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- Loney v Nursing and Midwifery Board of Australia[2020] QCAT 486
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Loney v Nursing and Midwifery Board of Australia[2020] QCAT 486
Loney v Nursing and Midwifery Board of Australia[2020] QCAT 486
QUEENSLAND CIVIL AND ADMINISTRATIVE TRIBUNAL
CITATION: | Loney v Nursing and Midwifery Board of Australia [2020] QCAT 486 |
PARTIES: | LYNETTE LONEY (applicant) v NURSING AND MIDWIFERY BOARD OF AUSTRALIA (respondent) |
APPLICATION NO/S: | OCR328-20 |
MATTER TYPE: | Occupational regulation matters |
DELIVERED ON: | 10 December 2020 (ex tempore) |
HEARING DATE: | 10 December 2020 |
HEARD AT: | Brisbane |
DECISION OF: | Judge Allen QC, Deputy President Assisted by: Ms April Blair Mr Stephen Lewis Dr Kim Forrester |
ORDERS: | The decision of the respondent of 24 September 2020 is set aside. |
CATCHWORDS: | PROFESSIONS AND TRADES – HEALTH CARE PROFESSIONALS – NURSES – LICENCES AND REGISTRATION – where the applicant is a registered nurse and endorsed enrolled nurse – where the respondent took immediate registration action pursuant to s 156 of the Health Practitioner Regulation National Law (Queensland) and suspended the applicant’s registration – whether the tribunal reasonably believes that, because of the applicant’s conduct, performance or health, the applicant poses a serious risk to persons – whether the tribunal reasonably believes that that immediate registration action is otherwise in the public interest Health Practitioner Regulation National Law (Queensland), s 3A, s 156, s 199 Queensland Civil and Administrative Tribunal Act 2009 (Qld), s 19, s 20 LCK v Health Ombudsman [2020] QCAT 316 Oglesby v Nursing & Midwifery Board of Australia [2014] QCAT 701 Zaphir v Health Ombudsman [2017] QCAT 193 |
APPEARANCES & REPRESENTATION: | |
Applicant: | E Bassingthwaighte of Hall Payne Lawyers |
Respondent: | M J Lucey of Clayton Utz |
REASONS FOR DECISION
- [1]Ms Lynette Loney (the applicant) has applied, pursuant to s 199 of the Health Practitioner Regulation National Law (Queensland) (National Law), to review the decision of the Nursing and Midwifery Board of Australia (the Board), on 24 September 2020, to take immediate action in relation to her registration as an endorsed enrolled nurse and registered nurse by suspension of such registration pursuant to s 156 of the National Law.
- [2]Section 20 of the Queensland Civil and Administrative Tribunal Act 2009 (Qld) (QCAT Act) provides that the Tribunal must hear and decide the review by way of a fresh hearing on the merits with the purpose of the review being to produce the correct and preferable decision. Pursuant to s 19 of the QCAT Act, the Tribunal must decide the review in accordance with the enabling Act under which the reviewable decision being reviewed was made, in this case, as already stated, the National Law.
- [3]Section 156(1) of the National Law relevantly provides as follows:
156 Power to take immediate action
- (1)A National Board may take immediate action in relation to a registered health practitioner...registered in a health profession for which the Board is established if —
- the National Board reasonably believes that —
- because of the registered health practitioner’s conduct, performance or health, the practitioner poses a serious risk to persons; and
- it is necessary to take immediate action to protect public health or safety; or
...
- (e)The National Board reasonably believes the action is otherwise in the public interest.
- [4]The Board acted pursuant to s 156(1)(a) of the National Law in making its decision. In this proceeding the Board has sought to defend its decision both on the basis of s 156(1)(a) and the additional basis provided for immediate action in s 156(1)(e).
