Correspondence with NMC List of emails exchanged with NMC List

Transcription

NMC 041969/2013 & 042682/2013
Correspondence with NMC
re cases 041969/2013 & 042682/2013
List of emails exchanged with NMC
(In two separate images. One email [highlighted] appears in both images.)
List of emails exchanged with Morgan-Cole, (NMC's solicitors)
Page 1 of 66
NMC 041969/2013 & 042682/2013
Page 2 of 66
List of emailed attachments
(Some of these documents are attached to more than one email.)
1. Letter from Wilma Thomson (Lifestyle Care) – three pages, dated 4.10.2012
2. Page 92 of "Controlled Drugs" (CD) register: administration of midazolam to JG, March 2012
3. Report submitted to Royal College of Nursing (13.8.2012) – See separate PDF,
"Statement of John Geoffrey Hunt" – Statement-JohnHunt-2012g04-h13.pdf
4. Email, 23.2.2013, to Karen Baker (Lifestyle Care) – role and job-title unknown
5. Email, 18.4.2013, to Val Norris (Safeguarding Adults, London Borough of Hounslow)
6. Email, 10.5.2013, from Val Norris (Safeguarding Adults, London Borough of Hounslow)
7. Summary handed to Chiswick Police at "informal interview" on 28.5.2013 – two pages
8. Email, 23.7.2013, from Chiswick Police
9. NMC's Consent form for case 042682/2013: no Consent form supplied for case 041969
10. Clarification of developments since March 2012: – See separate PDF,
"Coniston Lodge: Supplement for 041969/2013 and 042682/2013" – NMC-2013k05.pdf
11. Witness statement drafted by solicitors Morgan-Cole, 16.4.2014, 9 pages: – See separate PDF,
"WITNESS STATEMENT OF JOHN GEOFFREY HUNT" – MorganCole-WitnessStatement.pdf
12. Amended statement, returned to Morgan-Cole 21.4.2014, 10 pages: – See separate PDF,
"WITNESS STATEMENT OF JOHN GEOFFREY HUNT" –
MorganCole-WitnessStatement-Amended+CD92.pdf
List of "snail-mail" letters received from NMC
13. Panel decision re Olufunke Oluwasanmi, 041969/2013, 29.7.2014
14. Panel decision re Jeannine Gappy, 042682/2013, 23.10.2014
15. NMC referrals of Janine [sic] Gappy and Olufunke Oluwasanmi, 8.12.2014
NMC 041969/2013 & 042682/2013
Page 3 of 66
2013.5.23
To: [email protected]
From: John Hunt <[email protected]>
Subject: Nursing home resident with advanced bowel cancer
Cc:
Dear Peter,
At the Patient & Public Engagement Forum last week, you kindly offered to ring me to
discuss the report below.
Last night I was invited by local police to discuss this incident, and now have an
appointment for Tuesday morning.
I am happy to attend: however, having learnt only two days ago that two police forces
had responded very differently to a single incident, (not related to this), I wonder how much
relevant experience and expertise local police will have. -- Less, I suspect, than the NMC.
I should therefore be grateful to have some idea, preferably before Tuesday, of a view
from the NMC, (though clearly not, at such short notice, a definitive ruling).
Regards,
John Hunt.
On <date>, during a night shift, a resident with advanced bowel cancer unexpectedly
developed severe difficulty breathing. I discussed this with the nurse on duty in XXX,
(YYY), explaining that, although he had been admitted for palliative care some
months earlier, the only end-of-life medication he was receiving was occasional PRN
Oramorph, so I wanted to ring the out-of-hours doctor, to keep him comfortable.
As she agreed with my plan, I rang and was asked to give the resident oxygen until the
doctor arrived. As our rooms do not have oxygen points, I borrowed the oxygen
concentrator delivered for the resident in room 26 who had never used it in the two
years since his admission.
When the doctor arrived, he prescribed Salbutamol nebuliser PRN and Amoxycillin
TDS: but an hour later, when ZZZ arrived, she switched off the oxygen before
instructing day staff to begin injecting Midazolam. (Exhibit EEE)
123, Twickenham Road, Isleworth. TW7 6AW
Tel.: 020-8568 7416
NMC 041969/2013 & 042682/2013
Page 4 of 66
2013.5.23
From: Peter Lynn <[email protected]>
To: John Hunt <[email protected]>
Subject: RE: Nursing home resident with advanced bowel cancer
Dear John
Thanks for your email.
I managed to speak yesterday to our expert nursing adviser and showed her the document you handed me last
week.
In summary, on the face of the document there is not necessarily anything that gives rise to concern. For
example, was the oxygen actually still required at that point? turning it off at that stage may have been
appropriate. Also, Midazolam is used in palliative care, although we don't know if it had been prescribed.
It would really depend on whether there was further information to suggest there may be a concern about the
nurse's actions.
As envisaged in your email, this is not a definitive ruling, or a ruling of any sort. We can give full consideration
to the issues, but we would need a complete account of what exactly happened, and when, and would need to
identify the nurse concerned.
I am in the office tomorrow and would be happy to speak to you about this. Let me know.
Kind regards
Peter
Peter Lynn
Head of External Liaison<?xml:namespace prefix = o ns = "urn:schemas-microsoftcom:office:office" />
Fitness to Practise
020 7681 5979
NMC 041969/2013 & 042682/2013
Page 5 of 66
2013.6.21
Cc:
Dear Peter,
At 18:21 2013-05-23, you wrote:
week.
...
We can give full consideration to the issues, but we would need a complete account of what exactly happened,
and when, and would need to identify the nurse concerned.
I had an email from the police last Friday, expecting to make contact this week: but I'm
still waiting to hear from them.
Today I spoke to the local authority. They have also heard nothing, but said they would
"nudge" the police this afternoon.
I'll keep you informed.
Regards,
John H.
NMC 041969/2013 & 042682/2013
Page 6 of 66
2013.6.26
Noted John, thank you.
regards
Peter
Peter Lynn
Fitness to Practise
020 7681 5979
NMC 041969/2013 & 042682/2013
Page 7 of 66
2013.6.26
Cc:
At 10:19 2013-06-26, you wrote:
Noted John, thank you.
Email received from police this evening: relevant officer about to start a week's leave,
and will resume enquiries on return. Is apparently still trying to answer the question I
discussed with you about a month ago.
Regards,
John H.
NMC 041969/2013 & 042682/2013
Page 8 of 66
2013.7.25
Cc:
Dear Peter,
At 18:21 2013-05-23, you wrote:
week.
In summary, on the face of the document there is not necessarily anything that gives rise to concern. For
example, was the oxygen actually still required at that point? turning it off at that stage may have been
appropriate. Also, Midazolam is used in palliative care, although we don't know if it had been prescribed.
It would really depend on whether there was further information to suggest there may be a concern about the
nurse's actions.
As envisaged in your email, this is not a definitive ruling, or a ruling of any sort. We can give full consideration
to the issues, but we would need a complete account of what exactly happened, and when, and would need to
identify the nurse concerned.
Following the referral of this case by the London Borough of Hounslow, Chiswick
Police interviewed me "informally" about this on 28th May, and advised on 23rd July "that no
Criminal Investigation will take place". There is no indication of their rationale, so I've asked
(optimistically) whether they can indicate briefly the principal factor(s) which led to their
decision.
The oxygen was initially recommended for this resident by the Harmoni out-of-hours
service when I rang to request a GP, and was confirmed by the GP when he arrived. The
midazolam had been prescribed for this resident, (the previous year, I believe), but had never
been administered: as I explained to the visiting GP before he prescribed amoxycillin and
salbutamol.
