Whittington Hospital nurse threw away medical records of head injury patient

Proscovia Nakaggwa Sendijja has been found guilty of misconduct. Photo: Polly Hancock

Proscovia Nakaggwa Sendijja has been found guilty of misconduct. Photo: Polly Hancock - Credit: Archant

A nurse threw away the records of a patient with a dangerous head injury after failing to flag up his condition, a disciplinary panel heard

The Whittington Hospital Picture: Steve Parsons

The Whittington Hospital Picture: Steve Parsons - Credit: PA ARCHIVE IMAGES Steve Parsons

Proscovia Sendijja, who worked as a staff nurse in the Accident and Emergency department at the Whittington Hospital, has appeared before the Nursing and Midwifery Council (NMC) facing allegations of misconduct.

The panel will decide whether she should be struck off.

She admits discarding the medical records of a drunk patient who fell and was rushed to the Whittington during the night shift on March 1 to 2 last year.

And she admits forging a doctor’s signature for a prescription on the new document with which she replaced the old one.

But Sendijja said her actions weren’t carried out to hide that the man – Patient A – was given an extremely low Glasgow Coma Score (GCS), indicating his head injury was severe, or that she failed to flag this up with senior staff.

The panel heard Sendijja did not notify a doctor about Patient A’s condition.

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He was later wheeled to a major trauma centre with a brain haemorrhage.

Rhiannon Saddler, presenting the case for the NMC, said Sendijja was supervising a student nurse, Titania Dawkins, who later appeared as a witness at the hearing.

Ms Dawkins assessed Patient A, giving him a GCS of eight at 23.40pm and 12.10am – indicating he was severely unwell and needed immediate medical intervention.

She alerted Sendijja, but her mentor failed to act in that half hour or tell other staff.

The NMC’s Miss Saddler said the GCS showed Patient A was “on the verge of a coma” and should have been “immediately escalated” to someone more senior.

At around 12.30am, Patient A vomited and a senior nurse, Nadine Kalenga, and Dr Alun Henry, attended to him, before he was rushed to the trauma department.

Sendijja described how she crossed out student nurse Ms Dawkins’ GCS notes on Patient A’s medical records.

She replaced the eights with 10s, claiming she had assessed Patient A’s condition and found him less unwell.

But this looked “messy”, so she discarded the old medical notes and started afresh on a new document, copying over a prescription and forging a doctor’s signature.

The new document had no record that the student nurse had found a GCS of eight.

Dr Henry told the panel he found medical notes in the waste bin.

“The three GCS scores had been scribbled out,” he said.

He told the panel a GCS of eight or 10 are both very serious.

“I was extremely concerned that the score had not been brought to my attention,” he said.

The hearing was told Sendijja regrets not calling a doctor immediately. And she knows she shouldn’t have thrown the original medical document away or forged a doctor’s prescription on the new document.

Miss Saddler alleges Sendijja discarded the medical notes to conceal the fact that a GCS of eight had been recorded but not acted upon.

Oliver Renton, representing Sendijja said: “She acted in a thoughtless, rather than a mendacious manner. This was an instance of very poor record keeping.”

The hearing continues.

‘It was stupid but my actions were not dishonest’

Nurse Proscovia Sendijja worked in the Whittington gynaecology ward before moving to the Accident and Emergency department, and was on duty for the night shift of March 1 to 2, 2015.

Appearing in a grey skirt suit, she told the panel the team was understaffed that night.

They were four nurses down and there was only one emergency medical registrar on duty, as well as three junior doctors who she claimed just started that day.

When Sendijja was first assigned Patient A, who she found lying on the floor, she said she did a Glasgow Coma Score (GCS) assessment to check his level of consciousness.

But she did not make a note of this initial assessment.

“The GCS was low but I expected it, based on the assumption that the patient was intoxicated,” she said. “I wouldn’t expect to get a 15/15 on a patient who was intoxicated.”

Sendijja instructed the student nurse she was supervising, Titania Dawkins, to look after Patient A and carry out further GCS readings, which could reveal the severity of his head injury.

Meanwhile Sendijja was handed another patient arriving after a road accident and she rushed to care for him in the cubicle next to the student nurse.

Sendijja claims when Ms Dawkins told her of Patient A’s GCS score, she was placing blocks around the road accident patient to avoid a spinal injury.

Sendijja says she did not think Ms Dawkins’ GCS reading of eight was accurate.

“[At eight] the patient is not able to breathe by themselves [...]

“I could hear the patient saying to the student nurse, ‘I’m feeling sick’ and shortly after, the patient vomited. That told me the patient was OK.”

But Sendijja later added: “I should have escalated the score to the senior nurse or the doctor.”

Explaining why she discarded the student’s medical notes, after crossing out the scores and writing new ones, she said: “Because it wasn’t clear. I thought that other people would not be able to read and understand the information.”

Sendijja went on to transfer notes onto a fresh document.

She wrote out a prescription onto the new document, forging a doctor’s signature.

Sendijja said: “I was trying to transfer the information that was in the old document.

“I just didn’t want it to go unnoticed that there was a treatment given to the patient.

“That’s an action I did without thinking. I just did it. It was a stupid thing to do.”

Sendijja claims her actions were not intended to hide Patient A’s alarming GCS score and her failure to call for help.

She said she regrets her actions, which “caused damage to my personal reputation as well as a lack of trust from others”.