How fitness to practise fears raise suicide risk for troubled nurses

Campaign group calls for better support for nurses reported to regulator

Nurses having counselling are more likely to consider suicide if facing a fitness to practise hearing, RCN figures show

  • One in three nurses receiving counselling and facing an FtP case has considered suicide
  • The number facing disciplinary cases who have killed themselves isn’t known
  • NMC is considering a new approach, with hearings held only in exceptional cases

Picture: Charles Milligan

Troubled nurses who seek counselling from the RCN are more likely to have considered suicide if they face disciplinary action by the regulator, figures from the college show.

The figures show that 36% of nurses receiving counselling who are facing fitness to practise proceedings (FtP) by the Nursing and Midwifery Council have thought of ending their lives.

This falls to 21-24% for nurses who are distressed enough to ask for counselling but are not in trouble with the regulator.

Nurses who admit experiencing suicidal thoughts and mental illness while facing investigations into their fitness to practise say more support is needed.

‘Guilty until proved innocent’

Nursing Standard revealed evidence of a suicide risk for NMC-referred nurses in an investigation in 2016.

At that time, nurses criticised the NMC over the length of time it took to deal with FtP, as well as poor communication, a lack of signposting to support services and a perception that nurses in such cases are ‘guilty until proved innocent’.

Many of these issues have been raised again by a pressure group called NMCWatch: Registrants Care, which is campaigning for better support for nurses who have been reported to the regulator.

‘I have spoken to nurses who have lost everything – jobs, relationships, houses. How do you recover from that?’

Tanja Koch, RCN counselling service coordinator

NMCWatch surveyed nurses who have been referred to the NMC to highlight how this had affected their mental health.

More than half of the 48 nurses who have responded so far say they have had suicidal thoughts related to a referral, as well as issues including paranoia, poor self-confidence, acute anxiety, mood swings, eating issues and self-harm.

Anxiety and stress take their toll

RCN counselling service coordinator Tanja Koch says NMC referrals can take years to conclude, and the anxiety and stress they cause can have a profound, detrimental effect on nurses’ lives.

‘The anxiety and stress is often acute. The shock and trauma of being referred has the biggest impact at first, and then it depends on what support structures people have around them,’ says Ms Koch.

‘I have spoken to nurses who have lost everything – jobs, relationships, houses. How do you recover from that?’

Because RCN counsellors tend to see nurses at the start of the referral process for a course of around six sessions, it is not known if any have ever gone on to take their own life, she says.

It is almost impossible to tell how many nurses in such cases may have done so, she says. Some cases make news headlines, but many others do not.

Picture: Charles Milligan

Fitness to practise cases

  • Currently the NMC receives around 5,500 referrals a year, including from employers, from members of the public and self-referrals
  • Approximately 80% of cases are concluded within 15 months
  • In 2016-17, the NMC’s independent panels imposed more than 1,200 sanctions, around half of which involved removing a professional from the register permanently or temporarily
  • The NMC currently spends more than 70% of its budget – obtained from the £120 registration fee – on regulating fitness to practise

North Devon nurse Elizabeth Watts took her own life at the start of 2011, four days after the NMC started hearing details of allegations about her conduct, following a referral claiming she had a sexual relationship with a patient.

London charge nurse Amin Abdullah died after setting himself on fire outside Kensington Palace in 2016, following a disciplinary process at his hospital that resulted in his dismissal.

Although not subject to NMC proceedings, Mr Abdullah had suffered a mental breakdown over how his NHS employers handled his dismissal, an inquest heard.

‘I felt I had let down everyone around me and wasted my career. If I hadn’t had support I had it would have been a different story’

Cathryn Watters, NMCWatch founder

One nurse, who asked to remain anonymous, says: ‘There is no detail on suicides, but we all know it is happening. The NMC is not reporting such incidents or even collecting statistics.’

Charge nurse Amin Abdullah had
a mental breakdown after his
dismissal, an inquest heard.

No record of nurses’ deaths

Another nurse, who also requested anonymity, says he supported a fellow nurse who was suspended from the register and subsequently took her own life.

He says: ‘She was dealing with anxiety and depression and I referred her on to a psychiatrist as I thought she posed a suicide risk. Later I heard from a colleague that she had an NMC hearing coming up and she had killed herself. It really had an impact on me.’

He adds that he has heard similar stories about other nurses going through referrals.

‘Other people have threatened or attempted suicide, some have been admitted to hospital, or cut, harmed or severely hurt themselves.’

The fact that the NMC has no public record of deaths, let alone suicides, among nurses who are the subject of FtP investigations is of concern to many.

In 2016, the NMC told Nursing Standard it did not keep a record of incidents in which a nurse or midwife who was subject to FtP proceedings had died before their case concluded.

‘Prevent people from becoming suicidal’

The RCN’s Ms Koch says: ‘I would like the NMC to collect some statistics so they have some awareness around individuals’ mental health.

‘Then they could reflect on their processes and prevent people from becoming suicidal.’

32 out of 88

nurses (36%) who were receiving RCN counselling in 2017 and had been referred to the NMC considered suicide

The NMC said in 2016 that it understood the stress nurses go through in such situations and would be starting a project to gauge the mental health impact of FtP investigations on them.

Two years on, this project has not materialised.