I attach the two-page document (May 2013) which I gave the police at the interview,
outlining the background, and the statement (August 2012) for the Royal College of Nursing
to which this refers. If required I can also supply the three-page reply from Lifestyle Care,
and the photocopy of the page in the CD book recording the administration of midazolam to
this resident: but I imagine these will not be relevant to deciding whether a Fitness-toPractise is appropriate.
Regards,
John H.
NMC 041969/2013 & 042682/2013
Page 9 of 66
2013.8.08
Dear John
I am sorry not to have responded to your email and will do so more fully next week.
Kind regards
Peter
Peter Lynn
Fitness to Practise
020 7681 5979
NMC 041969/2013 & 042682/2013
Page 10 of 66
2013.8.09
Cc:
At 18:03 2013-08-08, you wrote:
I am sorry not to have responded to your email and will do so more fully next week.
For completeness, I attach the remaining items previously mentioned: copy of page
from Controlled Drugs register, and three-page letter from Lifestyle Care (whose excuses
were later refuted by the Local Authority investigation).
Regards,
John.
NMC 041969/2013 & 042682/2013
Page 11 of 66
2013.8.09
Subject: Out of Office: Nursing home resident with advanced bowel cancer
Thank you for your email. I am out of the office on Friday 9 August.
If your message is urgent please contact Renee Aleong, External Liaison Officer, on 020 7681 5906.
If this is a request under the Freedom of Information Act or Data Protection Act, please direct your
query to [email protected] as this email will not be forwarded.
NMC 041969/2013 & 042682/2013
Page 12 of 66
2013.8.16
Dear John
I consulted our nursing adviser again. In summary, the conclusion is that we should make a proper assessment
of this matter under our procedures, which will involve our screening team making some preliminary inquiries.
Can you make a referral please, either through completing and submitting the referral form on our website, or
sending a letter, which you would be happy to be disclosed. this should set out your concerns in full and attach
the supporting information.
Can you do that?
I will now be out of the office on leave for two weeks. I am copying my colleague Renee Aleong into this email.
she is not familiar with the background to this matter but you can call her for advice, on my number below, if
you wish.
Kind regards
Peter
Peter Lynn
Fitness to Practise
020 7681 5979
NMC 041969/2013 & 042682/2013
Page 13 of 66
2013.8.20
Cc:
Dear Renee,
At 17:47 2013-08-16, Peter Lynn wrote:
... Can you make a referral please, either through completing and submitting the referral form on our website,
or sending a letter, which you would be happy to be disclosed. this should set out your concerns in full and
attach the supporting information. ...
Is the correct form the one "for the public" at www.nmcuk.org/Documents/FtP_Information/Referral%20form%20for%20-%20public.DOC ? Or
should I use another form, given that my report concerns a nurse who was then a colleague?
Regards,
John Hunt.
NMC 041969/2013 & 042682/2013
Page 14 of 66
2013.8.21
From: Renee Aleong <[email protected]>
To: "'John Hunt'" <[email protected]>
Dear John
Please use the form in the link you have provided (from the NMC website). You can also send in additional
documents if required.
Regards
Renee
Ren 饠 Aleong
External Liaison Officer
Fitness to Practise Directorate
020 768 15906
Nursing and Midwifery Council
1st Floor
1 Kemble Street
London WC2B 4AN
www.nmc-uk.org
020 7462 5800 (switchboard)
NMC 041969/2013 & 042682/2013
Page 15 of 66
2013.8.21
Cc:
At 08:52 2013-08-21, you wrote:
Please use the form in the link you have provided (from the NMC website). You can also send in additional
documents if required.
Many thanks.
John H.
NMC 041969/2013 & 042682/2013
Page 16 of 66
2013.8.27
Subject: New referral -- Mabel Oluwasanmi
Cc:
Dear FtP,
As requested by Peter Lynn on 16th August, I am submitting the attached referral form,
together with the documents listed in Section 6. -1.
2.
3.
4.
5.
6.
7.
8.
Three pages of letter from Wilma Thomson, (Lifestyle Care).
Page 92 of CD book -- Midazolam injections for John Gibbs
Report submitted to Royal College of Nursing (13.8.2012)
Email, 23.2.2013, to Karen Baker (Lifestyle Care)
Email, 18.4.2013, to London Borough of Hounslow
Email, 10.5.2013, from London Borough of Hounslow
Summary handed to Chiswick Police at "informal interview" on 28.5.2013
Email, 23.7.2013, from Chiswick Police
Contact details:
Chiswick Police -- Claire Hine / 020-8247 6589 / [email protected]
Lifestyle Care -- Wilma Thomson
Lifestyle Care -- Karen Baker / [email protected]
London Borough of Hounslow -- Val Norris / 020-8583 4515/6216 / [email protected]
Royal College of Nursing -- Sharon Bissessar / 020-7841 3321 / [email protected]
Witnesses:
Nurses Sabina Khadka and Angela Talos (married autumn 2012 [??], married surname not
known) should be traceable through NMC database. Their email addresses a year ago were
[email protected] and [email protected]
Michele Leon (carer) returned to the Seychelles in Nov. 2012, reverting to her maiden
name: Michele Danielle Monthy. She was due to start a nursing diploma in Feb. 2013 at the Victoria
Hospital. As the population is under 90,000, and the hospital is apparently adjacent to the Ministry
of Health, she should be easily contactable through
www.health.gov.sc/index.php?option=com_content&view=article&id=139&Itemid=142
Regards,
John Hunt.
Tel.: 020-8568 7416
NMC 041969/2013 & 042682/2013
Page 17 of 66
2013.8.27
Cc: [email protected]
Dear Peter,
At 17:47 2013-08-16, Peter Lynn wrote:
I consulted our nursing adviser again. In summary, the conclusion is that we should make a proper assessment
of this matter under our procedures, which will involve our screening team making some preliminary inquiries.
Can you make a referral please, either through completing and submitting the referral form on our website, or
sending a letter, which you would be happy to be disclosed. this should set out your concerns in full and attach
the supporting information.
Can you do that?
I have just emailed the referral form, duly completed, with a set of attachments. I hope
this is satisfactory.
Regards,
John H.
NMC 041969/2013 & 042682/2013
Page 18 of 66
2013.8.27
Subject: Out of Office: Nursing home resident with advanced bowel cancer
Thank you for your email. I am now out of the office until Monday 2 September.
If your message is urgent please contact Renee Aleong, External Liaison Officer, on 020 7681 5906.
If this is a request under the Freedom of Information Act or Data Protection Act, please direct your
query to [email protected] as this email will not be forwarded.
NMC 041969/2013 & 042682/2013
2013.8.27
From: Renee Aleong <[email protected]>
Thanks John. Our Screening team will contact you about the progress of the referral.
Regards
Ren 饠 Aleong
External Liaison Officer
020 768 15906
1st Floor
1 Kemble Street
London WC2B 4AN
www.nmc-uk.org
Page 19 of 66
NMC 041969/2013 & 042682/2013
Page 20 of 66
2013.8.27
From: Lucy Macleod <[email protected]>
Subject: RE: New referral -- Mabel Oluwasanmi
Dear Mr Hunt
This is to confirm receipt of your correspondence - it has been forwarded to Registrations for response.
