Reasons for the substantive hearing of the Conduct and Competence

Committee panel
held at
NMC, 61 Centrium, London
on
16th - 20th March 2009

Name: Deborah Marie Purdue

PIN: 80Y3449E
Part (s) of register: Registered Nurse – Adult
Registered Midwife

Facts proved: Charges 1a, b, 2a, b, 4a, c, d, e & 5

Facts not proved: Charges 3 & 4b
Fitness to practise: Impaired
Sanction: Striking Off Order
Interim Order: Interim Suspension order for 18 months

Charges as amended read out as follows:

That you, whilst working as an independent midwife, on the night of 18 and morning
of 19 July 2005:

(1) Failed adequately

(a) to monitor

(b) to safeguard

the foetal wellbeing of Patient A;

(2) Failed adequately to asses

(a) the condition of Patient A

(b) the progress of Patient A’s labour;

(3) Failed to communicate effectively with Patient A;

(4) Failed to take appropriate action where the progress of Patient A’s
labour fell outside normal parameters in that you :-

(a) failed to consider all possible causes of foetal tachycardia at

04:00 hours,04:30 hours, 0.5:30 hours, 05:55 and 06.00hours or
to take appropriate action;

(b) went for a walk at 04.30 leaving Patient A unattended;

(c) delayed attempting to carry out vaginal examination until 05:30

hours;

(d) allowed Patient A to get into her birthing pool at around 06.05
 hours and remain in the pool until approximately 06.15 hours;

(e) did not consider transferring Patient A to an obstetrics unit until

06:15 hours;

(f) allowed Patient A to wait unaccompanied in her garden while an

ambulance was awaited;

(5) Failed to maintain an adequate record of the care delivered to Patient A.

AND in light of the above, your fitness to practise is impaired, by reason of your
misconduct.

Reason for the finding of facts

The charges relate to the home delivery of Patient A, who was 36 years old, prima
gravida. Gestation was 41 weeks + 5 days. The registrant was commissioned by
Patient A to provide care throughout her pregnancy. The registrant is an Independent
Midwife.

Charge 1(a)

The RCM, Evidence based Guidelines for Midwifery led Care in Labour, Foetal Heart
Rate Monitoring Good Practise Points states:

“Intermittent auscultation with a hand held instrument is the recommended method

for the woman who is healthy and has had an otherwise uncomplicated pregnancy.

This consists of measuring the foetal heart after a contraction for a minimum of 60
seconds:
Every 15 minutes in the first stage
Every 5 minutes in the second stage.

All values should be recorded.

Similar guidance is also contained within the WHO Safe Motherhood Guide and in
NICE guidelines Care of Women and their Babies during labour.

We find that the registrant has failed adequately to monitor the foetal well being of
Patient A. Her labour record notes, Exhibit 2, shows that she has not documented
regular auscultation as per the guidelines contained within the WHO and NICE
documents. She has also stated in her evidence that she did not follow the guidance
of recording the auscultation of every 15 to 30 minutes during the first stage of
labour.

Therefore the panel finds the facts in Charge 1(a) proved.

Charge 1(b)

The WHO document states that a vaginal examination is one of the essential
diagnostic actions in the assessment of the start and the progress of labour.
The registrant has explained that she wanted Patient A to go through the process of
child birth with minimum intervention from herself. However the registrant did not
conduct a vaginal examination until 4 hours and 25 minutes after her arrival. In her
labour notes the registrant has recorded that Patient A had vomited on a number of
occasions. In her evidence she has stated that vomiting could be an indication that
the baby could be born very soon. She has also stated that Patient A was not in
established labour. Had the registrant conducted a vaginal examination on arrival or
shortly afterwards at Patient A’s home then this would have provided her with an
accurate clinical picture of what stage of the labour Patient A was in. Therefore the
panel is satisfied that the registrant failed adequately to safeguard the foetal well
being of Patient A. We therefore find the facts in charge 1(b) proved.

Charge 2(a)

The NICE guidelines, Care of Women and their Babies during labour states:-

Your midwife will check you and your baby’s progress by monitoring your blood
pressure, temperature and pulse and checking when you have emptied your bladder,
how often you are having contractions and how far your labour has progressed.

