College of Nurses of Ontario v. The Member, 2000 ONCNO 50765

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

Panel:

Chairperson, RN

Member, RPN

Public Representative

BETWEEN

COLLEGE OF NURSES OF ONTARIO

COUNSEL for College of Nurses of Ontario

• and -

The Member

COUNSEL for the Member

Heard: April 14, 2000

REASONS FOR DECISION

A panel of the Discipline Committee of the College of Nurses of Ontario convened on April 14, 2000, to hear the following allegation.

1. You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Code, and paragraph 1.1 of Ontario Regulation 852/93, in that on or about May 1, 1997, while employed as a Registered Nurse at a hospital, in the Province of Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession with respect to your assessment, care and treatment of a client known as "the Client".

PLEA

Counsel for the Member informed the panel that the plea was incorporated in the Agreed Statement of Facts (paragraph 20) and that the Member recognized her error. Counsel for the Member also informed the panel that the Member had taken steps voluntarily to re-educate herself on the issue in question.

AGREED STATEMENT OF FACTS

The Member

1. The Member obtained her basic nursing training in England in 1960. She commenced working as a nurse in Canada in 1961 and obtained experience at a variety of hospitals in Ontario. She worked for six years on a part-time basis on a medical and surgical floor before returning to England to complete her mid-wifery training in 1974.
2. On her return to Ontario, she worked at a university medical centre before commencing employment at the Hospital in 1978. The Member has continued to work on a full-time basis in the obstetrical unit of the Hospital since 1978.

The Facility

3. The Hospital is a 100-bed general hospital.
4. The obstetrical unit has 14 beds, with priority given to obstetrical clients. On occasion, the beds on the unit are available for general surgery, medical or pediatric clients. There are approximately two births per day on the unit.
5. The staffing on the unit consists of three Registered Nurses on an extended day shift from 07:00 to 19:00 hours. One of the RNs is in charge with responsibilities for staffing problems, workload and ensuring lab slips are processed. The charge nurse also has a client assignment of 5-6 clients (in addition to babies). A second RN is responsible for labour and delivery and the third RN is responsible for the rest of the clients on the floor. In the event that there is more than one client in active labour, additional staff can be called in.
6. The general practice in the unit was to provide one-to-one nursing care for clients in active labour. The nursing model in place is primary nursing. The nurses used monitors exclusively for fetal heart monitoring. No auscultation devices were available for use.

The Client

7. The Client was admitted to the Hospital at approximately 04:00 hours on April 30, 1997 under the care of her family practitioner. The Client had three previous miscarriages; this was her first full-term pregnancy of 38 weeks gestation.

The Client's Initial Progress in Hospital

8. The Client's membranes ruptured at her home at approximately 19:00 hours on the evening of April 29, 1997. At the time of her admission, the Client was assessed as having mild contractions every 5-8 minutes for 30 seconds. Her cervical dilation was 1 cm with scant pink show. The fetal heart rate was 135 beats per minute with no abnormalities noted.
9. The Client was seen in consultation by the obstetrician, at 15:00 hours on April 30, 1997. Her labour appeared to be getting stronger with increased frequency and duration of contractions. Intravenous Ampicillin, as well as Demerol and Gravol intramuscularly, were administered per the obstetrician's orders.
10. The Client received an epidural anaesthetic at approximately 21:00 hours. Her labour pattern remained moderate. An external fetal heart monitor was applied continuously at this time with no abnormalities noted.

Allegation 1(a) Contravention or failure to maintain the standards of practice

11. The Member was assigned to care for the Client from 07:00 to 19:00 hours on May 1, 1997.

12. At approximately 13:00 hours on May 1, 1997, the Client was seen again by her family practitioner and in consult by the obstetrician. At this time, the Client was fully dilated, however, her contractions were beginning to slow down and her labour pattern was becoming less active. The fetal heart rate was 145 beats per minute. The obstetrician diagnosed the Client with dysfunctional labour and ordered an augmentation of labour by Syntocinon induction. The obstetrician instructed that the Client be reassessed one hour after her contractions were re-established.

13. The Member began the Syntocinon infusion at approximately 13:15 hours in accordance with the obstetrician's orders. Within one hour, the Client's contractions were strong, occurring every 2-3 minutes and lasting 60 seconds in duration. The infusion was accordingly decreased. At 15:00 hours, the Client began to push.

14. From 13:15 hours to 14:50 hours, although the fetal heart rate was audible within normal limits, the quality of the fetal heart monitor tracing was poor. During this time, the Labour Progress Record indicates that the fetal heart rate was monitored every 15 minutes with a rate noted between 140-150 beats per minute. No further documentation regarding the status of the fetal heart rate pattern was made.