Kind regards
Lucy Macleod
Administrator
0207 681 5800/5801
1st Floor
1 <?xml:namespace prefix = st1
Street
London WC2B 4AN
www.nmc-uk.org
[email protected]
ns = "urn:schemas-microsoft-com:office:smarttags" />Kemble
From 11 June 2012 revised indicative sanctions guidance, a new conditions of practice
guidance and revised conditions of practice library will apply to hearings before fitness
to practise committees. From this date, these documents will replace any guidance you
may have previously received or accessed via the NMC website. These documents are
available on our website at www.nmc-uk.org/sanctions <?xml:namespace prefix = o ns
= "urn:schemas-microsoft-com:office:office" />
NMC 041969/2013 & 042682/2013
Page 21 of 66
2013.10.31
From: Gemma Wyatt <[email protected]>
To: "'[email protected]'" <[email protected]>
Subject: NMC Referral 042682
Dear Mr Hunt
<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
I write further to your telephone conversation with my colleague, <?xml:namespace prefix = st1 ns =
"urn:schemas-microsoft-com:office:smarttags" /> Jerusalem Gebremeskel on 30 October 2013 regarding the
referral you made to the Nursing and Midwifery Council (NMC).
Please find attached the consent form for you to complete and return as discussed.
This document is password protected. The password will be sent in a following email.
Kind regards
Gemma Wyatt
Screening Case Administrator
020 7681 5481
1 Kemble Street
London WC2B 4AN
www.nmc-uk.org
020 7681 5481
NMC CASE 042682.pdf
NMC 041969/2013 & 042682/2013
Page 22 of 66
2013.10.31
Subject: NMC Referral 042682
Dear Mr Hunt
The password for the previous email: oct0426823110Gw
Kind regards
Gemma Wyatt
020 7681 5481
<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /> 1 Kemble
Street
London WC2B 4AN
www.nmc-uk.org
020 7681 5481
NMC 041969/2013 & 042682/2013
Page 23 of 66
2013.10.31
Subject: Re: NMC Referral 042682
Cc:
At 10:19 2013-10-31, you wrote:
I write further to your telephone conversation with my colleague, Jerusalem Gebremeskel on
30 October 2013 regarding the referral you made to the Nursing and Midwifery Council
(NMC).
Please find attached the consent form for you to complete and return as discussed.
This document is password protected. The password will be sent in a following email.
Thank you for your two emails this morning. I have now printed the consent form.
Two questions:
Q.1: Presumably the consent form is to be returned by post: but to what address, (Kemble
Street?), and for whose attention?
Q.2: When I spoke to Jerusalem yesterday, I agreed to email her details of what we
discussed. Should I send this to her (at [email protected] ??) or to you? - I now hope to complete the first draft this afternoon.
Regards,
John Hunt.
NMC 041969/2013 & 042682/2013
Page 24 of 66
2013.10.31
To: 'John Hunt' <[email protected]>
Subject: RE: NMC Referral 042682
Dear Mr Hunt
Thank you for your email.
The postal address which you should send your completed consent form to is:
First Floor
1 Kembe Street
London
WC2 4AN
And for the attention of Jerusalem Gebremeskel
Also, please send any correspondence to Jerusalem's email address as she is the case officer for this case. Her
email address is [email protected].
Many thanks
Gemma Wyatt
020 7681 5946
<?xml:namespace prefix = st1 ns = "urn:schemas-microsoft-com:office:smarttags" /> 1
Kemble Street
London WC2B 4AN
www.nmc-uk.org
020 7681 5481
NMC 041969/2013 & 042682/2013
Page 25 of 66
2013.10.31
Subject: Cases 041969/2013 and 042682/2013: Chronology of Referrals
Cc:
Dear Jerusalem,
As discussed yesterday, I attach clarification of how these referrals have developed since March
2012. I apologise that this has taken rather longer than I had hoped.
I have not yet begun searching my records for additional relevant evidence, but hope to be able
to email you something next week, perhaps on Tuesday.
Regards,
John Hunt.
NMC 041969/2013 & 042682/2013
Page 26 of 66
2013.10.31
Subject: RE: NMC Referral 042682
Cc:
At 11:43 2013-10-31, you wrote:
The postal address which you should send your completed consent form to is:
...
Also, please send any correspondence to Jerusalem's email address as she is the case officer for this case. Her
email address is [email protected].
Many thanks. I have just emailed her the first report.
Regards,
John Hunt.
NMC 041969/2013 & 042682/2013
Page 27 of 66
2013.11.05
Subject: Cases 041969/2013 and 042682/2013: Additional relevant evidence
Cc:
Dear Jerusalem,
I hope you were able to open the PDF I emailed on Thursday, and have also received the
consent form.
Am now attaching additional details, as you requested. The PDF contains two sections: the
second, about Jeannine, consists of an entry for 12.11.2012 and selected emails which I sent to the
RCN between August and November 2012. As the RCN complaint about Jeannine was logged in
March 2012, the emails assume some prior knowledge. I shall be happy to clarify, if required.
Please note that a few of the staff mentioned may still be working at Coniston Lodge: and if
Jeannine sees their names (or is otherwise able to identify them) she is likely to be
vindictive. Additionally, one of the residents (mentioned on p.13, para.4) is not named, but
Jeannine would be able to identify her. -- What is NMC policy in such cases?
Regards,
John Hunt.
NMC 041969/2013 & 042682/2013
Page 28 of 66
2014.4.02 [Solicitor used by NMC]
Subject: Your ref: KRB.457325.353
Cc:
Dear Natalie,
At the end of our discussion this morning (Wed., 2nd) I mentioned four points. However, only
two of these were included in the report for the RCN.
Verbal abuse is mentioned in section [4] of the email on pages 34 and 35, (both paragraphs). EiPhyu had previously worked as a carer, but by the time of this incident had joined the administrative
staff in the office. She later thanked me for mentioning the incident, saying that the abuse she
received had noticeably decreased.
The instruction by Jeannine Gappy to Ella, in blatant contradiction of the previous complaint to
me about loaning an oxygen concentrator to another resident, is mentioned in paragraph 9.19, while
9.23 records Mabel's later insistence that nurses were not permitted to administer oxygen even in
an emergency, unless previously prescribed.
Mabel's suggestion that a resident about to return from hospital (Mr. Harish Shah, room 31)
should share the suction machine of another resident (John Harrington in room 26) was included
right at the end of my two-page email on 18th April to Val Norris / Adult Protection / Hounslow, (two
sentences).
I mentioned Mabel's instruction to protect residents from the resident with (undiagnosed)
mental health problems (Egon Philips -- "EP" in section 10 of the RCN report) by locking them all in
their rooms at night, (a flagrant breach of Deprivation of Liberty protocol), at the bottom of the
second page of my "Exit Interview Questionnaire" to Lifestyle's Karen Baker on 23rd Feb..
A fifth issue which I did not mention on the 'phone was "care plans". This seems rather trivial in
comparison with the death of Mr. Gibbs. However, it was the subject of section 6 of the RCN
report. Paragraphs 6.9 and 6.21 mention the chaos and futility of an impromptu training session
which Mabel held one morning: and 6.24 notes Mabel's insistence that forms could not be altered
to record a resident's true situation or needs.
I hope this is helpful. But please let me know if you would like further clarification.
Regards,
John Hunt.
Tel.: 020-8568 7416
NMC 041969/2013 & 042682/2013
Page 29 of 66
Subject: NMC Investigation - Private and Confidential
From: "Natalie Taylor" <[email protected]>
To: <[email protected]>
Dear John
Please find attached a copy of the witness statement that has been drafted for you in relation to the NMC
investigation into nurse OO. The statement is password protected and the password is the name that you
knew Ms OO by (beginning with m). Please note that the password is all in lower case letters.
