Following the Striking off Order by the NMC Fitness to Practice Panel at the hearing of McKee on 7 January 2022, there has been considerable media coverage about the behaviour and decision-making of this nurse. He was one of two nurses, employed in the Crisis Service of Humber NHS Foundation Trust, jointly responsible for the final assessment of Sally on 25 July 2014. The fact that there were two nurses responsible for the decision to refuse Sally admission to hospital, contrary to her Care Plan and the advice of other professionals who knew her better, the consequences of which actions had a direct causal relationship to Sally’s death hours later, has not gone unnoticed. Questions have been raised as to the outcome of the plethora of investigations with respect to the second nurse.
Gemma Pearson (now Marsh) was the second nurse involved in this final assessment. At that time she was a Band 6 nurse and had been employed in the Crisis Service for approximately 6 years. Immediately following the inquest, in October 2015, she and McKee were referred to the NMC.
In January 2021 the NMC case examiners concluded their consideration of the case of Pearson. The NMC identified and investigated five regulatory concerns:
- Failure to carry out an adequate clinical/gatekeeping assessment of Patient A
- Failure to adequately reassess Patient A when their risk increased after the initial clinical/gatekeeping assessment
- Contribution to the death of Patient A
- Failure to adequately record the assessment of Patient A and/or the clinical rationale for not admitting Patient A
- Failure to treat Patient A with dignity and respect.
The investigation found that on the evidence available, regarding each of the regulatory concerns 1,2,3 and 5 that “there is a realistic possibility that the facts alleged would be found proved. As such, we consider that there is a case for you to answer on the facts of this regulatory concern”.
The investigators then considered whether there was a realistic possibility that, in the light of the above concerns, Pearson’s fitness to practise would be found to be currently impaired, 6.5 years after Sally’s death. They acknowledged that the concerns raised about Pearson were serious and had raised issues about her clinical skills and judgement, however, because of the “insight, remediation and six years of continued safe practice, you have demonstrated” concluded there was “no case for you to answer.” Therefore, the case never reached the Fitness to Practice stage.
Needless to say, Pearson failed to demonstrate any remorse whatsoever during the eight days she attended the inquest. When specifically asked by our barrister whether she wished to apologise to the family, she declined to do so an has never acknowledged the consequences of the part she played in the final assessment which directly contributed to Sally’s death.
Postscript: In October 2017, three years after Sally’s death and two years after being reported to the NMC, whilst still under investigation by the regulatory body, Humber NHS Foundation Trust promoted Pearson to a Clinical Lead, Band 7 in the Crisis Service where she still works.
Justice for Sally 