nurse who failed at-risk patient who hanged himself is struck off
By Greg Mills
PSYCHIATRIC nurse who failed to regularly check an at-risk patient
who later hanged himself has been struck off the nursing register.
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.
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.
nurses had almost 60 years of experience between them. Both had
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
complained of hearing voices to police officers and was returned
to the hospital.
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
on patients were haphazardly carried out throughout the night and
Turver did not ensure the 3am observation
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.
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
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
"This was a very serious departure from proper nursing standards
and a serious failure in personal performance on the shift in question.”
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
"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
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
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."
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
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.
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."
can make people worse
Louise Pembroke, service user, London
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.
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.
people can kill themselves on 15 min observation. I lost a friend
by hanging - she was on 15 min observation.
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
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!
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
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