Please read the statement carefully. If you are happy with the statement, please sign and date each page and
return the statement to me. If you would like to make any amendments to the statement, please feel free to
do so. Please make your amendments to the attached Word document before printing, signing and returning it
to me. If you would prefer to make your amendments by hand, please ensure that each amendment is
initialled. If there are a number of handwritten amendments, I will arrange for the statement to be retyped
and sent to you for signature.
Please ensure that your statement is not shared with any third party.
The NMC impose strict time limits on investigations so I should be grateful if you could return your signed
statement to me by 23 April 2014. If you have access to a fax machine, please fax a copy of your statement to
me at 02920 385 615. Alternatively, please scan and email a copy of your signed statement to me.
If you have any queries in relation to this, please do not hesitate to contact me on the direct dial telephone
number below.
Thank you for your continued assistance in this matter.
Kind regards
Natalie
Natalie S Taylor Legal Assistant
on behalf of Morgan Cole LLP | Solicitors
Direct Line: 029 2038 5514
Direct Fax: 02920385615
Bradley Court | Park Place | Cardiff CF10 3DR
Tel: 029 2038 5385 | Fax: 029 2038 5300 | DX: 33014 Cardiff
Web: www.morgan-cole.com
Witness Statement of John Hunt.doc
NMC 041969/2013 & 042682/2013
Page 30 of 66
Subject: Re: NMC Investigation - Private and Confidential
Cc:
Dear Natalie,
At 14:59 2014-04-16, you wrote:
Please find attached a copy of the witness statement that has been drafted for you in relation
to the NMC investigation into nurse OO. The statement is password protected and the
password is the name that you knew Ms OO by (beginning with m). Please note that the
password is all in lower case letters.
Please read the statement carefully. If you are happy with the statement, please sign and date
each page and return the statement to me. If you would like to make any amendments to the
statement, please feel free to do so. Please make your amendments to the attached Word
document before printing, signing and returning it to me. If you would prefer to make your
amendments by hand, please ensure that each amendment is initialled. If there are a number
of handwritten amendments, I will arrange for the statement to be retyped and sent to you for
signature.
Congratulations on separating the wheat from the chaff, and sorting the essentials into a
coherent order. I am attaching my slightly revised version, signed and dated, in PDF format,
protected using the same password, (still in lower case).
I've now supplied some of the details missing from our discussion on 2nd April. I've
split para. 25 into two paragraphs: so subsequent paragraphs have been renumbered. If
you're maintaining a list of sources or informants, please note:
para. 8: I did not speak to the GP when I rang Harmoni, only when he arrived at the
Home;
para. 16: Patience Quagraine was working in Wren, so she did not take handover from
Angela Talos;
para. 17: I was told by Angela, not Ella, about Ms Gappy's instruction to borrow the
oxygen concentrator;
para. 23: Miki Kobayashi told me that Mabel wanted two residents to share a suction
machine;
para. 25: Irina Hristo told me that Egon Phillips, (who already had considerable
previous "form"), had begun entering residents' rooms.
I see that the list of exhibits, (JH1 - JH8), does not include the photocopy of page 92 of
Heron's Controlled Drugs register. I believe you said you have this, but I'm attaching a
scanned image for good measure. The first entry on the page, (undated -- incorrectly),
somewhat illegibly appearing to record receipt of the Midazolam from Wren, bears Mabel's
signature as witness. The second line was witnessed by the same person, before being
crossed out. The third line, with the same date and time as the second line, but different
entries in the "Quantity supplied (to service user)" and "Quantity Disposed" columns, has
been signed by Sabina Khadka and witnessed by Angela Talos, recording the first injection of
NMC 041969/2013 & 042682/2013
Page 31 of 66
Midazolam to Mr. Gibbs at 9 a.m. on 15/3/12. -- Would it be helpful to include this with the
other exhibits? I'm therefore including a second version of the PDF, suitably amended on the
final page, and protected with the same password.
Please let me know whether you require or advise any further changes or clarification.
Regards,
John Hunt.
Tel.: 020-8568 7416
NMC 041969/2013 & 042682/2013
Page 32 of 66
Subject: Out of Office AutoReply: [WARNING : MESSAGE ENCRYPTED] Re: NMC Investigation Private and Confidential
From: "Natalie Taylor" <[email protected]>
To: "John Hunt" <[email protected]>
Thank you for your email. I am currently out of the office until 22 April 2014. I will respond to your email as
soon as possible on my return.
This email will not be forwarded in my absence.
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This e-mail is sent on behalf of Morgan Cole LLP unless the word 'Private' appears in the subject heading, in which case it is sent by the sender on
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NMC 041969/2013 & 042682/2013
Page 33 of 66
2014.11.06
From: "Dr. John Hunt" <[email protected]>
Subject: Fitness to Practise: feedback on two recent cases
Cc:
Dear NMC,
As your page www.nmc-uk.org/ftp-feedback does not allow me to give you this feedback, I am
emailing it.
Your template rulings on cases 041969/2013 and 042682/2013 (both cryptically marked
IC/Ref/OP/Dec/RB) advise that "the panel directed that there was no case to answer" (page 1, para.
2), despite noting later that "there was sufficient evidence to establish a case to answer" (page 2,
para. 3).
In the first case you record that the registrant "removed the oxygen mask of a patient", but not
that her subsequent actions led directly to his premature death while being treated by a GP fully
cognisant of the patient's condition and prognosis. You assert that the registrant was "acting in the
best interests of the patient and that her actions were clinically appropriate". Regardless of what the
interests of the patient may or may not have been, it is hard to see how, under current UK
legislation, the NMC can condone a unilateral decision to euthanase a patient and deem it
"appropriate". The panel (041969) doubtless noted that, although this patient had been admitted
some months earlier with a terminal prognosis, there was no documentation of any agreement to
withhold treatment for opportunistic infections. Examples of the registrant's extreme incompetence
were included in the supplementary evidence emailed on 5.11.2013: though there is no evidence
that the panel considered this.
Attempting to justify the first ruling you quote an extract from "an undated reference from the
Home Manager" which stated (ambiguously) that the registrant "demonstrated exceptional
confidence and resourcefulness". Confidence can be misplaced though the registrant had previously
told staff that she was "jack of all trades and master of none": while lawyers instructed by the NMC
submitted examples of her exceptional resourcefulness wanting two residents with MRSA to share a
suction machine (para. 23-24), flouting elementary principles of infection control, and instructing
that residents should be locked in their rooms when another resident was wandering with malicious
intent (para. 2527), in direct contravention of "Deprivation of Liberty" policy! You admit that the
reference was undated, but fail to note that the Home Manager was herself the subject of a referral
at the time: specifically the second case, submitted at the request of the NMC!
In the second case you record that the registrant "provided poor patient care", (though "wilfully
dangerous" would have been more appropriate), and neglected to include her corruption (e.g
falsifying records of the administration of controlled drugs and other medication) and other
documented abuses. Your reasons for doing nothing appear to be that the registrant retains her
post (page 1, para. 5) and that an email from her employer alleges she is "competent to continue to
practice" [sic] (page 2, para. 5). You mention documents submitted by the RCN (page 1, para. 7) and
undated "findings" by the CQC (page 2, para. 5), though without citing any mitigating evidence from
either body. Yet the supplementary evidence emailed on 5.11.2013 documents how the RCN were
kept informed for several months of continuing deterioration under this registrant's
NMC 041969/2013 & 042682/2013
Page 34 of 66
management: did the panel (042682) consider this?
