Panel:

Chairperson, RN
Member, RPN
Public Representative
Independent Legal Counsel

BETWEEN

COLLEGE OF NURSES OF ONTARIO Counsel for College of Nurses of Ontario

and -

HEATHER M. LEACH # 92-2206-8

Counsel for Heather M. Leach

Heard: OCTOBER 25, 1999

A panel of the Discipline Committee was convened on October 25, 1999 to hear allegations brought before it by the College of Nurses against HEATHER MARIE LEACH, R.N. as outlined below in the Notice of Hearing. Ms. Leach was present as was her defence counsel.

Counsel for the College reviewed the Notice of Hearing with the panel.

The panel was advised that the hearing would proceed by way of Agreed Statement of Facts.

The following allegations were contained in the Notice of Hearing:

You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that on or about June 23 and 24, 1998, while employed as a Registered Nurse at a health facility in Brampton, Ontario, you contravened the standard of practice of the profession or failed to meet the standard of practice of the profession with respect to administration of morphine to a client.
You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that on or about June 23 and 24, 1998, while employed as a Registered Nurse at a health facility in Brampton, Ontario, you engaged in conduct or performed an act or acts, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably regarded by members as disgraceful,

dishonourable or unprofessional, with respect to your administration of morphine to a client.

Counsel for the College advised the panel that Ms. Leach had admitted Allegation #1 in a signed Agreed Statement of Facts which was entered into evidence. The panel was also advised that the College did not intend to call any evidence with respect to Allegation #2 and was not seeking a finding with respect to that Allegation.

Counsel for the College introduced into evidence an Agreed Statement of Facts executed by Ms. Leach which provided as follows:

Ms Leach obtained a Diploma of Nursing from Fanshawe College in 1992 and a Bachelors of the Science of Nursing from University of Windsor in 1994. Ms. Leach is not currently engaged in the practice of nursing.
In 1994, Ms Leach began employment with the facility. She worked on surgical and medical units prior to becoming permanent part-time staff on the pediatrics unit in November, 1997.

Allegation 1

Ms Leach worked a scheduled shift on the pediatrics unit of the facility from 1930 hours on June 23, 1998 to 0730 hours on June 24, 1998. During her shift she was assigned to the care of client.
The client was an infant recovering from surgery. The operative procedure was uneventful and the client was transferred to the pediatrics unit at approximately 1300 hours in good condition.
At approximately 2200 hours, Ms Leach assessed that the client required analgesia. She found no Medication Administration Record for the client, so she completed a new one.
Ms Leach found the following order for analgesia in the client's health record:

"-demerol 5-10 mg q3-4h prn

-gravol 5-10 mg q3-4h prn"

While transcribing the order onto the Medication Administration Record, Ms Leach mistakenly wrote "Morphine 5-10 mg q3-4h prn."
Ms Leach then prepared and administered 5 mg of Morphine intravenously to the client. She recorded on the Daily Narcotic and Controlled Drug Sheet and the Medication Administration Record that she had administered "Dem, 5" at 2200 hours.
At 0240 hours, Ms Leach again prepared and administered 5 mg of Morphine intravenously to the client. She again recorded on the Daily Narcotic and Controlled Drug Sheet and Medication Administration Record that she had administered 5 mg of Morphine. She recorded on the Pediatric Worksheet that she had administered "Dem 5" at 0240 hours.
Ms Leach also documented the administration of Demerol in three places on the hospital's computer charting system. On the "Pain Assessment" area of the computer record, she charted that she had administered 5 mg of Demerol at 2200 hours on June 23, 1998 and 5 mg of Demerol at 0240 hours on June 24, 1998. In the "Pain Assessment - Surgery" area of the computer record, she charted that she had administered Demerol at 2200 hours on June 23, 1998 and Demerol at 0240 hours on June 24, 1998. Under the section headed, "Assessments Queries", Ms Leach charted that she had administered Demerol at 2200 hours on June 23, 1998 and again at 0240 hours on June 24, 1998. These entries were subsequently changed by Ms Leach to reflect that Morphine had actually been administered, when her error became apparent, as required by nursing standards.
At 0610 hours, the client was found without vital signs. CPR was initiated and a Code Blue was called immediately. Resuscitation was unsuccessful and the client was pronounced dead at 0646 hours on June 24, 1998. The client died as a result of the administration of Morphine by Ms Leach.
Ms Leach acknowledges that her conduct amounted to professional misconduct, as set out in allegation 1 of the Notice of Hearing, in that she failed to meet the standards of practice of the profession by administering Morphine to the client rather than Demerol as ordered.

