Bungling NHS Direct call handler whose bad advice helped cause death of boy, 3, avoids being struck off
Sam Morrish died from severe sepsis during a flu epidemic in December 2010 following a catalogue of blunders
A INCOMPETENT NHS Direct call handler who contributed to the death of a three-year-old boy with the wrong advice avoids being struck off.
Nurse adviser Daisy Chipunza admitted contributing to Sam Morrish's death after she did not recognise the seriousness of his illness.
She had been found to previously fail to respond with the right advise and action when working for the NHS and also for the South East Coast Ambulance Service between October 2010 and March 2014.
In one case she failed to discuss sending an ambulance after one caller told her their partner had taken 30 paracetamol.
Today she was suspended from practice for nine months.
When Sam's mother called for help in December 2010 on her son's condition, Chipunza gave her the wrong advice over the phone.
At the start of the phonecall between Chipunza and Sam's mother, Susannah, she tells Chipunza there are "blobs" in her son's vomit, described as "a very dark brown colour which you could describe as coffee colour".
She is advised to take her young son to an out-of-hours GP service and to phone NHS Direct again if his symptoms worsened.
Chipunza recorded the call outcome for Sam's parents to speak to a GP within six hours.
Sam had been treated by two GPs at The Cricketfield Surgery, Newton Abbot, Devon and his parents had also sought advice from NHS Direct and Devon Doctors Ltd, a local out-of-hours GP service, before he was finally taken to Torbay Hospital at 10:30pm on 22 December, 2010.
He died on the morning of 23 December 2010 as a result of group A streptococcal septicaemia.
After his death a report published in June 2014 by Health Service Ombnudsman, titled 'An avoidable death of a three-year-old child from sepsis' found that "every organisation that provided care to Sam failed in some way".
It concluded: "Had Sam received appropriate care and treatment, he would have survived."
After finding her fitness to practice was impaired by reason of misconduct panel chair May Thomas told Chipunza: "In our judgement, your failings demonstrated serious deficits in clinical assessment skills, clinical judgement and risk assessment which are vital ingredients in the competencies expected of a registered nurse undertaking the role that you were fulfilling.
"Further, we cannot ignore the fact that these failures made some contribution to the tragic consequences which followed.
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"We have taken into account your previous good history and the adverse effects that the events surrounding charges 1 and 2 may have had on you.
"We have also taken into account the fact that making risk assessments and clinical evaluations when not meeting a patient face to face is a more difficult task.
";Nevertheless, a nurse is responsible for his or her own practice and although some of these elements may amount to mitigation, this cannot detract from the need to maintain the basic standards expected of registered nurse.
"In all the circumstances, we found that serious misconduct has been established.
"On the issue of insight, we have taken full account of all the evidence, including your reflective pieces.
"However, when you gave evidence we noted a reluctance in some instances by you to fully accept when you were at fault.
"We have concluded that, whilst you do have a degree of insight, you have failed to demonstrate that this insight has been successfully translated into your clinical practice."
Earlier Gareth Thomas, for the NMC, said: "The allegations are, in all cases, similar in the sense that there is alleged a failure to handle those calls appropriately and in many cases giving the wrong advice that has the effect of putting patients at risk of harm.
"In one case, that risk materialised in the sense the allegation is that the registrant contributed to the death of a three-year-old boy.
"The panel will see that Patient A (Sam) had become unwell during a flu epidemic. The family sought advice from NHS Direct.
"The registrant wasn't the only practitioner to have contact. However, when the local GP surgery was closed, Parent A contacted NHS Direct for some advice and spoke to the registrant.
"Eventually, the patient was admitted to hospital, but sadly died of group A streptococcal septicaemia.
"The NMC's case is that the registrant failed on a number of occasions to recognise the seriousness of cases and failed to respond with the appropriate advice and action."
Chipunza admitted giving incorrect answers to questions and contributing to Sam's death as a result and her fitness to practice was found impaired.
Today a panel suspended her for nine months.
Panel chair Ms Thomas said: "We took into account that you had a long unblemished career as a nurse before these incidents, that you had demonstrated extensive efforts at remediation, including self funded courses and that you provided excellent character and professional references.
"We also took into account that you worked in a challenging area of telephone triage, were in a noisy environment with poor hearing equipment during some of the calls and were signed off on a number of action plans.
"With regard to insight, we have already noted that you have some insight but that you have had difficulty translating this into your current practice.
"Of particular concern to us is that you continued to make errors despite being significantly supported.
"We have taken into account that you will not return to an area of work involving call handling. This decision does demonstrate a mature level of insight.
"We were not satisfied at present that conditions of practice order would be sufficient.
"In particular have taken into account the serious consequences of your actions.
"The public interest would not be served by a conditions of practice order and the seriousness of this case requires greater sanction.
"This period of suspension will give you further time to develop your practice."
Chipunza has 28 days to appeal.
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