consistently record fetal observations
according to trust policy (Records audit summary App 5)
 Midwife Smith’s understanding of her accountability as
demonstrated in the interview shows that....
 On the balance of probabilities, did it happen.......
Standards for Supervised Practice of Midwives
(NMC 2007)
This is currently under review
 Investigation of alleged lack of Competence
 Criteria for use of Supervised Practice
 Decision for Supervised Practice
 Structure for Supervised Practice
 Monitoring of Supervised Practice
 Follow-up of Supervised Practice
Decision for use of Supervised Practice
 The LSA will ensure the investigation has met the NMC




requirements.
Ensure a health assessment of the midwife has been
carried out
If Supervised Practice is required, the midwife should not
practise within another LSA until such time as the
supervised practice has been completed
If supervised practice is not commenced, not completed or
failed in meeting its objectives, the LSA Midwifery Officer
must refer the midwife to the NMC
The midwife may complain to the LSA about the process
but this will not delay or interfere with any
recommendations made.
Structure of Supervised Practice (in summary)
 Joint plan between Investigating SoM, Midwife, Educational







Lead, Head of Midwifery & supported by Named Supervisor
Advised and approved by LSAMO
Programme of Objectives and Learning Outcomes specific
to the incident(s)
No less than 150 and up to 450 hours with extension with
LSA approval of 150hours
Aim to be completed in 6 months
Midwife must be supernumerary to the rota
Supported by a ‘sign-off’ mentor
Cannot be involved with the teaching of students
 Create some objectives for Midwife Smith
Keeping it on track
 The midwife, her ‘sign-off’ mentor, the midwife teacher and Named
Supervisor of Midwives should meet at indicated intervals with the
Investigating Supervisor (and the Head of Midwifery) to consider
progress
 Records of completion or failing of the programme will be kept by the
‘sign-off’ mentor and retained in the midwives supervisory file and sent
on to the LSA
 Throughout any supervised practice programme a midwife remains
accountable for her actions. Any further incidents of unsafe practice
during this period should be communicated to the LSAMO.
 It may be agreed that new learning outcomes be accommodated or if
considered seriously enough, the programme may be terminated and
the LSAMO refer the midwife on to the NMC.
When the programme is over- what next?
 A programme of continued support should be put in place for those
midwives who have successfully completed a Supervised Practice
Programme
 If the Supervised Practice Programme is failed, the midwife will be
Suspended from Practice by the LSA and referred on to the NMC
 The midwife is normally required to share information about
programmes of supervised practice with future employers and Named
Supervisors of Midwives
 There is no limit indicated as to the number of Supervised Practice
Programmes a midwife can successfully complete prior to referral to
the NMC. This is left to the discretion of the LSA!
When does the LSA have to refer to the NMC?
 Poor health that renders the midwife until to practise safely
 Misconduct (Verbal or Physical abuse, theft, deliberate






failure to care or keep adequate records)
Intractable lack of competence
Failure to undertake or successfully complete a programme
of Supervised Practice
Convictions or Cautions
Referral from another regulator (NPSA or other professional
register)
If referred, clear evidence of Investigation and Supervised
Practice processes must be provided to the NMC
The NMC may refer back for further LSA actions if these
are deemed inadequate
The NMC Process
 Unlikely to accept referrals from employers without evidence of LSA
processes.
 Will ask the LSA to investigate for parents or families who direct initial
complaints to the NMC
 Will accept referrals from the LSA where the LSA have investigated and
have proceeded to Suspend from Practice despite not completing any
Supervised Practice Programme if this is not recommended
 Will reverse Suspensions from Practice if there is no evidence of an LSA
investigation that meets the NMC standards
 Will not accept referrals from employers where the midwife has been
dismissed without evidence of LSA processes unless for misconduct
When does the LSA have to refer to the NMC?
 If it is alleged that if a nurse or midwife is guilty of lack of
competence the employer should have tried to address
these issues.
 For example it is unlikely that if you made a one off
mistake you would be referred to the NMC
 The employer/LSA would identify any learning needs and
set out a plan of training.
 If a registrant continued to show lack of competence
despite training opportunities or failed to engage in training
they would be referred to FTP.
Health Referral to NMC
 Those registrants with health issues would be
referred to a special health committee with
medical practitioners on the panel to offer expert
opinion.
 These may be held in private due to the sensitive
information although the outcome would be made
public.
 Mainly related to drug, alcohol issues or untreated
serious mental illness.
Process when referred to the NMC?
 If not resolved at a local level then full details of
the investigation along with statements are sent
to the NMC
 This is then reviewed by the Investigating
Committee who can -
close the case with no further action taken
 refer the case to a panel of the Conduct Competence
Committee (CCC) in cases about alleged impairment of
fitness to practise
 for reasons of ill health, refer the case to a panel of
the Health Committee (HC)