- [5]The approach of the Tribunal to such proceedings is not controversial. The Tribunal approaches the matter on the basis that an immediate action order does not entail a detailed enquiry by the Board or by this Tribunal. It requires action on an urgent basis because of the need to protect the public.[1] That does not mean that the material available to the decision-maker should not be carefully scrutinised in order to determine the weight to be attached to it.[2]
- [6]The criteria provided in s 156(1)(a) of the National Law are that of a reasonable belief as to a serious risk.
- [7]A belief is the inclination of the mind toward assenting to rather than rejecting a proposition. In Oglesby v Nursing & Midwifery Board of Australia,[3] the then Deputy President Horneman-Wren SC DCJ stated:
I am not of the view that it is necessary to be satisfied that certain conduct will be engaged in by a registered health practitioner before the reasonable belief can be held that the practitioner poses a risk to persons. In my view, it is not even necessary to be satisfied that it is more probable than not that the practitioner will engage in some conduct in the future.
In my view, a reasonable belief may be held that a practitioner poses a serious risk to persons if, based upon evidence of past conduct, there is a real possibility that the practitioner will engage in conduct which could be harmful to persons. If the possibility of engaging in the conduct was so remote as to be fanciful, or the possible harm trivial, then I would not think that a belief could reasonably be held that the practitioner posed a serious risk to persons.
- [8]In LCK v Health Ombudsman,[4] Judicial Member McGill SC respectfully agreed with such comments except insofar as the last sentence suggested a view that there is a serious risk to persons whenever the risk is not so remote as to be fanciful and harm if the risk materialises is more than trivial. Judicial Member McGill SC did not agree with that comment. I respectfully agree with the comments of Judicial Member McGill SC.
- [9]As to the term, “serious risk”, the term is not defined in the legislation and takes its ordinary meaning in its statutory context. The word “serious” is defined in the Macquarie Dictionary as:
Of grave aspect; weighty or important; giving cause for apprehension; critical; to be considered as an extreme example of its kind.
- [10]In assessing whether a person poses a serious risk to persons it is helpful to consider the nature of the risk, the likelihood of its eventuating and the seriousness of the consequences if the risk does eventuate. That is the approach that has been adopted by this Tribunal in decisions concerning s 113 of the Health Ombudsman Act 2013 (Qld) and in my view is equally apt to the terms of s 156(1)(a) of the National Law.
- [11]As regards s 156(1)(e) of the National Law, the concept of the “public interest” has no fixed technical meaning and takes its content from the statutory context in which it is used. Given the paramount guiding principle of the National Law that the health and safety of the public are paramount,[5] it will largely be focused on the effect on the health and safety of the public, but it is wider than that. The example provided in the legislation shows that immediate action can be required in the public interest in order to maintain public confidence in the provision of health services.[6]
- [12]I agree with the comments of Judicial Member McGill SC in LCK v Health Ombudsman[7] that public confidence is not to be assessed by way of a shallow and superficial view of the public as to the relevant facts. It should be assessed by way of a rational analysis and understanding of all the circumstances of the situation being considered. Public confidence in the nursing profession is not to be assessed on the basis of the lowest common denominator but should be assessed by reference to a thoughtful and balanced approach to the circumstances. The public interest is not only confined to a consideration of public confidence in the health profession:
Other relevant matters are the maintenance of a regulatory system which responds in a fair and proportionate way to situations, the effect on the individual practitioner, and the desirability of the training and expertise of the health practitioner, developed at some cost over some time, not being wasted. There is also the consideration that immediate action should be no wider than is necessary in the circumstances.[8]
- [13]Immediate action was taken because of events which occurred during a nursing shift of the applicant in the orthopaedic ward of a south-east Queensland public hospital on 8 June 2020.
- [14]The applicant has given an account of those events in an affidavit sworn on 10 December 2020. It is in terms consistent with an account given by the applicant to management at the hospital as early as 13 June 2020 and with subsequent submissions made on behalf of the applicant to the Board prior to the Board taking immediate action. The Board has not required the applicant for cross-examination in these proceedings and the contents of the applicant’s affidavit remain unchallenged. It is therefore helpful to recount the applicant’s version of events given the lack of any suggestion that it should not be relied upon by this Tribunal as an accurate account.
