Benjamin Orrill

Nursing &
Midwifery
Council

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Dr C J L Swann, Assistant Coroner
Leicester City and South Leicestershire
The Town Hali
Town Hall Square
Leicester
LE1 9BG

20 January 2017

Dear Madam

Benjamin Orrill

Further to your Report to Prevent Future Deaths made under Paragraph 7, Schedule 5,
of the Coroners and Justice Act 2009 and Regulation 28 and 29 of the Coroners
(Investigations) Regulations 2013, I  am writing to provide you with our response.

We note the concerns you have raised relating to the regulation of advanced nursing
practice. To help explain how we fulfil our statutory objective to protect the public, we
have enclosed with this letter a document that summarises our statutory framework and
provides background information about advanced practice.

We are aware of the particular concern raised about the registered nurse who reviewed
Mr Orrill in the weeks leading up to his death. We are working closely with you in
relation to this and are considering the concerns in accordance with our statutory
functions.

We will not be taking any further action in relation to the concerns you have raised
because, for the reasons we summarise in the enclosed document, we believe that our
statutory framework and the process of revalidation are sufficient to protect the public in
respect of advanced practice.

hope that the attached information is helpful, If we can provide any further input on this
matter, please do not hesitate to contact me again.

Yours faithfully

,,;,;. -~

._~___~

Jackie Smith
Chief Executive and Registrar

Enclosure; NMC and advanced practice

 Nursing &
Midwifery
Council

The NMC and advanced practice

Our statutory framework

The NMC was created by the Health Act 1999, and is governed by a number of pieces
of secondary legislation. The Council's principal functions are set out in Article 3(2) of
the Nursing and Midwifery Order 2001 (`the Order'):

"The principal functions of the Council are to establish from time to time
standards of education, training, conduct and perFormance for nurses and
midwives and to ensure the maintenance of those standards."

The over-arching objective of the Council in exercising its functions is the protection of
the public:

"The pursuit by the Council of its over-arching objective involves the pursuit of
the following objectives —

(a) to protect, promote and maintain the health, safety and wellbeing of the
public;
(b) to promote and maintain public confidence in the professions regulated under
this Order
(c) to promote and maintain proper professional standards and conduct for
members of those professions." (Article 3(4A) of the Order)

I n addition to establishing and ensuring the maintenance of standards, the Council is
required to establish and maintain. a register of qualified nurses and midwives (Article
5(1) of the Order).

Our register is divided into parts and sub-parts, with each part having a designated title
indicative of different qualifications and different kinds of education or training. An
individual is only entitled to use the title corresponding to the part of the register in which
he is registered. This is set out in Schedule 1 of the Nurses and Midwives (Parts and
Entries in the Register) Order of Council 2004:

Parts and Sub-Parts of the Register

Designated Title

Nurses:
Sub-Part 1
Sub-Part 2

Midwives

Registered nurse: first level
Registered nurse: second level

Midwife

Specialist Community Public Health
N urse

Specialist community public health
nurse

I n addition, Article 7 of that order and our standards require that certain, specified
q ualifications are recorded on our register. These are:

Page 1 of 7

 • community practitioner nurse prescriber.

• nurse independent prescriber.

• nurse independent/suppiementary prescriber.

• specialist practitioner qualifications in adult, mental health, learning disability,,
children's, general practice, community mental health, community learning
disabilities, community children's and district nursing: and

• lecturer or practice educator.

To obtain any of these qualifications, the nurse or midwife must have met the standards
of education and training which are published on our website
(www.nmc-uk.orq) and (by statutory requirement) are communicated to education
providers and other relevant stakeholders.

A person commits an offence, if with intent to deceive (either expressly or by
implication), he falsely represents himself to be registered in the register, or a particular
part of it, or to be the subject of any entry in the register; or uses a designated title to
which he is not entitled, or falsely represents himself to possess qualifications in nursing
or midwifery (Article 44 of the Order).

Registration and renewal of registration through revalidation

I n order to be registered in a part, or sub-part of the register and use one of the
designated titles set out above, an individual has to satisfy a number of statutory
registration conditions in Article 9 of the Order:

• holds an approved qualification,

• has appropriate cover under an indemnity arrangement,

• is of sufficiently good character to be capable of safe and effective practice.

• has the necessary knowledge of English.

• has paid the prescribed fee.

Once an individual satisfies these conditions and is entered on the register, they
become accountable to the NMC for all of their professional activities. All registered
nurses and midwives are required to uphold the professional standards contained within
the NMC's Code of Conduct: Professional standards of practice and behaviour for
nurses and midwives (NMC 2015) (Appendix 1), whether they are providing direct care
to individuals, groups or communities, or whether they are in employed or self-employed
practice.

This commitment to professional standards is fundamental to being part of the nursing
or midwifery profession and failure to abide by The Code may result in fitness to
practise proceedings being initiated to protect the public (see further below).

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 As well as upholding the professional standards set out in The Code, all registered
nurses and midwives are required to renew their registration every three years by
meeting the statutory registration conditions in Article 10(2) of the Order:

• has appropriate cover under an indemnity arrangement.

