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Mental health nurse is struck off the NMC register over patient’s death

NMC finds Susannah Ajayi unfit to practise – but points to ‘systematic failures’ as mitigating factors

NMC finds Susannah Ajayi unfit to practise – but points to ‘systematic failures’ as mitigating factors

  • Mental health nurse failed adequately to monitor a patient
  • Nurse worked four shifts without adequate breaks
  • Trust said it reviewed procedures after patient's death and urges staff to declare work they do elsewhere


Ms Ajayi worked a night shift at the Lister Hospital’s mental health unit in Stevenage
Picture: Alamy

A mental health nurse who chose to work four shifts in a row and failed adequately to monitor a patient who was later found dead has been struck off.

A Nursing and Midwifery Council (NMC) panel found nurse Susannah Ajayi unfit to practise at a hearing last month.

Ms Ajayi admitted agreeing to work the night shift of 22-23 August 2013 for Hertfordshire Partnership NHS Foundation Trust as a bank nurse – despite having worked beforehand at a private hospital without adequate rest time before starting the third shift.

Inappropriate shift pattern

She said she should have disclosed it was inappropriate to work this shift pattern. European Working Time Regulations state workers should have 11 consecutive hours of rest in any 24-hour period.

During the night shift, a woman was placed in Ms Ajayi's care at Lister Hospital's mental health unit in Stevenage. The patient had been found by police near railway tracks having narrowly missed being hit by trains.

At 9.15am on 23 August 2013, the woman was found dead, having absconded from the unit. She sustained multiple traumatic injuries after falling from a height.

The NMC found the woman had been inadequately observed by Ms Ajayi, and that the nurse had either failed to perform, or had incorrectly performed, a suicide risk assessment, and had inappropriately identified the patient as being at a low risk of suicide.

Failed to keep adequate records

The NMC found Ms Ajayi had failed to keep adequate records for the patient.

In its discussion of the evidence, the Fitness to Practise (FtP) panel took into account that Ms Ajayi ‘may have felt pressured by the trust management to take on the [night] shift’. In response, a trust spokesperson told Nursing Standard the organisation urges staff to declare work done elsewhere. The trust conducted an operational review following the patient's death.

The panel found financial motivation played no part in Ms Ajayi’s decision to take on the extra shifts.

Ms Ajayi admitted to working another shift at the private Cygnet Hospital later on 23 August, having worked the three previous shifts.

The NMC ruled that Ms Ajayi’s decision to take on the night shift and her care of the woman who was later found dead, along with other charges, left it with no option but to remove her from the register.

Mitigating factors

In mitigation, the regulator said the unit’s ‘systematic failures’ may have contributed to Ms Ajayi working the shift. It also said the unit was not well designed for one-on-one observation. 

The FtP panel noted the emotional effect the events have had on Ms Ajayi, who has 18 months to appeal against the NMC's ruling.

A Hertfordshire Partnership NHS Foundation Trust spokesperson said it had reviewed its operational procedures and policies following the incident.

‘Appropriate procedures’

‘We reinforced the importance of following all the appropriate procedures and policies to our staff and in particular, the importance of vigilance in the completion of documentation,’ they said.

The spokesperson urged employees to follow obligations to declare other employment.  

RCN national officer Kim Sunley said nurses were increasingly being asked to fill staffing gaps because of high vacancy rates.

‘We’re aware members are being called in on their days off to do shifts,’ she said.

‘Nurses are aware of the pressure their colleagues are under and don’t want to let their colleagues and patients down.’

Effect of nurse fatigue

But Ms Sunley warned of the effect of nurse fatigue on both patient and personal safety, especially in complex matters such as drug calculations and monitoring a patient’s behaviour in a mental health setting.

While it is nurses’ responsibility to ensure they are fit to work, Ms Sunley added that employers must see staff receive adequate rest between shifts.

She urged RCN members who feel they are being put under pressure to take on shifts when they are fatigued to contact their college representative or steward.

An NMC spokesperson said the combination of police, coroner and an internal trust investigations meant the regulator only received Ms Ajayi’s case in late 2015 more than two years after the incident. 

During the NMC’s investigation in 2016, new evidence came to light leading to additional charges and a further delay.


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