- [15]The applicant deposed to the events which led to the Board taking immediate action in the following terms:
The Incident
- On 8 June 2020 I was involved in an incident with a patient that has resulted in my registration being suspended (the Incident). My recollection of the incident is as follows.
Background
...
- I arrived at the Hospital at about 1.30pm, and participated in a handover. I recall the patient the subject of the Incident being mentioned during the handover as we were told that we would need to insert a catheter for this patient, after the emergency department had, contrary to the proper procedure, not inserted the patient’s catheter and had not provided the patient with a nerve block.
- The handover noted that the patient was violent and that he had an AIN assigned to watch him and in order to ensure that he did not harm himself as a result of his dementia or his surgery, or a combination of the two. The handover also identified that he responded better to females treating him, so we should avoid having male staff members in the room or providing treatment.
- As I was the most senior and experienced of the nursing staff in my POD, I was instructed by the medical officer to insert a catheter for the patient.
First Attempt
- At about 2.00pm I attempted to insert the patient’s catheter. I was with the student nurse who had been assigned to me for the duration of my shift and a graduate RN, who was also working alongside me.
- I approached the patient and explained the procedure to him. The patient grunted at me and I understood this to mean that he was acknowledging what I had said and consenting to the procedure.
- I then pulled back the sheet and attempted to clean the area.
- The patient began to kick out violently with his legs. As he was lashing out at the nursing staff, he was screaming at us in English and in his native German.
- I was concerned for my safety and the safety of her (sic) colleagues so I called of (sic) the procedure and we left the room. I then contacted the patient’s treating doctor and advised the doctor that we had been unable to perform the procedure on the patient, due to his reaction.
- The doctor said to me, words to the effect of:
‘Ok, but I will need you to do a bladder scan on the patient.’
Second Attempt
- At about 2.15pm, I went back into the patient’s room with the student nurse in order to attempt to perform a bladder scan. I explained to the patient what I needed to do and asked that he consent to the procedure. He grunted at me again.
- I pulled back the sheet in order to do the bladder scan, however, as soon as this occurred, the patient again began violently kicking out with his legs. The patient was yelling and screaming incoherently. The patient was speaking mostly in German, however, I was able to identify the word ‘bastards’ being used multiple times.
- I saw the student nurse come within inches of being kicked by the patient and, again, concluded that it was not possible to safely perform the procedure on the patient.
- Despite the fact that the patient was elderly and recovering from hip surgery, this did not seem to impact on the force with which he was kicking out with his legs or his range of movement.
- The student nurse and I left the room, and I called the patient’s doctor to advise that the procedure could not be performed. The doctor did not ask me to perform any further treatment on the patient and I continued to undertake other work on the ward.
Third Attempt
- At about 6.30pm, when I returned from my break, I checked on the patient and concluded that his incontinence pad needed to be changed. As this would involve the patient needing to be moved, and due to my past experience with the patient, I sought the assistances (sic) of Personal Service Assistants (PSAs) in moving the patient.
- Initially the PSAs that responded to my request for assistance were males, however, as it was recorded that the patient did not respond well to males touching him, I sent the PSAs back and requested assistance from female PSAs.
- When the female PSAs arrived the student nurse, the AIN, the PSAs and I, discussed how we would attempt to move the patient. It was agreed that I would be stationed at the patient’s head and would try to restrain his arms if they were flailing; the two PSAs would be at the patient’s waist and legs, respectively; the student nurse was stationed on the other side of the patient’s bed and the AIN was responsible for replacing the incontinence pad when the patient was rolled.
- I entered the patient’s room and explained to the patient what we were going to try to do. The patient grunted.
- As we began to try to move the patient, he again became violent and attempted to kick and hit out at us. He was yelling and screaming incoherently and, at some point, the patient was able to free his arms and hands and began to try to hit the hospital staff.
