‘Serious risk of harm’ - nurse handed out wrong medication and attempted to cover it up

A Liverpool nurse was suspended for two months after administering medicines to the wrong patient and attempting to cover it up.

The Nursing and Midwifery Council found that Zanele Lisa Sibanda’s fitness to practise was impaired and fell seriously short of the expected standard after giving a patient at Clatterbridge Hospital, Wirral, medication meant for someone else and then claiming she had not done so.

A three-day NMC fitness to practise hearing held earlier this month said the mental health nurse put patients at “serious risk of harm.”

The written determination said that on April 26 2020, Ms Sibanda administered controlled drugs to somebody referred to as Patient B, when they were meant for Patient A and failed to report the error. This was done without another nurse present, contrary to controlled drug standard procedure.

Ms Sibanda told a colleague that evening the medication was missing and when asked on April 27 if she had administered it by a colleague, she said no and a search was conducted. The fellow nurse, referred to as Colleague 1, noted four missing medications prescribed to Patient A.

The report said: “Later in the shift, Patient B woke up and spoke with Colleague 1 regarding the recent medication that you had administered to him. Patient B told Colleague 1 that he had a good period of sleep from the medication and he observed that it looked different in colour from his usual medication.”

Through speaking with Patient B, Colleague 1 noted that it appeared Ms Sibanda had given Patient B the medication that was actually prescribed for Patient A. Colleague 1 carried out observations on Patient B and was of the view that no actual harm materialised from this medication error.

In response to the medication error at the time, Ms Sibanda said she was sorry and “felt too scared to say what had actually happened.” The findings said the nurse deeply regretted her actions and her “subsequent dishonest conduct arose as a result of your mental state and was not intentional”.

The NMC panel was mindful that Ms Sibanda’s action placed both patients “at a risk of serious harm”. They said it was fortunate that risk did not materialise and the continued dishonesty by the nurse “prevented appropriate monitoring of Patient B and implementation of any corrective actions” stemming from the medication error.

The panel found that her actions did fall seriously short of the conduct and standards expected of a nurse and amounted to misconduct. However, in evidence they were satisfied that since then, Ms Sibanda had been working unrestricted as a registered nurse and no further regulatory concerns about her nursing practice have been raised.

The three-person panel was therefore not persuaded that there was a risk of repetition. As a result, despite an initial application for a six month suspension, Ms Sibanda was suspended for two months with no opportunity for review.