• is of sufficiently good character to be capable of safe and effective practice.

• has met the prescribed requirements for continuing professional development.

• has carried out 450 hours of registered practice in the previous three years, or

undertaken additional education, training or experience,

• has paid the prescribed fee.

From April 2016, all nurses and midwives in the UK have been required to complete the
Revalidation process in order to maintain their registration with the NMC. This is a
continuous process that nurses and midwives must engage with throughout their career
in order to demonstrate their continued ability to practise safely and effectively. It
requires nurses and midwives to:

• carry out 35 hours of continuous professional development of which 20 hours

must be participatory;

• obtain five pieces of practice-related feedback;

• produce five written reflective accounts in relation to a continuing professional

.development activity/feedback/event or experience in their practice;

• have a reflective discussion with an NMC-registered nurse or midwife;

• declare that they are of sufficiently good character to be capable of safe and

effective practice;

• hold evidence to demonstrate they have an appropriate indemnity arrangement

in place; and

• demonstrate to an appropriate confirmer that they have complied with the

Revalidation requirements.

Revalidation reinforces The Code by asking nurses and midwives to use it as the
reference point for all the requirements, including their written reflective accounts and
reflective discussion. It is designed to highlight The Code's central role in the nursing
and midwifery professions and encourages nurses and midwives to consider how it
applies in their everyday practice.

Fitness to practise proceedings

As set out above, when joining the register and renewing their registration, nurses and
midwives commit to upholding the professional standards set out in The Code. If a
registered nurse or midwife fails to uphold The Code, we have statutory powers to take
action through our fitness to practise processes under Part V of the Order.

Page 3 of 6

 Where a concern is raised about a registered nurse or midwife, the NMC's screening
team in our fitness to practise directorate assesses whether it is capable of amounting
to an allegation of impaired fitness to practise. If it is, the case is referred to the
investigating committee and an investigation is carried out. At the conclusion of the
investigation, case examiners decide whether there is a case to answer and, if there is,
the case is referred to a practice committee to determine whether it is necessary to take
any action against the registrant in order to protect the public. If the practice committee
concludes that an allegation of impaired fitness to practise is well founded, then they
have the power under Article 29(5) to:

• make astriking-off order, which has the effect of removing a registrant's name

from the register and preventing them from applying for restoration for five years;

• make a suspension order for up to one year, which prevents the registrant from

practising as a registered nurse or midwife

• make a conditions of practice order with which the registrant must comply for up

to three years

• caution the registrant for between one and five years, which results in the register
being' publicly annotated to show that the registrant has received a caution order.

I n addition to the above, at any time until an a case has concluded, we have the power
to refer a registrant for an interim order hearing on the grounds that it is necessary for
the protection of members of the public, is otherwise in the public interest, or is in the
interests of the persons concerned (Article 31 of the Order). If it is considered that it is
necessary to restrict a registrant's practice, a Practice Committee can take immediate
action by imposing an interim conditions of practice order or interim suspension order
on their registration.

Advanced practice

Programmes for additional post-registration training as an ANP have been developed by
the professional body for nurses, the Royal College of Nursing, in conjunction with the
Royal College of General Practitioners for ANPs in General Practice. These
programmes can only be undertaken by registered nurses with an active registration
and who have registered independent prescriber qualifications.

I n considering its role in relation to such ANP programmes, the NMC had regard to a
report published by the Council for Healthcare Regulatory Excellence, which is the
independent regulator for nine health and social care regulators, including the NMC.
The report was entitled Advanced Practice: Report to the four UK Health Departments
(Appendix 2) and concluded:

"We believe that much of what is often called `advanced practice' across many of
the health professions does not make additional statutory regulation necessary.
Often what is termed advanced practice reflects career development within a
profession and is appropriately governed by mechanisms other than additional

Currently the Professional Standards Authority

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 statutory regulation. The existing provisions of the regulatory framework mean
that whatever the level or context of a professional's practice, they are always
accountable to their regulatory body for their practice. All health professionals
have duties from the core Code/Standards document of their respective
regulatory body only to practise where they are capable of doing so safely and
effectively. The activities professionals are undertaking do not lie beyond the
scope of existincLregulation" (our emphasis added)

In light of this report and for the reasons set out below, the NMC considered that the
existing regulatory framework would adequately protect the public against any risks
associated with the development of ANPs.
In order to undertake .an ANP programme, an individual must be a registered nurse with
a registered independent prescriber qualification. Accordingly, nurses who have the
ANP qualification will, as a matter of course, be regulated by the NMC both in terms of
their ordinary registration and their prescribing qualification. They must uphold the
standards of conduct and performance set out in The Code, in the same way as all
other registered nurses and midwives.
Certain standards .will be of particular relevance to any senior nurse or self-employed
registrant, whether or not they have undertaken an ANP programme, when carrying out
their particular roles, As has been , a person who has an ANP qualification will
necessarily be working at an advanced level, and may include working independently in
self-employed practice. However, it is important to note that undertaking an ANP
programme is in noway apre-requisite to working at an advanced level or in self-
employed practice, and there will be senior nurses (some of whom may also be working
in independent practice), who will not have undertaken an ANP programme.