The RCN became well aware of what a slippery fish this registrant is, and admitted she was
getting "ridiculous" support from the regional director in contesting the joint complaint by nursing
staff. Indeed, on 11.1.2013 the regional RCN officer admitted that the home was unsafe, and the
CQC dysfunctional. The CQC confirmed this by inspecting the home in March 2012, failing to note
that that day only one of the four units had a nurse on duty! The CQC inspected again in January
2013, following six "unexpected" deaths in one unit within a fortnight, (one third of the
residents): but the CQC, although notified by the home, seemed blissfully unaware, and published
another glowing report. When the local authority subsequently conducted its own inspection, L.A.
staff were amazed at the discrepancies between the authority's findings and the CQC's. Yet the
NMC takes the CQC's word (or its silence) as gospel!
Only last week, London press reported that the CQC is "complicit in the wrongdoing of nursing
homes": and "The Times" reported a campaign "You Forgot about the Birds" against the RSPB. Your
reports on these two cases suggest that the NMC has completely and utterly forgotten about the
patients! Isn't the NMC supposed to be recreating itself, since being slated in 2012 by the Council
for Healthcare Regulatory Excellence? Is there a realistic programme for achieving this? How
much longer will it take? When will this start to become evident from the output of the "Fitness
to Practise" department?
In both cases you advise (page 3) that I may seek a judicial review of your decisions, though
without indicating the likely cost, duration, or outcome, based on previous reviews of NMC
rulings. By coincidence I attended the recent Crown Court hearing of the Ntege "sham marriages"
case, which collapsed in its seventh week due to prosecution incompetence and corruption by police
and immigration officials. (The trial alone was estimated to have cost
2m. www.thetimes.co.uk/tto/news/uk/crime/article4246126.ece ) A week later the collapse of a
similar case was reported, owing to Home Office delays. - www.telegraph.co.uk/news/uknews/immigration/11195771/Imams-sham-marriage-trialcollapses-after-Home-Office-blunder.html So I am not in a hurry to avail myself of your kind offer.
Do you think the NMC will be able to answer any of the above questions?
Regards,
John Hunt.
NMC 041969/2013 & 042682/2013
Page 35 of 66
2014.11.06
From: NMC Fitness To Practise <[email protected]>
To: "Dr. John Hunt" <[email protected]>
Subject: Auto Response: NMC Fitness to Practise
Thank you for your email, which will be forwarded to the appropriate team for action.
This email address ([email protected]) is now intended only for general enquiries
about fitness to practise.
Emails about cases already being investigated or dealt with under our fitness to practise procedures
should now be sent directly to the email address of the individual officer or team dealing with the
case.
NEW complaints or referrals about a nurse or midwife should be emailed to:
[email protected]
Emails about registration should be directed to the appropriate email address from the list on our
website:
[email protected]
[email protected]
[email protected]
NMC 041969/2013 & 042682/2013
Page 36 of 66
2014.12.08
Subject: Re: Fitness to Practise: feedback on two recent cases
Cc:
Dear Susan,
At the end of the workshop on 24th Nov. I told you that I had received only an automated
response to the email I sent to the FtP address on 6th Nov.. -- "Thank you for your email, which will
be forwarded to the appropriate team for action." (15:49 2014-11-06)
You kindly offered to pursue this. However, I regret that I have still heard nothing.
Please can indicate how long it will take to receive a reply?
Many thanks,
John Hunt.
NMC 041969/2013 & 042682/2013
Page 37 of 66
2014.12.09
From: Susan Law <[email protected]>
Dear John,
From
Dear Susan,
The Nursing and Midwifery Council has its registered office at 23 Portland Place, London W1B 1PZ,
and is a registered charity in England and Wales (charity number 1091434) and in Scotland (charity
number SC038362).
NMC 041969/2013 & 042682/2013
Page 38 of 66
2014.12.10
Cc:
Dear Susan,
At 09:25 2014-12-09, you wrote:
Dear John,
From
Dear Susan,
The Nursing and Midwifery Council has its registered office at 23 Portland Place, London
W1B 1PZ, and is a registered charity in England and Wales (charity number 1091434) and
in Scotland (charity number SC038362).
I'm afraid I don't know what you intended to say, as all I received in your email was the
above.
However, I have now received by snail-mail a letter dated 8th Dec. from Orla
McHugh. It states that "the extent to which a registrant's alleged conduct is capable of being
remediated" [sic] is relevant when considering current impairment, though fails to consider
the NMC's published concerns (in "Indicative sanctions guidance to panels", May 2012) that
"public interest must be at the forefront of any decision on sanction and this includes the
particular need to protect patients" (para. 15) and "maintenance of public confidence in the
professions and the regulatory body" (para. 16.2).
Personally, I should have thought that condoning a nurse's unilateral decision to
euthanase a patient fails to protect patients and the public interest, and is liable to destroy any
public confidence in the regulatory body. FtP seem to think otherwise.
Regards,
John H.
NMC 041969/2013 & 042682/2013
Page 39 of 66
2014.12.10
From: Susan Law <[email protected]>
Subject: FW: Fitness to Practise: feedback on two recent cases
Dear John,
Sent: 09 December 2014 09:26
Dear John,
I passed the copy of your email directly to our complaints team. I am sorry you have not heard from
them. I am not in the office today, but will follow this up with them tomorrow.
From: Re: Fitness to Practise: feedback on two recent cases
Thank you for your email, which will be forwarded to the appropriate team for action." (15:49 201411-06)
You kindly offered to pursue this. However, I regret that I have still heard nothing.
Please can indicate how long it will take to receive a reply?
NMC 041969/2013 & 042682/2013
Letter from Wilma Thomson (Lifestyle Care) – three pages, dated 4.10.2012
Page 40 of 66
NMC 041969/2013 & 042682/2013
Page 41 of 66
NMC 041969/2013 & 042682/2013
Page 42 of 66
NMC 041969/2013 & 042682/2013
Page 43 of 66
Page 92 of "Controlled Drugs" (CD) register: administration of midazolam to JG
NMC 041969/2013 & 042682/2013
Page 44 of 66
Email, 23.2.2013, to Karen Baker (Lifestyle Care) – role and job-title unknown
Subject: Exit Interview Questionnaire
Cc:
Dear Karen,
I was surprised to receive your "Exit Interview Questionnaire" form on 19th Feb., over
five weeks after expiry of my notice, following my resignation on 5th Jan. 2013. I hope that
my answers, below, to the seven questions on form LSC-MP37 (Part 2, Rev. 1, 07/11) are
helpful.
Regards,
John Hunt,
(formerly Staff Nurse at Coniston Lodge, Feltham; employee no. 138346).
Q.1 What did you like most about your job?
Caring for the residents; helping to cheer them up; sometimes being able to improve
their quality of life; camaraderie with colleagues; good relations with residents' family and
friends. However, job satisfaction decreased markedly following the transfer from Southern
Cross to Lifestyle Care in Nov. 2011.
Q.2 What did you dislike about your job?
I hope you are already aware that in March 2012 some nursing staff (including myself)
lodged a complaint with the Royal College of Nursing against the new Home Manager. Some
nurses would have added their voices, but were not RCN members: others were members but
were afraid to complain, (possibly because of experiences in their home countries). There
was also significant staff turnover under the new Home Manager: and it was felt unfair to
new staff to ask them to join the complaint.