Allegation 2

The College tenders no evidence with respect to this allegation.

PLEA INQUIRY

In order to ensure that Ms. Leach's admission of professional misconduct was made freely and voluntarily, the panel asked Ms. Leach five questions as follows

Do you understand the nature of the allegations that have been made against you?
Do you understand that by admitting the allegations you are waiving the right to require the prosecution prove the case against you and the right to have a hearing?
Do you understand the consequences of admitting to the allegations made against you?
Did you voluntarily decide to admit the allegations against you?
Do you understand that the agreement between the prosecution and the defence counsel with respect to the penalty imposed does not bind the discipline panel?

Ms. Leach answered in the affirmative to the above five questions.

FINDING OF PROFESSIONAL MISCONDUCT

The panel accepted the Agreed Statement of Facts.

The panel finds that Ms. Leach committed an act of professional misconduct as set out in Allegation #1.

JOINT SUBMISSIONS ON PENALTY

Counsel for the College presented to the panel a Joint Submission as to Penalty which provided as follows:

Ms. Leach and the College of Nurses of Ontario ("the College") jointly submit that the appropriate penalty for this case is for the Discipline Committee to make an order as follows:

a. directing the Registrar to suspend Ms. Leach's certificate of registration for a period of four months;

b. directing the Registrar to impose a term, condition or limitation on Ms. Leach's certificate of registration, requiring Ms. Leach to successfully complete a Medication Course at a College of Applied Arts and Technology acceptable to the Director, Investigations and Hearings ("the Director"), of the College prior to resuming the practice of nursing; and

c. requiring Ms. Leach to attend before a panel of the Discipline Committee for an oral reprimand prior to resuming the practice of nursing.

PENALTY DECISION

The panel deliberated and decided to accept the Joint Submission as to Penalty.

REASONS FOR DECISION

Given the tragic outcome that resulted from Ms. Leach's failure to meet the standard of practice of the profession with respect to the administration of morphine to the client, the panel gave careful consideration to the submissions made by both counsel. The panel recognized that the intent of penalty decisions is not to punish Ms. Leach and exact retribution, but rather to protect the public, maintain high professional standards and preserve public confidence in the nursing profession. It is from this perspective the panel assessed and decided to accept the Joint Submission on Penalty.

In accepting the penalty, the panel took into consideration not only the nature and tragic outcome of the misconduct, but, the mitigating factors presented in the Agreed Statement of Fact which were reiterated by both counsel in their submissions on penalty. Mitigating factors considered by the panel included the fact that Ms. Leach is no longer engaged in the practice of nursing, as well as, Ms. Leach's:

previous good nursing record

admission that her conduct amounted to professional misconduct, as set out in allegation #1 of the Notice of Hearing, in that she failed to meet the standards of practice of the profession by administering Morphine to the client rather that Demerol as ordered

genuine remorse over the tragic outcome resulting from her failure to meet the standards of practice of the profession related to the administration of medication

admission of misconduct which eliminated the need for a lengthy discipline hearing to prove the allegations

full participation in the Inquest into the death of the client, held earlier this year, in which every aspect of the case and the actions of Ms. Leach were scrutinized in the Coroner's Court.

Based on counsel's submissions and the mitigating factors, the panel agreed that the Joint submission as to Penalty was appropriate. The panel decided to accept the Joint Submission as to Penalty and believe that by suspending Ms. Leach's Certificate of Registration requiring Ms. Leach to successfully complete a Medication Course (at a College of Applied Arts and Technology) acceptable to the Director, Investigations and Hearings of the College prior to resuming the practice of nursing, and requiring Ms. Leach to attend before a panel of the Discipline Committee for an oral reprimand the objectives of specific deterrence to Ms. Leach's future conduct, remediation to prevent a recurrence of the particular misconduct by Ms. Leach, and general deterrence to the members of the profession will be fulfilled, thereby serving the College's mandate to protect the public interest.

I, , RN, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel as listed below:

, Chairperson Date Member, RPN

Public Representative

College of Nurses of Ontario v. Leach, 1999 ONCNO 36512

Case Summary