The registrant has recorded in Patient A’s notes an initial set of observations which
were taken not long after her arrival. However the labour notes do not record any
subsequent observations. Had the registrant conducted regular observations then
she would have been in a better position to assess adequately the condition of
Patient A and therefore we find the facts in Charge 2(a) proved.

Charge 2(b)

The registrant did not conduct a VE of Patient A until 4 hours and 25 minutes after
her arrival. A VE is the prime method of measuring the dilation of the cervix and of
the patients’ progress in labour. We find that her failure to conduct a VE at an earlier
stage constitutes a failure to assess the progress of Patient A’s labour. Deviations
from an arbitrarily defined normal rate of dilation should be an indication for a review
of the labour management plan. Therefore we find the facts proved in Charge 2(b)
proved.

Charge 3.

The panel has taken into account that Patient A was not communicative, she also
stated that she did provide updates to the patient. Therefore the facts are not proved.

Charge 4.

In order for us to find any of the charges in charge 4 proved the panel has to be sure
that Patient A’s labour fell “Outside normal parameters”.

Appendix D, of the Safe Motherhood document which is produced by the World

Health Organisation provides guidance on definitions of establishing what the base
line should be for Foetal Heart monitoring. It states that a normal base line should be
110 to 160 beats per minute.

The NICE document, Electronic Foetal Monitoring, provides a table categorisng

Foetal heart rate features. It states that a baseline of 110 bpm to 160 bpm is
considered to be reassuring. A reading of 100bpm to 109bpm and 161bpm to
180bpm is non reassuring. Additionally it states that a reading below 100bpm and
above 180 bpm is abnormal. It also states that a reading falling outside the
reassuring category is considered to be suspicious.

The registrant in her evidence stated that she followed the guidance contained within
in the WHO Safe Motherhood document and the RCM Good Practise Points. She
also stated that she was aware of the NICE guidance document and found it useful.

Patient A’s labour notes have recorded that between 0200 hours and 0600 hours that
there wrere 5 readings in excess of 160 bpm therefore the panel finds that Patient
A’s labour falls outside normal parameters.

Charge 4(a).

There are several possible causes of foetal tachycardia one of which is a breech
presentation. The registrant has stated in her evidence that she did not consider a
breech presentation to be one of the causes of foetal tachycardia. However she did
admit in response to her own counsel that it did not appear to her that the baby may
have been in a breech position although she knew that it could be an indication of an
increased foetal heart rate. The panel finds that it was inappropriate not to consider
all the possible causes of foetal tachycardia. Therefore the facts in charge 4(a) are
proved.

Charge 4(b).

The registrant has recorded in the patient notes that she went for a walk with the
secondary independent midwife Mrs Findlay at 0430 hours. She also stated in her
evidence that she went for a short break. However she also stated that she did not
leave Patient A unattended as she was with her husband. The panel does not
condone that both midwives went for a walk at the same time. The panel finds the
facts in relation to the registrant going for a walk but we have heard evidence that
Patient A’s husband may have been with her during this period. Therefore the panel
does not find this allegation proved.

Charge 4(c).

The WHO document says “Vaginal Examination is one of the essential diagnostic
actions in the assessment of the start and progress of labour”. The NICE guidelines
also state, “Your midwife will need to examine your cervix to know how far your
cervix has dilated so your progress in labour can be monitored”. The registrant
arrived at Patient A’s home at 0132 hours and established that Patient A was in
labour but no attempt was made to carry out a vaginal examination until 0530 hours.
During that period there were at least 4 foetal heart readings over 160 bpm. In light
of this information and the clinical picture at the time the panel is satisfied that the
registrant delayed attempting to conduct a vaginal examination until 0530 hours and
that such a delay was inappropriate. Therefore the facts have been proved.

Charge 4(d)

The facts under (d) have been admitted by the registrant.

The panel finds that it was improper for the registrant to allow the patient to get into
the pool because of the pattern of FH readings over a period of over four hours. Six
readings have been recorded as being in excess of160 bpm.

The registrant has recorded at 0605 hours that Patient A wanted to get into the pool,
meconium passed. At 0615 hours more meconium, in pool. The registrant has stated
in her own evidence that the meconium confirmed that this was a breech position.
The panel finds that it was inappropriate for the registrant to allow the patient to get
into the pool. Therefore we find the charge proved.