15. From 14:50 to 15:45 hours, the fetal heart monitor tracing shows a complete absence of any readable fetal heart pattern. During this time, the Labour Progress Record indicates that the fetal heart rate was monitored every 30 minutes with a rate noted between 138-155 beats per minute. No further documentation regarding the status of the fetal heart rate pattern was made.

16. At 15:45 hours, the Member began to have difficulty hearing the fetal heart tones. She was able to hear fetal heart tones at a rate between 130 to 158 beats per minute during contractions, but could not hear fetal heart tones between contractions.

17. The Member requested and received assistance from a colleague, who confirmed the Member's observations of the fetal heart tones. The Client was moved to the delivery room where the Member and her colleague changed the fetal heart monitor. The difficulty in hearing the fetal heart tones continued.

18. At 16:00 hours, the Member notified the family practitioner that she was having difficulty detecting the fetal heart tones and that the fetal heart was slowing at times. The Member discontinued the Syntocinon infusion per the family practitioner's orders. At 16:15 hours, the Member called the family practitioner once again to confirm that he was on his way to the Hospital.

19. The family practitioner arrived in the delivery room at approximately 16:25 hours followed in approximately 5 minutes by the obstetrician and performed a vacuum extraction. Fetal heart tones were absent with the exception of fetal heart tones heard two minutes prior to delivery at between 130 and 140 beats per minute. Resuscitation attempts were unsuccessful and the child was stillborn.

20. The Member acknowledges that her conduct amounted to professional misconduct, as set out in allegation 1(a) of the Notice of Hearing, in that she failed to meet the standards of practice of the profession by:

    • failing to recognize the need to ensure that there was a continuous quality tracing of the fetal heart rate in order to assess that the fetal heart rate pattern was reassuring;
    • failing to inform the attending physician or the consulting obstetrician of the difficulty in maintaining continuous fetal monitoring;
    • failing to adequately assess the fetal heart rate, rhythm, presence or absence of accelerations, decelerations or a change in baseline every five minutes as expected during the pushing phase of the second stage of labour;
    • failing to assess the maternal pulse with sufficient frequency to ensure that the tones heard were fetal heart and not maternal pulse tones;
    • failing to immediately increase the main intravenous and initiate oxygen therapy when unable to locate a fetal heart rate; and
    • failing to document all required parameters of fetal health surveillance.

PLEA INQUIRY

On conducting a plea inquiry, Council for the Member informed the panel that the Member had read a copy of the plea inquiry and that the Member understood and accepted the conditions.

DECISION

The panel accepted the Agreed Statement of Fact as presented by the Counsel for the College of Nurses of Ontario. Accordingly, the panel finds that the Member has committed an act of professional misconduct as provided by subsection 51(1)(c) of the Code and paragraph 1.1 of Ontario Regulation 852/93 in that she failed to meet the standards of practice of the profession as set out in paragraph 20 of the Agreed Statement of Facts.

JOINT SUBMISSION ON PENALTY

Counsel for the College and the Member submitted a Joint Submission on Penalty to the panel which provided as follows:

WHEREAS the Member has provided proof to the Director of Investigations and Hearings that that she has met with an expert in obstetrical nursing approved by the Director to review the assessment and monitoring of fetal heart rate patterns and the appropriate response to signs of fetal distress;

THE MEMBER AND THE COLLEGE jointly submit that the appropriate penalty in this case is for the Discipline Committee to make the following order:

Requiring the Member to appear before the panel of the Discipline Committee to be reprimanded, at a date to be arranged, but in any event within three months of the date the order becomes final.

DECISION

The panel accepted the Joint Submission on Penalty as presented. Accordingly, the panel orders that the Member appear before this panel of the Discipline Committee to be reprimanded, at a date to be arranged, but in any event within three months of the date the Order becomes final.

REASONS FOR DECISION

The panel found that the Joint Submission on Penalty was fair and appropriate. There were a number of mitigating circumstances in this case. The Member had a long-standing, unblemished career in nursing. The Member submitted three letters of reference in her support. She has shown a sincere and mature approach to re-education. This is evidenced by her voluntarily taking courses in the assessment and monitoring of the fetal heart. The Member also consulted with the College's expert in obstetrics to review the Member's specific errors in this case. This was a custom-tailored re-education session from the expert who reviewed this case.

The panel agrees with both counsel that from a public protection point of view, adequate re-education has already occurred and that issuing an oral reprimand is the appropriate penalty in this case.

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 [ ]