Nurse not struck off over death of inmate left lying on floor for 21 hours

A duty nurse at HMP Peterborough who failed to administer an insulin injection to a diabetic inmate who had been left on the floor for 21 hours has not been struck off by the Nursing and Midwifery Council.

Lesley Watts was the nurse on shift when 45-year-old prisoner Annabella Landsberg, who had Type 2 diabetes, was taken to hospital where she died three days later on September 6, 2017.

At Ms Landsberg’s inquest, it was heard that she was left on a concrete floor for 21 hours without any assistance. Staff at the female separation and care unit of HMP Peterborough said that Ms Landsberg was first observed on the floor at 6pm on September 2, which Ms Watts was informed of when she came on shift at 7.30am the next day.

In a virtual hearing on Monday (April 19), the Nursing and Midwifery Council heard how Ms Watts had not made any attempt to assess her patient but had only looked through the cell observation window three times between 7.30am and 3pm.

At the hearing, it was heard that other prison staff had been reluctant to go into Ms Landsberg’s cell after she had to be physically forced inside the night before.

HMP Peterborough
(Image: Google)

Ms Watts said that each time she did observe Ms Landsberg, she had been lying on the floor but said she had moved and could be heard snoring.

Isabella Knight, who presented the case against Ms Watts, said that she had failed to observe or recognise the deterioration of her patient, and also had failed to assess her wounds, airways, blood sugar levels, blood pressure or oxygen saturation levels.

Later Ms Watts and other staff did enter the cell. Ms Watts admitted that she then poured a cup of water over Ms Landsberg, which another staff member said had “shocked them”.

Ms Watts had then told the patient: “There are residents that are really ill and they are having to wait to see me because I have got to come and see you, you need to get up, you are pathetic”.

The clinical nurse manager was then called to assess the patient, as staff believed that Ms Landsburg would react differently to another staff member.

The manager noted that prison officers who knew Ms Landsberg had said she was “fine” and “she had just been mucking about all night and would not get off the floor”.

The manager said she then became concerned because force had been used to get Ms Landsberg into her cell, and that she had not moved from the floor where “she had thrown herself” 21 hours earlier.

On assessment, Ms Niemiro said that the patient was actually very ill and said that other staff then began blaming Ms Watts for not doing a proper assessment.

Ms Landsburg, who had arrived in the UK after fleeing Zimbabwe after being the victim of a gang rape, was soon rushed to hospital where she died three days later.

Her body was repatriated to Zimbabwe after her children were denied access to enter the UK for the funeral.

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Ms Watts didn’t attend the hearing on Monday but agreed to all the facts presented through a representative. The hearing also heard evidence in regards to another altercation involving Ms Watts a year later.

Following Ms Landsberg’s death, Ms Watts was removed from her position at HMP Peterborough and began working at Hinchingbrooke Hospital.

On her first day at the hospital, Ms Watts was told to administer an insulin injection to a patient by a consultant. Ms Watts had said that she did not know how to do an insulin infusion, so was instructed to speak to the nurse in charge.

Hinchingbrooke Hospital
(Image: Sunday Mirror)

However, when the consultant checked back later that afternoon, they discovered that Ms Watts had not monitored the insulin levels of the patient, the prescribed shot had not been given and she had not checked the patient for a number of hours. The patient was said to be very unwell, was struggling to breathe, and said that they were “feeling worse than she previously had”.

Staff also added that on two subsequent occasions Watts had not followed care plans. The Nursing and Midwifery Council panel found that Ms Watts had seriously failed to undertake clinical observations of patients and had verbally and physically abused a patient.

But it took into account the remorse that Ms Watts had shown afterwards, that she had undertaken further training relating to her failings, and had clearly reflected on her actions. It also said that she had many positive testimonials and had engaged with the process of the hearing.

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It also found that before the two incidents she’d had an “unblemished career” and that having since stayed in healthcare there had been no further incidents. The panel said it was in the public’s interest in “allowing a competent nurse to resume practice”.

It concluded that for 18 months, Ms Watts would always have to be supervised by other staff and would report to a case officer every month.

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