Oswestry nurse suspended for six months for changing teenage boy's medical notes

Sheena Hughes' fitness to practise has been deemed "impaired" by the Nursing and Midwifery Council as a result of her misconduct surrounding the death of Charlie Davies, who suffered from Duchenne muscular dystrophy, and fell while getting undressed in his bedroom.

The 15-year-old suffered a fractured femur which, in turn, led to him developing a condition that ultimately led to his death.

Ms Hughes' misconduct hearing went before the Nursing and Midwifery Council in London, where seven charges were proved against her.

They heard that on April 30, 2015, when completing admission documentation for Charlie, she did not record the baseline observations on the admission sheet of his notes, and she did not adequately review observations carried out by a student nurse, and therefore did not observe that the patient’s oxygen saturation level was 87 per cent at the time.

The council also heard that on or around May 5, 2015, Ms Hughes altered the notes on Charlie's observation chart, which showed 87 per cent oxygen saturation, to instead record 97 per cent oxygen saturation.

Ms Hughes' conduct was described as "dishonest" as she knew the oxygen saturation level was not 97 per cent and she sought to conceal the fact that she had not reviewed his true oxygen saturation levels in good time on April 30, 2015.

The committee also concluded that on or around May 6, 2015, she removed his admission sheet from his medical records, took the admission sheet off hospital premises and destroyed it.

Members of the panel, which heard Ms Hughes' case, found that conduct to be "dishonest" as they said she sought to conceal the fact that she had not recorded baseline observations on the admission sheet.

The panel also found that Ms Hughes provided incorrect information at the coroner's inquest, relating to when she made her employer aware of her actions.

Charlie, of Balmer Crescent, Welshampton, fell on April 29, 2015. He was taken to the Royal Shrewsbury Hospital and later to the Robert Jones and Agnes Hunt Orthopaedic Hospital in Gobowen.

While in hospital, Charlie’s pulse, heart rate and oxygen saturation levels were monitored. These were taken by a student nurse. But despite Charlie’s oxygen saturation level falling to a dangerously low 87 per cent no alarm was raised.

Ms Hughes told the 2015 inquest she had been aware that Charlie was on the ward but had not been made aware that his levels had initially fallen. It was only when his condition deteriorated further that he was transferred to the Royal Stoke Hospital where he died the following day.

Four days later Sister Hughes changed the notes to read that his oxygen level was recorded at 97 per cent rather than at 87 per cent. She said she did this because she panicked and was under a great deal of stress.

Bev Tabernacle, director of nursing at Oswestry's Orthopaedic Hospital, said: "This is a tragic case and our profound sympathies again go out to Charlie's family for their loss.

"The coroner made clear that Charlie’s death could not be avoided, however that does not excuse the conduct of this member of staff, which fell well below the standards we expect and our patients deserve.

"This was a serious error of judgement, which is why we launched an immediate internal investigation and referred the matter to their professional body, The Nursing & Midwifery Council. It is reflected in the outcome of this hearing."