For this joint complaint I reported maladministration under six headings. Although I
complained about my personal experiences, (following RCN guidelines), I knew that
colleagues suffered the same problems, often worse than I did. -Annual Leave and Excessive Hours -- e.g. requests unactioned for several months or totally
ignored, despite reminders; pressured into working 16 / 18 / ... hours within a 24-hour period;
Home Manager denied that having just five or six hours between shifts contravenes the
European Working Time Directive.
Care Plans -- poor-quality Lifestyle forms, (some patently never proof-read, others cannot be
photocopied legibly); transition from Southern Cross paperwork repeatedly obstructed by
management; training refused; verbal instructions countermanded; forcefully instructed to
discard information prematurely; Deputy Manager insisted that multichoice questions on care
plan forms MUST be answered by selecting one of the preprinted choices, even when all are
inappropriate for a particular resident.
NMC 041969/2013 & 042682/2013
Page 45 of 66
Supplies + Infection Control -- repeated shortages of gloves, aprons, wipes, incontinence
pads, detergent for crockery + cutlery, paper towels, patient tissues; staff bought milk out of
their own money, so that residents could have drinks; lack of nursing supplies, e.g. mouth
swabs, "homely remedies", suction catheters for tracheostomy care, wound dressings; some
nights no bread, biscuits, jam, marmalade, or butter for residents (some of whom are diabetic)
to have snacks: cleanliness and basic hygiene thus frequently compromised.
Bullying and Harassment -- both Home Manager and Deputy Manager shout at staff,
sometimes reducing them to tears; many long-standing nurses have left; some new nurses
leave rapidly -- some after working just one or two shifts; staff rung at home and harassed
about trivia; continued persecution of staff who have left employment; after I resigned I was
informed by the RCN that I could have made a successful claim for constructive dismissal,
had I not had a "bank" contract.
Training / Palliative Care / Use of Oxygen -- "Mandatory training" scheduled haphazardly,
taking no account of which shifts staff were working; details posted at short notice; a session
scheduled for Good Friday was cancelled, but notices advertising the session, with names of
assigned staff, were not modified, so staff turned up for the cancelled session; similar fiasco
one month later for May Bank Holiday.
On 2nd Feb. 2012, as advised at an RCN meeting the previous day, I notified the Home
Manager in writing that I should not be asked to give palliative care or use syringe drivers
until I had received appropriate formal training. Although the flow of residents requiring
palliative care or syringe drivers did not cease, no training on syringe drivers was arranged
until the end of November: nearly ten months later. I did not hear of any palliative care
training.
The Home Manager told me that I was low priority for training because of my "bank"
contract: and told a colleague she was low priority for training because she works nights. At
night only four nurses are (or should be) on duty, (though sometimes a unit has no nurse at
night -- occasionally even during a day shift): so if one nurse has not been trained for a
particular procedure, there are at most three colleagues to ask for assistance. Nurses from
overseas sometimes admit to having once been trained in their own country, but (quite
correctly) refuse to perform a procedure at Coniston if they have not been trained to current
UK standards. Some nights I discovered that NO nurse on duty had been trained to
catheterise a male patient, or to take blood samples.
In March I was detained by the Home Manager in her office, with the Deputy Manager,
for two hours after the end of a night shift, and castigated for giving oxygen + antibiotics +
nebulisers to a 98-year-old "palliative care" resident, (as prescribed towards the end of the
relevant shift by an out-of-hours doctor). An hour after the doctor left the Deputy Manager
arrived, switched off the oxygen, and then instructed day staff to begin injecting
Midazolam. I heard that the resident died some hours later: and a colleague, unimpressed
with the actions of the Deputy Manager and the compliant day staff, observed succinctly,
"They killed that man". Deputy Manager later advised me that staff are not allowed to
administer oxygen unless prescribed, even in an emergency: although Lifestyle Care policy
LCS-CWI-28 ("Use of Oxygen") states, "In an emergency staff may use their discretion, (e.g.
CPR)".
NMC 041969/2013 & 042682/2013
Page 46 of 66
Resident with Mental Health Problems -- No Mental Health nurses worked at Coniston: and
one nurse who suggested to the Deputy Manager that employing one or two might be helpful
was later rung off duty by the Home Manager and chastised for daring to offer the
suggestion. A male resident verbally abused the Home Manager just days after her
appointment in Nov. 2011. In March 2012 he began refusing medication and refusing to
speak to anyone. One month later, still refusing both, he shouted and screamed for four hours
when I was on duty. Emergency services refused to attend, but, after one hour of 'phone
calls, senior advisers recommended, in the event of further deterioration or any recurrence,
asking police and ambulance to attend together. He repeated this behaviour one afternoon
mid-June, while the Home Manager was working: then, at midnight, during my shift, he
absconded on his Zimmer frame. I spent seven of the remaining eight hours of that shift
attempting to deal with him, before police and ambulance took him to the mental health unit
at the local hospital. Inexplicably, he returned to Coniston the following day. Over the
following months he repeatedly absconded, and began going into the rooms of other
residents, attempting to give intimate personal care to elderly women. The Deputy Manager
instructed me to lock all the OTHER residents in their rooms at night: though I refused to do
this, as an unwarranted deprivation of liberty. One morning in December, when I was not on
duty, he attacked one of the carers and was removed by police. Another resident (who, in
younger days, had worked in the police force) remarked that, if he'd attacked any other carer
on duty that shift, the outcome might have been fatal. -- If the Home Manager took ANY
action between Nov. 2011 and Dec. 2012, she failed to communicate it to nurses in the
resident's unit; failed to prevent what might have been a fatality; failed to ensure provision of
appropriate care for this resident; and failed to eliminate the risk which he posed to other
residents, (which I first highlighted to her in writing in Nov. 2011, 13 months before his
removal).
Q.3 What are your views about management and leadership in the Care Home?
Home Manager: not fit to practise either as a nurse or in any managerial role; has no
redeeming features whatsoever.
Deputy Manager: not fit to practise either as a nurse or in any managerial role; does
have humanity, but displays this sparingly, so many staff are intimidated.
Lifestyle Head Office: appalling response to joint complaint through RCN -- accepted
complaints, (some wholly, some partially -- with unbelievable "justification"); failed to
acknowledge that it was a joint complaint; failed to propose any action. Astounding refusal
to consider evidence by GP's at local surgery and by nursing staff at local
hospice: apparently on the spurious grounds that they are not Lifestyle employees. Although
some training was subsequently provided, no provision was made to monitor competencies
for night staff: and no evidence that training needs of staff were being assessed and
addressed. I saw no evidence of improvement regarding any of the other issues.
When I resigned, I discovered that both the "admin" email address (cited in the footer of
Lifestyle's headed paper) and "info" (publicised at www.lifestylecare.co.uk/contact-us.php)
bounced, reporting that the addresses did not exist. I reported this to Paul Ware, Chief
Operating Officer, in emails on 8th and 11th January. But this evening, six weeks later,
emails to "admin" are still bouncing. --
NMC 041969/2013 & 042682/2013
Page 47 of 66
The following message to <[email protected]> was undeliverable.
The reason for the problem:
5.1.0 - Unknown address error 550-'Invalid recipient <[email protected]>
(#5.1.1)'
I wonder whether ANY manager at Lifestyle Care is fit to manage even a bowl of
goldfish. I believe other staff share my rock-bottom esteem.
Q.4 What was your experience of employee morale and motivation?