However, the regulator is consulting on new plans that could see nurses avoid FtP hearings by disclosing errors early, in a bid to move away from an ‘adversarial, cumbersome and distressing’ process.

‘At the time of my hearings, my mental health deteriorated significantly, to the point of self-harming and intense thoughts of suicide’

Lisa Scott, a nurse suspended by the NMC over mental health concerns

An NMC spokesperson also says the regulator has started to look at the health of registrants involved in FtP, but had no further details.

Nurses’ own stories of the impact that FtP referrals have had on their mental health make for concerning reading.

‘Support was critical’

NMCWatch founder Cathryn Watters, an experienced and senior cancer nurse, found herself fighting a decision to remove her from the register on grounds of dishonesty over what she says was a minor irregularity in a job application.

Picture: Charles Milligan

Ms Watters successfully appealed the decision by representing herself at the High Court and has since been inspired to raise awareness about the mental health burden of referrals to the regulator.

Ms Watters says support was critical. ‘If I hadn’t had a husband and employers looking after me, I wouldn’t be nursing again.

'At times throughout the FtP process and afterwards I felt suicidal and even considered it on more than one occasion.

‘I felt I had let down everyone around me and wasted my career. If I hadn’t had the support I had it would have been a different story.

‘What about people who haven’t got a supportive partner, or already have mental health issues?

‘Anecdotal evidence from those contacting our online support group suggests that these issues are not going away and are nearly always unreported for fear it will give their regulator even more ammunition to state they are unfit to practise.

‘Even when after many months of investigation there is found “no case to answer” registrants still describe experiencing extreme distress.’

‘The new approach to FtP would allow us to deal with cases more quickly, reducing the impact on those involved while still achieving the same public protection outcomes’

NMC spokesperson

Neurological nursing centre manager Jo Barnett was referred to the NMC, along with a number of nurses on her team, after a patient admitted to hospital with renal failure later died.

Ms Barnett was ultimately found fit to practise, but she says the ordeal of FtP proceedings took its toll.

‘I think I only now realise how ill I was last year,’ Ms Barnett says. ‘I became anxious, I couldn’t concentrate, I was almost paranoid, had memory problems and was in tears every single day.’

Lack of support

Ms Barnett says she had RCN counselling, cognitive behavioural therapy, and three months off work before she was able to get back on track again.

A lack of support has also been a major issue for nurse Lisa Scott, who was suspended from the NMC register over concerns about her mental health.

Ms Scott, who has various diagnoses including anxiety, depression and an eating disorder, says: ‘Throughout the FtP process there has been no support from the NMC, despite this being a health case, and in particular for mental health reasons.

‘At the time of my hearings, my mental health deteriorated significantly, to the point of self-harming and intense thoughts of suicide.’

Within the medical profession there has been a growing awareness of the profound distress that FtP investigations can cause in people whose careers are at stake.

In 2014, the General Medical Council (GMC) pledged to review how it treats doctors after it found that as many as 28 doctors may have killed themselves while facing FtP investigations.

The GMC appointed England’s former national clinical director for mental health Louis Appleby to review its FtP processes so it can provide support to vulnerable doctors. The outcome of this review is expected to be made public soon.

An NMC spokesperson says: ‘We recognise that going through FtP can be a distressing experience and has a significant impact on all parties, including nurses and midwives.

New approach to hearings

‘That’s one of the reasons we’ve outlined plans for a new approach to FtP where hearings would only be held in exceptional circumstances.

‘These plans would allow us to deal with cases more quickly, reducing the impact on those involved while still achieving the same public protection outcomes.

‘We continue to meet regularly with nursing and midwifery representative groups as we develop our plans and we’re committed to working with them to improve our FtP for all involved.’

Ms Watters of NMCWatch says: ‘We want the NMC to finally take action on the evidence shown by many studies since 2011 demonstrating the impact of FtP on registrants, in order to help prevent future tragedies among referred registrants.’

Overhaul could see nurses avoid disciplinary hearings

The NMC has launched a consultation on plans that could see nurses avoid FtP hearings by disclosing errors early.

In March, the regulator agreed a proposal to overhaul the way it deals with complaints about nurses and midwives. It is asking for opinions from the public and the profession on the plan, called Ensuring Patient Safety, Enabling Professionalism.

The NMC hopes it will encourage nurses to speak up at the earliest opportunity when things go wrong and to see the new FtP process as an opportunity to learn and reflect.

Learn from mistakes

NMC chief executive Jackie Smith said at the time: ‘Where nurses and midwives speak up early and learn from their mistakes we want to see fewer hearings, and cases resolved much more quickly.

‘We want to move away from a process which is often adversarial to one that supports a learning culture where nurses and midwives can be open about what happened.

‘Our proposals aren’t about excluding anyone. Rather, we want to reduce the impact on all those involved while putting patient safety at the heart of what we do.’

Faster and more transparent

The NMC says the proposed approach puts more emphasis on employers resolving issues quickly, with the profession’s regulator only becoming involved if an internal investigation concludes it needs to.

The RCN welcomed the review, but says it will be looking at the details carefully. RCN head of legal services Rosalind Hooper said: ‘The college welcomes this consultation and agrees with the NMC that FtP should be a faster and more transparent process for nursing staff.

‘The nursing profession needs a system that encourages whistle blowing and candour, while balancing the need to protect the public alongside supporting nurses and midwives to address concerns about their practice.’

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