THE son of a vulnerable pensioner who died after a medication mix up said he is disgusted a senior nurse involved in her care has only been given a warning.
A tribunal heard Hazel Gillian Stears, the nurse-in-charge at the time 89-year-old Gwen Cartlidge was given the wrong medication at a Greenfield nursing home, “was not responsible for the tragic error”.
Mrs Cartlidge’s son Terry Cartlidge, 68, of Tan y Bryn, Greenfield, said he felt “let down by the whole system” after the verdict, adding “we will be taking this further”.
Mrs Cartlidge, referred to as “Resident A” during the hearing, had been in Morfa Newydd Nursing Home in Greenfield just two days when she was given another patient’s medication.
She died two days later on October 4 2011.
Yesterday a four-day hearing held in Cardiff by the Nursing and Midwifery Council (NMC) found Ms Stears had "failed to act appropriately" once she was aware of the error.
The tribunal was told Ms Stears was not responsible for the tragic error, but failed to tell the pensioner's family and GP, as well as not recording the mistake in her patient's care notes.
A three-person panel ruled Ms Stears' actions amounted to misconduct and her fitness to practise was impaired as a result.
They decided against banning Ms Stears, who it was heard had an otherwise "unblemished" career record.
NMC panel chair Naseem Malik instead issued a caution order, which will stay on Ms Stears' professional record for the next 12 months.
She said: "It is not alleged that Ms Stears was in any way responsible for the medication error, but she failed to act appropriately when she discovered that the medication error had occurred.
"Based on the evidence before it, the panel determined that a caution order was a fair and proportionate response.
"A caution order would satisfy the wider public interest in that it sends a clear message to the public and the profession that such behaviour is not tolerated.
"It was not in the public interest to restrict Ms Stears' practice."
But bereaved son Mr Cartlidge, speaking publicly to the Leader for the first time since his mother’s death almost three years ago, said he wanted to see “at the very least” Ms Shears struck off.
“I’m disgusted by the outcome,” said Mr Cartlidge, who had also cared for his mother for 20 years.
“We wanted her to be struck off.
“I just can’t believe it.
“I didn’t want her to go into a care home in the first place.
“I feel like I have been let down by the whole system.”
The hearing was told that on October 2, 2011 Ms Stears was the staff nurse of the upstairs section of the home.
At about 9am Mrs Cartlidge needed help eating her breakfast.
The NMC was told a care assistant went to see her and found a "number of tablets in a pot" on her table.
With the woman's consent, the care assistant stirred the medication into the porridge and helped feed her.
But shortly after Ms Stears then came into the room with Mrs Cartlidge’s medication - and discovered the wrong prescription had been administered.
The medication she had been given belonged to an elderly man who lived in the downstairs section of Morfa Newydd.
Less than two hours later, Mrs Cartlidge became unwell and went back to bed.
Doctors only discovered the mistake two days later when Mrs Cartlidge died on October 4.
The panel said the evidence was enough to find Ms Stears' misconduct had been proven.
It highlighted strict NMC guidelines saying nurses must "provide a high standard of practice and care at all times" and added the home's policy on administration errors were "unclear".
Ms Malik added: "Ms Stears had failed to provide Resident A with a level of care reasonably expected of a registered nurse - therefore exposing Resident A to unwarranted risk of harm."
Despite this the NMC described the incident as an "isolated" one on Ms Stears' otherwise "unblemished career".
Ms Malik said: "Resident A was an elderly lady whose condition was extremely frail at the time of her transfer to the home....(but) Ms Stears made early admissions to the charges, the incident was isolated relating to one patient (and) Ms Stears has demonstrated her remorse as well as insight into the incident."
The panel also noted the home was a "challenging" one where drug procedures "appeared to vary".
Ms Malik said the panel concluded that in all the circumstances the misconduct “was at the lower end of the spectrum” of impaired fitness to practise.
She added: "Furthermore, the panel did not consider that there was any evidence of general incompetence or specific areas of Ms Stears' practice in need of assessment or retraining.
"The panel was satisfied that a caution order, in this respect, would keep in the forefront of Ms Stears' mind that she needs to be aware of the conduct expected of a nurse."
The caution order means Ms Stears will have to disclose the formal warning to any current or future employer about the sanction for the next 12 months.
The hearing also heard It was still unknown how the medication mix-up occurred and whether the mistake was caused by staff or another patient.
Father-of-three Mr Cartlidge also spoke of his pain during the past couple of years - saying: “It has been really hard for me - I promised my mum I would never put her in a home.”
No one from the car home was available for comment at the time of going to press.