- As I was located closest to his torso, he was able to hit, pinch and grab at my arms. He landed a couple of hits on me but I did not really register the pain of these hits as I was focused on trying to resecure his arms.
- While I was trying to get his arms back under the sheet, I looked down at the patient and saw that he was biting me on the arm. Due to the chaos of the situation, I had not previously felt the bite, however, as soon as I saw his teeth digging into the skin on my arm, I began to feel the pain associated with the bite.
- In addition to the pain, I was overwhelmed with fear.
- I could see that the patient had blood in his mouth and it was not clear to me, in that moment, whether the blood that I could see was my blood or the patient’s own blood, or a combination of both.
- I was scared that he had broken the skin on my arm and I could see the saliva that was coming out of the patient’s mouth, on to my arm.
- I completely panicked in this instance. I tried to pull away from the patient and when I couldn’t I struck the patient on his shoulder. I did not strike the patient out of anger or frustration, as I would never do that to a patient – my reaction more along the lines of the way that one would react if bitten by an insect or a spider.
- My reaction was instantaneous. I did not step back, compose myself and then strike the patient. If I had been able to step back from the patient and have him release my arm, then I would never have struck him.
- I have encountered patients in the past that I would describe as difficult, violent, aggressive and/or frustrating, and I have never reacted in this manner.
- I deeply regret my reaction in this moment and that I did not recall the training that I have undertaken in respect of managing difficult patients and de-escalating situations.
- It should go without saying that, if I were ever to find myself in a similar scenario again, I would not act in this way as I accept entirely that my reaction was inappropriate and that nurses are expected to maintain control of their emotions when dealing with difficult and vulnerable patients. I would have called for assistance from my colleagues, if the patient was not releasing my arm from his bite, before again abandoning the treatment.
- Apart from the account provided above, my recollection of the incident is not entirely clear, as the incident was a blur and I was not thinking rationally. I don’t recall precisely how many times I struck the patient or the words that I used towards the patient in the immediate aftermath of the incident.
- It is likely that I struck the patient between 1 – 3 times; that I swore at the patient, including by using the word ‘fuck’; and that I spoke aggressively to him, including by saying to the patient words to the effect of ‘you do not get to do that to me!’
- Any suggestion that my conduct was the result of my frustration with the patient is not true. I understand that patients – particularly patients who suffer from Lewy Body Dementia – may not always make the best decision about their treatment, however, they are entitled to refuse treatment if they so choose. I don’t get frustrated with patients who refuse treatment because that is their right.
- I do not get frustrated or angry with patients who are aggressive towards nursing staff, because I recognise that there are often factors of which I am not aware (even in the context of whatever therapeutic relationship I have been able to build), that underpin such behaviour. Whenever I have experienced such behaviour in the past, I have always been able to remain calm and I have never once retaliated against a patient by hitting them or speaking inappropriately to them.
- [16]In her affidavit, the applicant details her personal background and employment background, including her nursing career. Prior to becoming an assistant in nursing, the applicant worked part-time at a retirement village, initially as a cleaner, then in the kitchen and afterwards as a carer. She enjoyed work as a carer and that motivated her considering a career in nursing. She completed a TAFE course to become an assistant in nursing in 2008 and soon afterwards began study to become an endorsed enrolled nurse. Whilst studying, she worked part-time at an aged care facility as an assistant in nursing.
- [17]In February 2009, just before completing her studies to become an endorsed enrolled nurse, the applicant enrolled in a Bachelor of Nursing degree. After obtaining registration as an endorsed enrolled nurse, the applicant continued to work at a number of aged care facilities, as well as undertaking hospital shifts and some shifts with Blue Care. Whilst studying her Bachelor of Nursing degree, the applicant worked as an endorsed enrolled nurse, predominantly at an aged care facility as well as undertaking shifts at a public hospital. The applicant graduated in November 2010 and obtained registration as a registered nurse soon afterwards. She subsequently undertook employment in public hospitals including primarily work in orthopaedics wards.
