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Care home nurse suspended over response to fall


A nurse who left an elderly lady with a gaping head wound for more than seven hours before calling an ambulance has been suspended for 12 months.

The 89-year-old dementia sufferer fell down a flight of stairs during the night at the Crown Nursing Home in Harwell, near Didcot, and died five days later.

Nurse Nonhlanhla Kubheka, 62, had contacted the care home manager at 4am but left her with the impression that the woman’s injuries were ‘not sufficiently serious’.

It was not until 10.30am, when a colleague discovered that the pensioner was bleeding profusely from her wound, that an ambulance was finally called, the Nursing and Midwifery Council heard this week.

Kubheka, who was salso dismissed by the care home, was found guilty of failing to make an assessment of the woman’s injuries before moving her, of not keeping proper records and of failing to call an ambulance after the fall in January 2006.

NMC panel chairman Judy Carr said the South African nurse, who is now living in Croydon, should have acted sooner to care for the pensioner, who was not named in the proceedings, being referred to only as Resident A.

“She was the nurse in charge of the shift and was therefore responsible for her care,” she said. “She plainly was under a duty to call the emergency services and she failed to do so.

“She did not adequately assess whether Resident A had suffered an internal head injury before she was moved from the site of the accident.

“As the last nurse in charge she should’ve carried out regular neurological observations to assess whether she had an internal head injury.

“There is no evidence that she did so.”

Salim Hefejee, for the NMC, added that the conduct “fell below the standard of a nurse.”

“It is very clear that these failures were very basic failures in nursing care,” he said.

“Clearly, there was a duty to protect and support the welfare of those in her care. And there’s a duty to ensure records are adequate.

“We have no evidence to suggest that she understands what she did was wrong and that this won't happen again.”

Deciding to suspend Kubheka, who did not attend the hearing, Ms Carr said her failures had been ‘serious’ but that it would be excessively harsh to ban her from the profession.

“She has not provided us with any information on mitigation, and has not engaged with the process at all,” she added. “But she has had a long career in nursing and this appears to be an isolated incident.”

Spokesman for the care home Jamie Reece said: “A staff member from the home was immediately dismissed and referred to the Nursing and Midwifery Council.

“A safeguarding investigation was carried out at the time of the incident and improvements to the home were made as a result. The health and wellbeing of residents is always our number one priority.”

In March 2009, the care home was cleared of any blame after eight residents died of pneumonia shortly after its heating broke down.

Oxfordshire County Council said there was no direct link between the breakdown and the deaths of the pensioners.

Comments(8)

mandate says...
6:49pm Sun 25 Jul 10

It is not at all an easy call to make when care workers/nurses are in a position whereby they have to make on the spot assessments of the severity of head injuries.
It is easy for critics to say that she should have called an ambulance to be on the safe side.
Unfortunately the nurse did'nt know whether or not this was a neccessary action to take. This resulted in a delay which may have worsened the old lady's chances of surviving (it is'nt certain that it would have saved her life, even if an ambulance had been called earlier).

This particular nurse made an error in her judgement of the seriousness of the elderly lady's injuries. She intended no malice against this woman. I personally think it was a bit harsh to ban her from nursing for 12 months because of this tragic error.
How many times have we read in the media about doctors making sometimes fatal mistakes, and never being held accountable for their actions.

beth01 says...
9:30pm Sun 25 Jul 10

Families put trust in nurses to take care of their relatives- mistakes or 'tragic errors' are not easily forgivable.

gel says...
10:57am Mon 26 Jul 10

Another case of a foreign medical worker screwing up. Surely common sense should have dictated she called for help for this poor pensioner. The fact that she didn't turn up for the discipliniary hearing shows what contempt she holds the authorities in, as she does for the patients in her so called care.
There is no excuse for such behaviour. If she's here on a work permit it should be rescinded; she may then understand the seriousness of the situation.

Berty says...
12:15pm Mon 26 Jul 10

I'm afraid I can't agree with you mandate. Something which the nursing profession does so much better than the medical profession is to stop bad nurses from endangering other people. I am curious why it took so long to ban her for 12 months and whether she was working in the time between the incident and the N&MC decision. The fact that she seemed not to realise her error is extremely worrying, as is the fact that no one noticed until 10:30 am! Who was caring for her in the morning shift? Why was that nurse not disciplined, as it shows she also made a serious error in care?

Nursing care is not about making "judgement calls" where life-threatening injuries are concerned; it is about making clinical decisions based on medical evidence. This case only serves to highlight the poor care those with dementia sometimes receive and the fact that dementia care should be treated as a specialism in the same way as paediatrics is. Sadly I think this is unlikely to happen.

vjp says...
1:06pm Mon 26 Jul 10

gel, Oxon/Berks border syas that another case involving a foreigner workin gin UK. Have you ever given a thought why foreigners are employed? Look around and see the dismal state of affairs in UK-- how many children finish secondary school? how many end up on benefits? In a first world country like UK education is not seen as a way out of poverty -- somewhere this flawed thinking has crept in -- we need to address this issue before starting to berate foreign workers.

Captain Birdseye says...
7:07pm Mon 26 Jul 10

vjp wrote:
gel, Oxon/Berks border syas that another case involving a foreigner workin gin UK. Have you ever given a thought why foreigners are employed? Look around and see the dismal state of affairs in UK-- how many children finish secondary school? how many end up on benefits? In a first world country like UK education is not seen as a way out of poverty -- somewhere this flawed thinking has crept in -- we need to address this issue before starting to berate foreign workers.
No vjp. It is because foreingers will work for next to nothing, not complain and expect no rights, because it is better than being back home. British workers expect to be able to have a life outside of work. That is why we don't take these "slave labour " jobs.

Berty says...
2:15am Tue 27 Jul 10

Registered General Nurses are paid the same, whatever their nationality, and in fact get a pretty decent hourly rate for nights. It's wrong to assume all foreign workers go for low-paid jobs.

vjp says...
8:27pm Wed 28 Jul 10

then should we feel very proud of the fact that our youth are doing nothing? who is going to pay any wages to uneducated and unskilled people? Not everyone does slave labour. There is a dearth of nursing staff in UK--this is a well known fact.


The Crown Nursing Home in Harwell The Crown Nursing Home in Harwell

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