Charge 4(e)

The facts under (e) have been admitted by the registrant.

In exhibit 2 the registrant has recorded that meconium was passed at 0605 hours.
However it was not until 0623 hours that the 999 call was made for an ambulance.
The 999 call should have been made as soon as the meconium was identified. We
are satisfied that the registrant’s actions were inappropriate Therefore we find the
charge proved.

Charge 5.

This charge has been admitted and is found proved.

Reason for the finding of impairment

The panel has heard submissions from the Case Presenter, Mr Millard and from the
registrant’s legal representative Ms Lewis. We have received and followed the advice
of the legal assessor.

Charge 1(a) and 1(b) relate to the failure to adequately monitor and safeguard the
foetal well being of Patient A. The NMC Code of professional conduct: standards for
conduct, performance and ethics, paragraph 1.4 states:

You have a duty of care to your patients and clients, who are entitled to receive safe
and competent care. The panel is satisfied that the actions of the registrant
breached this code. The registrant has recorded several FHR which fell outside the
normal range however despite these readings the Registrant has failed to take
appropriate action.

In relation to charges 2(a) and 2(b) there was a failure to assess the condition of
Patient A and the progress of her labour. This again is a clear breach of the NMC’s
Code of Professional Conduct, paragraph 1.4. Where the registrant failed to
adequately assess and record basic observations to provide an accurate clinical
picture.

Charge 4, (a), (c), (d), (e), relates to the registrant’s failure to take appropriate action
when Patient A’s labour fell outside normal parameters. Paragraph 8 of the NMC’s
Code of Professional Conduct states that as a registered nurse, midwife or specialist
community public health nurse, you must act to identify and minimise the risk to
patients and clients. Paragraph 8.5 also states that in an emergency, in or outside
the work setting, you have a professional duty to provide care. The care provided
would be judged against what could reasonably be expected from someone with your
knowledge, skills and abilities when placed in those particular circumstances.

Charge 5 relates to the registrant failure to maintain an adequate record of the care
delivered to Patient A. Paragraph 4.4 Health care records are a tool of
communication within the team. You must ensure that the health care record for the
patient or client is an accurate account of treatment, care planning and delivery. It
should be consecutive, written with the involvement of the patient or client wherever
practicable and completed as soon as possible after an event has occurred. It
should provide clear evidence of the care planned, the decisions made, the care
delivered and the information shared. The registrant has admitted that her labour
record notes for Patient A were not up to her usual standard.
The panel has considered in turn all of the facts which have been found proved and
have decided that they constitute misconduct.

The panel has paid regard to Ms Lewis’s submission that the sequence of events
which have given rise to our findings of misconduct occurred in July 2005 and there
has been no evidence to indicate that there has been any repetition.

We heard evidence from Christine Voce Head of Midwifery at Dorset County Hospital
and from Carol Hedley, the registrant’s current Midwifery Supervisor.

Their evidence related almost exclusively to the registrant’s performance as a bank

midwife within a NHS hospital setting. Christine Voce stated that she had received
verbal recognition of the registrant’s clinical performance from hospital based
midwives.

The panel has been provided with very little evidence in relation to the registrant’s
performance as an independent midwife. We note with concern that Ms Hedley has
recorded in her annual review record dated 20 October 2008 that the registrant
works approximately 50% more in the independent sector than in the NHS. The
panel has not been persuaded that the registrant has taken appropriate steps to
remedy her failures in relation to her independent practise and that there is no risk of
repetition.

We therefore find that the registrant’s Fitness to Practise is currently impaired.

Reason for the sanctions

The panel has considered your case very carefully and has decided to make a
striking off order. Your record in the NMC register will show that your name has been
removed.

Our reasons for this decision are that the panel considered the sanctions in
ascending order. The panel considered taking no action but the facts found were too
serious for this sanction.

The panel next considered a caution order. The level of clinical care provided by the
registrant could have caused direct or indirect patient harm. As to admission of facts
we take into account the registrants early specific admission related to Charge 5.
(Record keeping) For although she admitted the facts in sub charges (d) and (e) she
did not in any case admit that she had failed to take appropriate action. The
registrant had some insight into her failings but this related to her documentation of
the events. The panel accepts that this was an isolated incident but one which lasted
from when the registrant first arrived at Patient A’s home to her arrival at the hospital
at 07:10 hours.