Although SOME staff at Coniston, (nurses and carers and other roles) continue to want
to do a good job, motivation deteriorated markedly as soon as Jeannine Gappy assumed her
role. Her continued (and presumably deeply ingrained) habit of abusing, harassing, and
intimidating staff at work, off duty, and even after they have ceased employment at Coniston
does nothing to improve either morale or motivation. Although my own working relationship
with the Deputy Manager improved after some months, other colleagues reported that they
experienced no improvement.
Q.5 Do you feel you had the resources and support necessary to accomplish your
job? If not, what was missing?
Resources: regular shortage of supplies; training scheduled poorly or not at all; response to
routine administrative issues and to concerns inappropriate, delayed, or sometimes totally
ignored.
Support: nil. (Abuse: frequent.)
Q.6 What would make you consider returning to work again in the future?
With Lifestyle Care? You must be joking!
Q.7 What action if any could the company have taken to prevent you leaving?
As stated above: after I resigned I was informed by the RCN that I could have made a
successful claim for constructive dismissal, had I not had a "bank" contract. It became
increasingly clear from October, to me and to other nurses, that the Home Manager wanted to
oust me.
##############################
NMC 041969/2013 & 042682/2013
Page 48 of 66
Email, 18.4.2013, to Val Norris (Safeguarding Adults, London Borough of Hounslow)
Subject: Involuntary euthanasia
Cc:
Dear Val,
At 10:29 2013-04-15, you wrote:
I look forward to seeing you tomorrow.
As you requested on the 16th, I'm sending details about the action taken by the Deputy
Manager regarding a resident (in Room 35) who had been visited by an out-of-hours GP one
hour earlier.
I have since found photocopies of two further documents relating to this resident's care,
but one refers to an earlier drug error: prescribed Enoxaparin injections not given for ten
consecutive days in Dec. 2011/Jan.2012. The other is a handover sheet I wrote on 2.3.2012
for all residents in Heron, noting for him: "May need Oramorph. Other end-of-life med.s not
started yet."
I'm sending you three documents: the PDF report which I emailed to the RCN on
13.8.2012 as part of the joint complaint by nursing staff against Jeannine Gappy; the reply
(three pages) which I received from Lifestyle Care to my part of the joint complaint; and a
scanned image of the photocopy I showed you on Tuesday of page 92 of the Heron CD book,
(Controlled Drugs), recording Midazolam injections given to the resident -- two on
15.3.2012, one on 16.3.2012, and disposal of the remaining two ampoules apparently on
22.3.2012. (I have just identified two errors in the first entry, and four in the last. A trained
pharmacist might spot more.) Unfortunately I do not have photocopies of the other CD pages
for this resident. I imagine that this book has since been filled. Is it realistic to hope that,
despite the general chaos I observed in the archive store rooms, CD books might be archived
with greater respect than other documents?
Am shortly going out, so am attaching only the first two items, and will send the third
document in a separate email.
For further detail, this is a note I recorded on 15.3.2012, after returning home. -around 4:15, Michele reported that John G. was "unwell" RR 40, HR 140 gave
Lorazepam + saline neb.s / discussed with Patience in Wren / rang Harmoni / advised
to give oxygen / took concentrator from [room 26]; ...; doctor arrived added
Salbutamol neb.s PRN and Amoxycillin TDS to MARR chart intended to supply
Amoxycillin, then discovered he'd run out however, Wren had put three bottles for
Patricia for discarding; ...; Mabel seemingly annoyed that Id rung Harmoni at all
stopped oxygen (explaining that it's [for resident in room 26] even though
NMC 041969/2013 & 042682/2013
Page 49 of 66
concentrator, not cylinder, and never used); Sabina + Mabel + Angela preparing
Midazolam + Diamorphine + Hyoscine [for subcutaneous administration] as I left.
I returned on 19.3.2012 for a night shift, and then recorded:
John G. died on Friday, so now four rooms empty, and two further residents in
hospital; ... Patience in Wren says she's never seen Jeannine; also said "they killed
that man" on hearing how Mabel switched off oxygen and began preparing EoL
med.s.;
Although the report for the RCN was specifically about Jeannine Gappy, not about her
deputy, Mabel Oluwasanmi, para. 9.13 mentions this case in fair detail. This report was
included by the RCN with reports from other nurses, and sent to Lifestyle Care as
evidence. The response from Lifestyle Care (dated 4.10.2012, though postmarked
23.10.2012) responds explicitly to this paragraph in just one sentence at the bottom of page
2: "It would have been more appropriate to call the emergency services rather than use
another resident's prescribed equipment".
I apologise for the style of the report, which is to conform to RCN guidelines. Each of
sections 5 - 10 is written to be independent: so there is some duplication. It mentions several
other items that we have discussed:
para. 6.11 -- alteration of "Advanced Care Plan" from "Resuscitate" to "Do Not
Resuscitate";
para. 7.10 -- wrong size of suction catheters
para. 8.11 -- brief mention of this case
para. 8.15 -- wrong size of suction catheters
para. 8.19 -- further incident related to giving oxygen
para. 9.4 -- staff generally not competent with syringe drivers (yet no training available
until 23.11.2012)
para. 9.16 -- further brief mention of this case
para. 9.19 -- further case relating to oxygen concentrators
para. 9.21 -- staff have no dementia training -- even in the dementia unit, Kingfisher
para. 9.23 -- more details relating to 8.19 and to Mabel
If you have further denials from Coniston or Lifestyle, issues which have not arisen since
July/August 2012 may well be included in this report.
As the report was about Jeannine Gappy, I omitted to mention a further incident
regarding Mabel which I recorded on 25.3.2012. -[Resident in room 31] expected back from Guy's tomorrow, needing oxygen + suction
machine Mabel now saying he should share [suction machine for resident in room
26], as they both have MRSA
Regards,
John H.
NMC 041969/2013 & 042682/2013
Page 50 of 66
NMC 041969/2013 & 042682/2013
Page 51 of 66
NMC 041969/2013 & 042682/2013
Page 52 of 66
Email, 10.5.2013, from Val Norris (Safeguarding Adults, London Borough of Hounslow)
From: Val Norris <[email protected]>
To: 'John Hunt' <[email protected]>
Subject: RE: Nursing Home
Dear Mr Hunt,
Following our conversation last week, I wanted to update you that the DI who sits on our
Safeguarding Adults Board returned to day duties on Wednesday and I spoke to him about the
incident at Coniston Lodge on that day. I know that he has been taking advice from colleagues and
seeking advice from others with expertise in medical/palliative issues. He had hoped to get back to
me by the end of the week which has not happened however I will keep you updated with any
developments.