- [18]The applicant deposes as follows:
- During the course of my nursing career – with the exception of the incident that resulted in the suspension of my registration – I have never had any complaints about my professional performance or my interactions with patients.
- I have never had any issues where I have harmed a patient or spoken inappropriately to them.
- As I said above, I pride myself on the rapport that I am able to build with my patients as it is something that gives me both personal joy and professional satisfaction. I have not previously been the subject of any complaints to the NMBA or the OHO in respect of my conduct or performance.
- I have not previously been the subject of any disciplinary action from my employer. In fact, while I have been employed by the...Hospital and Health Service, I have received exemplary performance reviews – including, most recently, when I was assessed highly and commended for, among other things, being a ‘team player’.
- [19]The applicant also deposes that, having reflected on the events of 8 June 2020, she has pondered whether her unfortunate reaction to being bitten by the patient may have been influenced by her experience of previously being the subject of violence in her personal and working life and deposes to the circumstances of such prior experiences. That does seem to have been perhaps the motivation for the applicant to engage with psychological counselling since the incident. She was able to attend 12 sessions with a psychologist during which she has discussed and unpacked the circumstances of the incident.
- [20]As to the issue of whether the applicant presents a serious risk to persons such that her registration should be suspended, the Board has, in its submissions in these proceedings, focused upon the background history deposed to by the applicant and her own description of an imperfect recollection of the incident. The Board submits that the applicant’s description is something that could be described as the applicant having disassociated although the Board does not purport to use such term in a diagnostic sense. The Board submits, however, that it raises concerns as to the applicant having been unable to control her actions in a situation of stress, possibly influenced by those pre-existing experiences described by the applicant. The Board submits therefore that, in the absence of any independent evidence of a psychologist that the applicant has addressed such underlying issues, there is a risk of her similarly “disassociating” if confronted by foreseeable challenging behaviours by a patient and again responding with physical and verbal abuse. In those circumstances, it is submitted, the Tribunal would have a reasonable belief that the applicant, because of her conduct, performance or health, poses a serious risk to persons within the terms of s 156(1)(a)(i) of the National Law and that it is necessary to take immediate action to protect public health or safety. The Board does not submit that the applicant acted in a premeditated or intentional or deliberate manner in assaulting the patient. It is the lack of control exhibited by the applicant that is said to base the reasonable belief of a serious risk.
- [21]I do not accept the submission of the Board that the applicant should be regarded as having disassociated because of her incomplete recollection of the events. Given the traumatic circumstances of having been bitten by the patient and, one might expect, the trauma to the applicant of her own actions in uncharacteristically hitting a patient, it is not surprising that she might have a less than perfect recollection of every second of that encounter. I do not regard the applicant as having lost control, at least not to any greater extent than one might reasonably expect any person to have had a temporary loss of control in such circumstances.
- [22]I accept what is the unchallenged evidence of the applicant, that she acted instinctively as a consequence of her experiencing pain and fear, in a panic and defensively. A person defending themselves in those circumstances cannot be expected to weigh precisely the amount of defensive action which might be necessary. Intuitive reaction and instantaneous response is to be expected. This Tribunal should not judge the actions of the applicant as if she had the benefit of safety and leisurely consideration as to how she should respond.
- [23]Furthermore, I do not accept the submission made by the Board that the applicant acted in a way demonstrating a diminished capacity to control her actions in the face of challenging behaviour. The unchallenged evidence of the applicant is that she has dealt in the past with challenging patients in a way which has never attracted any criticism, let alone complaint. The circumstances of the prior workplace incident referred to in the material, including the applicant’s affidavit, demonstrated the applicant, faced with the considerable threat of physical and verbal abuse from a patient, acted in a calm, considered way to de-escalate the situation and remove herself from harm. The caring nature of the applicant and her ability to carefully consider patient care, and take appropriate steps towards patient care, even when dealing with challenging patients, is amply demonstrated by the earlier steps she had taken towards the care of this particular patient prior to the incident in question. I consider that this particular incident should be viewed as an aberration which occurred only because of the particular traumatic event of the applicant being bitten by the patient and seeing blood in the patient’s mouth whilst that occurred.