The panel accepts the registrant’s regret in relation to her standard of record
keeping. The panel has not heard any evidence of other failings and that there has
been no repetition of her behaviour since the incident.

The registrant has been working as a bank midwife in the Dorchester Hospital within
a NHS clinical environment but the panel has not been provided with evidence of any
rehabilitative steps related to her independent midwifery practise. We were provided
with a number of references and testimonials however only one makes mention of
the charges we have found proved. The panel is concerned that the testimonial
provided by another independent midwife suggests that the registrant should have
been less cautious and proceeded with the breech birth at home.
The panel next considered a conditions of practise order but the panel was satisfied
that there was no practical method of implementing this sanction.

The panel then considered a suspension order but felt that the misconduct was so
serious that it was not appropriate or in the public interest to do so.

Therefore the panel has decided to implement a striking off order. The charges relate
to an incident which occurred over a period of several hours whilst the registrant was
undertaking a home birth as an independent midwife. The facts which we have found
show a failure by the registrant in three different areas of clinical care.

1. Failure to carry out proper foetal heart rate auscultation

2. Failed to conduct an early vaginal examination
3. Allowing Patient A to get into the birthing pool after there had been several
readings of the foetal heart rate outside normal parameters

The registrant failed to listen to the FHR at regular intervals. She failed to listen to the
FHR for the appropriate time and she failed to take appropriate action when the
readings went outside normal parameters. All of these failures constitute a serious
departure from the relevant standards and in doing so there is a continuing risk to
patients and clients.

The registrant failed to carry out a vaginal examination until four and half hours after
her arrival at Patient A’s home. A vaginal examination is one of the essential
diagnostic actions in the assessment of labour. Had she not delayed conducting a
vaginal examination she would have been able to formulate a clinical picture of
Patient A’s condition at a much earlier stage.

The registrant allowed Patient A to get into the birthing pool. This was inappropriate
in light of several FH readings outside normal parameters. This exposed Patient A to
additional risk.

In addition to the serious clinical errors there is the unexplained and unacceptable
delay in making the 999 call. The registrant’s labour records for Patient A have
recorded that meconium was first identified at 0605 hours. The record also shows
that at 0615 hours there was a foetal heart rate of 80 bpm and more meconium in the
pool. In her evidence the second independent midwife Mrs Findlay stated that this
was fresh meconium. However it was not until 0623 hours that the 999 call was
made, a delay of 18 minutes after the meconium was first identified. The panel is
very concerned that despite the indication of a breech presentation and a second
independent midwife in attendance the registrant delayed contacting the emergency
services.

In light of the fresh meconium evidence and the low foetal heart rate we would have
expected a trained and experienced midwife to have made a 999 call immediately.
We take an extremely serious view of this failure as this delay may have put Patient
A’s baby at unnecessary risk. The panel has not heard any evidence explaining the
rationale behind her decision to delay contacting the emergency services.

The panel concludes that these failures constitute a serious departure from the
relevant standards and that there is a continuing risk to the public. We have
considered the public interest and we believe that confidence in the council and the
profession would be undermined if the registrant was not removed from the register.
Mrs Purdue may not apply for restoration until five years after the date that this
decision takes effect.
Reasons for Interim Order
The panel has considered this case very carefully. It has decided that it is necessary
to make an interim suspension order.

The period of this order is 18 months but if, at the end of the appeal period of 28
days, Mrs. Purdue has not lodged an appeal, the interim order will lapse and be
replaced by the final order. On the other hand, if Mrs. Purdue does lodge an appeal,
the interim order will continue to run.

The reasons for this decision are: We have considered the seriousness of the
charges which relate to serious departures of the code. We have already concluded
that there is possible risk of repetition and that serious harm that might occur if these
failings were repeated. The panel is not satisfied that steps could be taken to guard
against further harm. In reaching our decision that an Interim Suspension Order is
necessary we have given all appropriate weight to the Registrants previous character
and employment history.

Mrs. Purdue’s record in the NMC register will show that she is the subject of an
interim suspension order and anyone who enquires about her registration will be told
about the order.