 The Investigating Committee can also place an
interim suspension or conditions of practice order on
the registrant.
 This would be done to protect the public whilst
awaiting the substantive hearing.
Conduct and Competence Committee hearings
 CCC hearings are generally held in public; the
openness of the proceedings reflects the NMC's
public accountability
 The CCC consists of a panel of at least three people,
lay panel member, due regard (on same part of
register as registrant) plus one other
Panel
Member
Council
Officer
Legal
assessor
Panel
Member
Case
presenter
Observers/Past
witnesses
Press
Registrant
Legal
Representative
Conduct and Competence Committee hearings
 The panel will decide whether a registrant’s fitness
to practise is impaired by reason of:




Misconduct
Lack of competence
A criminal offence
Mental or physical health
Conduct and Competence Committee hearings
 Whilst making decisions (CCC) panels look for
the level of conduct and competence expected of
the average registrant, not for the highest
possible level of practice.
 They base all decisions on evidence heard at the
hearing and see no papers in advance of the
case.
 Before the panel makes a final decision they hear
information about the previous history of the
registrant and any evidence in mitigation from
the practitioner
Standard of Proof
 Used to be the criminal standard of proof (beyond
reasonable doubt) but not suitable as FTP is not a
criminal court
 As from November 2008 changed to civil standard –
‘balance of probabilities’

That is a fact will be established if it is more likely than not to
have happened
Sanctions
 Conclude that the case is not well founded and therefore





take no further action
Decide, taking into account all the circumstances of the
case, it is not appropriate to take further action
Issue a caution for a specified period of between one
and five years
Impose a conditions of practice for a specified period not to
exceed three years
Suspend the practitioner's registration for a specified
period not to exceed one year
Strike off the practitioner’s name from the register
FTP 2011-2012
 671,668 registrants (March 2011)
 Referrals in 2010/11 - 4,407
 This represents 0.6% of registrants
 48 percent increase since April 2009 (2010-2011: 4,211;
2009-2010: 2,986).
 922 interim orders imposed
 3,797 cases closed/concluded in 2011-2012
FTP 2011-2012
 952 cases sent for adjudication by the Investigating









Committee
866 sent to the Conduct and Competence Committee
86 sent to the Health Committee
365 nurses or midwives struck off the register
136 nurses or midwives suspended from the register
51 nurses or midwives had conditions imposed on how they
can practise
98 nurses or midwives received a caution order
13 appeals
Four applicants successful on application to be restored to
the register
One fraudulent or incorrect entry on the register
FTP 2011-2012
Source of new referrals
Number of new referrals
 Employer
 Member of public, service user or patient
 Police
 Self referral
 Other (including lawyers and colleague referrals)
 NMC Registrar
 Other regulatory or professional body
 Referrer unknown
Total
1,856
835
745
290
281
211
103
86
4,407
42%
19%
17%
7%
6%
5%
2%
2%
100%
FTP 2011-2012
Types of allegations
Total referrals
 Misconduct
4,250
 Lack of competence
2,412
 Criminal
1,385
 Health
145
 Police investigation
51
 Fraudulent entry
47
 Determination by another body
e.g INO, HCP)
10
Percentage
51%
29%
17%
2%
Less than 1%
Less than 1%
 Total
100%
8,300
Less than 1%
Range of issues
 Misconduct 68%






drug admin 9%
records 8.5%
neglect 6%
physical abuse/ violence 3%
verbal abuse of patients 2.5%
sleeping on duty 1%
 Lack of competence 21%


patient care 5%;
drug admin 3.5%
 Criminal 11%


drug misuse 2%
dishonesty 2%)
Hints and Tips for SOM’s
 Ensure that documentation is clear and logical –
pages numbers etc.
 Accurate evidence, signed by registrant etc
 Ensure that standards are followed- if system falls
down anywhere it is likely that the panel will
notice. It is better to address this at the time than
the case be affected.
 Examples include limited experience due to quiet
clinical area, poor supervision, lack of sensitivity
towards supervised midwife, no orientation period
in new area.
 Academic work- ensure midwife knows how it will be
marked, to what level required, that they are able to
update study skills, given feedback.
 Keep records of ALL communication
 Being a witness – behaviour, no collaboration, read
statement, be prepared to be contradicted.
 Time management at hearings
 Media attention
What happened to Midwife Smith?
 Your decision if you were on the panel?
 Any questions?