- [24]When considering whether or not the applicant presents a “serious risk”, I do not consider it likely that the applicant will in the future use inappropriate force or physically or verbally abuse a patient. Insofar as the Tribunal should consider the seriousness of the consequences of such a risk if it did eventuate, I merely note that there appears to have been no injury caused to this patient which, given his frailty, perhaps gives some indication as to the degree of force that was in fact used by the applicant.
- [25]The Tribunal does not confirm the decision made by the Board on the basis of s 156(1)(a) of the National Law.
- [26]Moving to the criteria provided in s 156(1)(e) of the National Law, on the basis of the findings of the Tribunal as to the applicant not presenting a serious risk to patients if she is allowed to practise, it is difficult to see how it could otherwise be in the public interest to take immediate action to suspend or otherwise restrict the applicant’s registration. It does not appear to me that such action would be required so as to maintain public confidence in the nursing profession. It seems to me that it would be quite contrary to the public interest for the profession and the community to be denied the services of a well-qualified and experienced nurse. I do not reasonably believe that action is required in the public interest.
- [27]I conclude that there is no basis for taking immediate action pursuant to s 156 of the National Law and the decision of the Board is set aside.
- [28]I acknowledge that such decision is not the subject of this review and I have heard no submissions regarding it by the decision-maker, but I do think it is appropriate to express my concerns as to how the applicant’s employer acted in suspending her employment from 13 June 2020.
- [29]It seems that that decision was made no later than 12 June 2020, given that that is the date of a letter from the chief operating officer of the Hospital and Health Service to the applicant advising her of her suspension of duty. It is somewhat concerning that, on the material that has been placed before the Tribunal on this review, the only accounts that had been recorded from witnesses to the incident, prior to that time, provided no evidence of the applicant acting inappropriately towards the patient. It would seem the only evidence adverse to the applicant available to her employer at the time of the suspension was an email from another registered nurse to his nurse unit manager providing a hearsay account from a wardsperson in what, in hindsight, is clearly terms which greatly exaggerate any aggression that was demonstrated by the applicant towards the patient. If that be the only evidential basis upon which the applicant’s employer chose to suspend her employment, it would be a highly dubious one.
- [30]It is also of particular concern that a memorandum of a clinical coach, dated 13 June 2020, recording a meeting between the applicant and other staff in which she was advised of her suspension on 13 June 2020 suggests that it was only at that time that the applicant had the opportunity to provide her account as to what occurred. The memo records, as noted earlier in these reasons, consistently with the applicant’s evidence before this Tribunal, that the applicant explained that the patient had hit her and had bitten her and there was blood in his mouth, and that she had responded by lashing out and striking the patient, “Yes, I had hit him, I was scared and it was instinctive”. If it indeed be the case that the first time that the applicant was invited to give her account of events was after a decision had been made to suspend her from employment, that would be an extraordinary denial of procedural fairness.
- [31]As I say, the decision-maker is not here to respond to such matters and I can only draw such inferences as are available from the material that has been placed before the Tribunal in these proceedings.
Footnotes
[1] Zaphir v Health Ombudsman [2017] QCAT 193 at [14].
[2] Zaphir v Health Ombudsman [2017] QCAT 193 at [15].
[3] [2014] QCAT 701 at [20].
[4] [2020] QCAT 316 at [31].
[5] National Law, s 3A.
[6] LCK v Health Ombudsman [2020] QCAT 316 at [34].
[7] Ibid at [35] and [42].
[8] Ibid at [43], footnotes omitted.