Regards
Val
Val Norris
Safeguarding Adults Consultant Practitioner,
London Borough of Hounslow Civic Centre,
Lampton Rd,
Hounslow
TW3 4DN
Tel: 020 8583 4515/6216
Fax: 020 8583 4134
NMC 041969/2013 & 042682/2013
Page 53 of 66
Summary handed to Chiswick Police at "informal interview" on 28.5.2013 – two pages
Death of John Gibbs, resident in room 35,
Coniston Lodge, Feltham, 15–16 March 2012
Extract from report, 13.8.2012, emailed to Sharon Bissessar (Regional Officer), Royal
College of Nursing, for joint complaint against home manager, Jeannine Gappy, (RCN Case
CM.53250)
On 15.3.2012, during a night shift, a resident with advanced bowel cancer
unexpectedly developed severe difficulty breathing. I discussed this with the nurse on duty in
Wren, (Patience Quagraine), explaining that, although he had been admitted for palliative care
some months earlier, the only end-of-life medication he was receiving was occasional PRN
Oramorph, so I wanted to ring the out-of-hours doctor, to keep him comfortable. As she agreed
with my plan, I rang and was asked to give the resident oxygen until the doctor arrived. As
our rooms do not have oxygen points, I borrowed the oxygen concentrator delivered for the
resident in room 26 who had never used it in the two years since his admission. When the
doctor arrived, he prescribed Salbutamol nebuliser PRN and Amoxycillin TDS: but an hour
later, when Mabel Oluwasanmi (deputy manager) arrived, she switched off the oxygen before
instructing day staff to begin injecting Midazolam. (Exhibit 9e)
Extract from email, 23.2.2013, responding to Exit Interview Questionnaire from Karen
Baker (job title not stated), Lifestyle Care
In March I was detained by the Home Manager in her office, with the Deputy Manager,
for two hours after the end of a night shift, and castigated for giving oxygen + antibiotics +
nebulisers to a 98-year-old "palliative care" resident, (as prescribed towards the end of the
relevant shift by an out-of-hours doctor). An hour after the doctor left the Deputy Manager
arrived, switched off the oxygen, and then instructed day staff to begin injecting Midazolam. I
heard that the resident died some hours later: and a colleague, unimpressed with the actions
of the Deputy Manager and the compliant day staff, observed succinctly, "They killed that
man". Deputy Manager later advised me that staff are not allowed to administer oxygen unless
prescribed, even in an emergency: although Lifestyle Care policy LCS-CWI-28 ("Use of
Oxygen") states, "In an emergency staff may use their discretion, (e.g. CPR)".
Extract from email, 18.4.2013, requested by Val Norris (Safeguarding Adults Consultant
Practitioner), London Borough of Hounslow
As you requested on the 16th, I'm sending details about the action taken by the Deputy
Manager regarding a resident (in Room 35) who had been visited by an out-of-hours GP one
hour earlier.
I have since found photocopies of two further documents relating to this resident's care,
but one refers to an earlier drug error: prescribed Enoxaparin injections not given for ten
consecutive days in Dec. 2011/Jan.2012. The other is a handover sheet I wrote on 2.3.2012
for all residents in Heron, noting for him: "May need Oramorph. Other end-of-life med.s not
started yet."
NMC 041969/2013 & 042682/2013
Page 54 of 66
I'm sending you three documents: the PDF report which I emailed to the RCN on
13.8.2012 as part of the joint complaint by nursing staff against Jeannine Gappy; the reply
(three pages) which I received from Lifestyle Care to my part of the joint complaint; and a
scanned image of the photocopy I showed you on Tuesday of page 92 of the Heron CD book,
(Controlled Drugs), recording Midazolam injections given to the resident -- two on 15.3.2012,
one on 16.3.2012, and disposal of the remaining two ampoules apparently on 22.3.2012. (I
have just identified two errors in the first entry, and four in the last. A trained pharmacist might
spot more.) Unfortunately I do not have photocopies of the other CD pages for this resident.
I imagine that this book has since been filled. Is it realistic to hope that, despite the general
chaos I observed in the archive store rooms, CD books might be archived with greater respect
than other documents?
...
For further detail, this is a note I recorded on 15.3.2012, after returning home. -around 4:15, Michele reported that John G. was "unwell" – RR 40, HR 140 – gave ½
Lorazepam + saline neb.s / discussed with Patience in Wren / rang Harmoni / advised
to give oxygen / took concentrator from [room 26]; ...; doctor arrived – added
Salbutamol neb.s PRN and Amoxycillin TDS to MARR chart – intended to supply
Amoxycillin, then discovered he'd run out – however, Wren had put three bottles for
Patricia for discarding; ...; Mabel seemingly annoyed that I’d rung Harmoni at all –
stopped oxygen (explaining that it's [for resident in room 26] – even though
concentrator, not cylinder, and never used); Sabina + Mabel + Angela preparing
Midazolam + Diamorphine + Hyoscine [for subcutaneous administration] as I left.
I returned on 19.3.2012 for a night shift, and then recorded:
John G. died on Friday, so now four rooms empty, and two further residents in
hospital; ... Patience in Wren – says she's never seen Jeannine; also said "they killed
that man" on hearing how Mabel switched off oxygen and began preparing EoL med.s.;
Although the report for the RCN was specifically about Jeannine Gappy, not about her
deputy, Mabel Oluwasanmi, para. 9.13 mentions this case in fair detail. This report was
included by the RCN with reports from other nurses, and sent to Lifestyle Care as evidence.
The response from Lifestyle Care (dated 4.10.2012, though postmarked 23.10.2012)
responds explicitly to this paragraph in just one sentence at the bottom of page 2: "It would
have been more appropriate to call the emergency services rather than use another resident's
prescribed equipment".
...
As the report was about Jeannine Gappy, I omitted to mention a further incident
regarding Mabel which I recorded on 25.3.2012. --
[Resident in room 31] expected back from Guy's tomorrow, needing oxygen + suction
machine – Mabel now saying he should share [suction machine for resident in room
26], as they both have MRSA
Attachments: Wilma Thomson's letter, Oct. 2012 + CD page for JG's Midazolam
NMC 041969/2013 & 042682/2013
Page 55 of 66
Email, 23.7.2013, from Chiswick Police
Subject: Coniston Lodge
From: <[email protected]>
To: <[email protected]>
Hello John
I hope you are well and had a good holiday.
To update you re my investigation. I have spoken to a number of people regarding Mr Gibbs and have
subsequently concluded that there will be no Criminal investigation regarding the issues surrounding his death.
I have spoken with my Detective Inspector and updated him regarding my findings and he is in agreement with
me that no Criminal Investigation will take place.
However we have both agreed that we do not want to leave it at that regarding the lodge and in particular the
deputy manager and I will be speaking with Val NORRIS re the policies in place at Coniston and any provisions
that need to be made and issues addressed regarding their procedures and training.
If you need to speak to me further or require any further information then please e mail me back as I am
currently night duty.
Kind regards
Claire
Claire Hine | Detective Sergeant | Community Safety Unit
Metphone | 36589 | Telephone 0208 247 6589
E mail | [email protected]
Address | Community Safety Unit , Chiswick Police Station , 209-211 High Road , Chiswick, W4 2DU
NMC 041969/2013 & 042682/2013
Page 56 of 66
NMC's Consent form for case 042682/2013: no Consent form supplied for case 041969
NMC 041969/2013 & 042682/2013
Panel decision re Olufunke Oluwasanmi, 041969/2013, 29.7.2014
Page 57 of 66
NMC 041969/2013 & 042682/2013
Page 58 of 66
NMC 041969/2013 & 042682/2013
Page 59 of 66
NMC 041969/2013 & 042682/2013
Page 60 of 66
NMC 041969/2013 & 042682/2013
Panel decision re Jeannine Gappy, 042682/2013, 23.10.2014
Page 61 of 66
NMC 041969/2013 & 042682/2013
Page 62 of 66
NMC 041969/2013 & 042682/2013
Page 63 of 66
NMC 041969/2013 & 042682/2013
Page 64 of 66
NMC 041969/2013 & 042682/2013
NMC referrals of Janine [sic] Gappy and Olufunke Oluwasanmi, 8.12.2014
Page 65 of 66
NMC 041969/2013 & 042682/2013
Page 66 of 66

Correspondence with NMC List of emails exchanged with NMC List

Transcription

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