February 19, 2009
By Greg Mills

......

A PSYCHIATRIC nurse who failed to regularly check an at-risk patient who later hanged himself has been struck off the nursing register.

Another nurse who was playing a computer game at the time of the death at Green Lane Hospital in Devizes, Wiltshire, has been found guilty of misconduct. But he can continue working as a nurse, a Nursing and Midwifery Council hearing concluded.

Katherine Banks, 38, from Corsham, was struck off for failing to respond to a panic alarm, inadequately observing patients and having her hair cut on duty.

John Turver, 58, from Trowbridge, was watching television and using a games console at the time of the hanging.

The nurses had almost 60 years of experience between them. Both had denied misconduct.

Before the patient killed himself in the early hours of March 12, 2006 he had on the day before stripped naked and left the acute Imber Ward.

He complained of hearing voices to police officers and was returned to the hospital.

The un-named patient was placed under half-hourly observations by day staff. They were downgraded to hourly checks when Banks, Turver and other colleagues came on duty that night.

Neither nurse had looked in on the patient after 8.30pm and failed to make sure he was looked at by other members of staff, the panel was told.

Checks on patients were haphazardly carried out throughout the night and Turver did not ensure the 3am observation
was done.

The pair left the nurses’ station unmanned on the ward between 3am and 4am on the morning of the patient’s death.

When a care assistant’s personal alarm sounded, all nurses were congregated in the smoking room, watching television, playing games and chatting.

Turver said he was told by Banks, his senior, it was a false alarm and he went back to work before seeing the crash trolley fly past his office to the patient’s room.

Turver admitted he only checked to see if the hourly 3am observation had been done as he was pumping up and down on the patient’s chest to try and revive him.

Banks' only mitigation put before the council's conduct panel was an email which read: "I feel I can't attend as the past four years has put me under extreme physical and mental strain and my GP is concerned that appearing at this hearing would set me back irrevocably."

She said that despite 18 years in service with an unblemished record she had no intention of reregistering to get back into her career.

She resigned from her post before disciplinary proceedings had reached their conclusion.

NMC chair Jillian Alderwick said of Banks that there was "no genuine expression of regret or apology".

"Properly conducted observations may have stopped him [the patient] harming himself or given a greater chance of success to resuscitation attempts.

"This was a very serious departure from proper nursing standards and a serious failure in personal performance on the shift in question.”

During the hearing last week Turver broke down in tears and said nursing had been a huge part of his life for 40 years.

Turver, who gave evidence in his defence, said: "It's been a very difficult time. I've spent 40 years nursing which has been a huge part of my life, fortunately I've never been in this situation before.

"Since the incident I have probably been more reflective in my practice, probably more careful with my practice."

Turver was dismissed from his hospital job after disciplinary proceedings were launched by Avon and Wiltshire Mental Health Partnership NHS Trust.

Turver said: "Despite everything that's happened and all the stress over the past three years which has been caused at home and work I feel I'm confident enough to do my job and I feel I do it well."

Turver had admitted playing the computer game, saying 'It was ignorance really. I was just interested. I had never seen it before, I fiddled with the switches for about ten minutes."

Ms Alderwick said of Turver: "There was no deliberate misconduct. Rather Mr Turver displayed poor judgement and poor practice in not personally assessing the patient.”

The panel said there were enough mitigating factors to impose a five-year caution and urge Turver to do a leadership and risk assessment course.

Turver can continue his present job for Rapid and Secure, which specialises in transporting people with mental health problems.

Consultant nurse Anthony Harrison who carried out an inquiry into the death said: “It was a very laissez-faire, very casual attitude to running a shift that was a concern to me.

"I think it would be very hard to justify all members of staff being in one room at the same time as doing hair-cutting, smoking, drinking, eating and watching TV, all for an extended period of time.”

Ms Alderwick said: "An appropriate assessment should have included a face to face interview with the patient or a face to face observation of how the patient was presenting and this should be recorded."

......

Observation can make people worse

From: Louise Pembroke, service user, London
Date: February 25, 2009

All staff members congregating in one room is not that unusual on acute wards - whether that's the office [referred to by some people as 'office nursing'] or a day room, so in that respect, this case is not that unusual. Although doing activities such as hair cutting whilst on duty cannot be explained as reasonable.

However, I would suggest that on the whole psychiatry is not that accurate at predicting likely suicide despite our risk adversive and risk assessment obsessed culture.

Also, people can kill themselves on 15 min observation. I lost a friend by hanging - she was on 15 min observation.

I'm not saying the staff in question don't have anything to answer for nor whether they are fit to practise, but it's all too easy to believe that risk assessment and intensive observation solves everything and protects everyone because it doesn't. Service users can find observations of the close and continuous kind highly intrusive with little or no meaningful engagement. It can make some people feel worse.

Equally I don't find psychiatric liaison in A&E aggressively forcing me to answer their suicide questions [always the first question] whilst witholding access to the surgical repair I need for self injury remotely supportive. It just makes me want to smack them!

So, I believe the whole issue of how we approach, assess and support people who are self harming or actively suicidal needs rethinking because it's currently not helpful to service providers or service users.

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