The following paragraphs of The Code are specifically designed to ensure that nurses
and midwives at any level do not work beyond their competence, These will be
discussed and reflected upon as part of the revalidation process:

All  nurses and midwives must:

\ • recognise and work within the limits of your competence (paragraph 13).

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•  make a timely and appropriate referral to another practitioner when it is in the
best interests of the individual needing any action, care or treatment (13.2).
• ask for help from a suitably qualified and experienced healthcare professional to
carry out any action or procedure that is beyond the limits of your competence
(13.3).

• complete the necessary training before carrying out a new role (13.5).
• raise and, if necessary, escalate any concerns you may have about patient or
public safety, or the level of care people are receiving in your workplace or an
other healthcare setting and use the channels available to you in line with our
guidance and local working practices (16.1).

• raise concerns immediately if you believe a person is vulnerable or at risk and

needs extra support and protection (17).

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 • advise on, prescribe, supply, dispense or administer medicines within the limits of
your training and competence, the law, our guidance and other relevant policies,
guidance and regulations (18).

• be aware of, and reduce as far as possible, any potential for harm associated

with your practice (19).

If a nurse or midwife, at any level of seniority, fails to uphold any of the standards in The
Code, we can take action in relation to their fitness to practise, which can include
removing them from the register. The practice of the nurse or midwife will be judged
against their actual level of expertise and experience, and the standards to be expected
in the given context. We would not usually use the ANP qualification as a measure of a
nurse's competence, although the fact that she has obtained such a qualification may
indicate that she has reached a particular level of seniority (not least because she will
have needed to obtain a prescribing qualification in order to undertake the course),

In addition, as registered nurses, nurses with the ANP qualification will also have to go
through our robust revalidation process, which is designed to provide regulatory
assurance that they are adhering to the standards set out in The Code and have
reflected on their particular'area of practice. It is specifically intended.to:

• raise awareness of The Code and the professional standards expected of nurses

and midwives, whatever their level of seniority;

• provide all nurses and midwives, no matter what their level of seniority, with the
opportunity to reflect on the role of The Code in their practice and to demonstrate
they are 'living' the standards;

• encourage all nurses and midwives, no matter what their level of seniority, to stay

up to date in their professional practice by developing new skills and
understanding the changing needs of the public and fellow healthcare
professionals;

• encourage a culture of sharing, reflection and improvement; and

• encourage all nurses and midwives to engage in professional networks and

discussions about their practice, whether they are in employed or self-employed
r padice.

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England 

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Nursing Directorate 
Skipton House 
80 London Road 
London 
SE1 6LH 

H.M. Coroner 
For Leicester City &South Leicestershire 
The Town Hall 
Town Hall Square 
Leicester 
LE1 9BG 

29th November 2016 

Dear Dr Swann 

Re: Regulation 28 report to preventfuture deaths: Benjamin Orrill 

note receipt of the above report of the 19th October made under paragraph 7, 
Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the 
Coroners(Investigations) Regulations 2013. 

also note that this report has been sent to
N ursing and Midwifery Council(NMC). 

 as Chief Executive of the 

My sympathies go to the family of Mr Orrill and thank you for drawing my attention to 
the concerns as outlined. within your report.  I  would like to address them individually 
as set out below: 

There is no regulatory body for advanced nurse practitioners: NHS England 
1.0 
has nc~ jurisdiction over the regulation of nurses. The NMC is the body which sets 
standards of education, training, conduct and performance and ensures that nurses 
and midwives keep their skills and knowledge up to date and uphold professional 
standards. They have processes to investigate nurses and midwives who do not 
meet those requisite standards and maintain a register of nurses and midwives 
allowed to practice in the UK. 

2.0  Advanced nurse practitioners may independently buy into a partnership and 
may not have an employer directly responsible for their appraisal; and therefore may 
be operating as independent practitioners without any supervision or regulation: 
Again NHS England has no mandate in relation to registered nurses who have 
chosen to practise independently. Those registrants remain accountable to the NMC 
as their regulatory body and through a process of professional revalidation are 
expected to maintain their registration. 

 
 However, NHS England as the commissioner expects general practices to complete 
within the annual electronic general practice self-declaration(eDEC)that they 
recognise the need to have the right knowledge, experience, qualifications and skills 
for the purpose of providing services in the practice and demonstrating capacity to 
respond to unexpected service changes.. The eDEC also states that all health care 
professionals employed in the practice have annual appraisals and where applicable 
personal development plans and that this is aligned to revalidation for doctors and 
also for registered nurses and midwives(according to requirements issued by the 
N ursing and Midwifery Council). 

As previously mentioned I  note that
also been sent this report and she will be able to provide more detail on the 
regulatory aspects signposted above. 

 as Chief Executive of the NMC has 

Yours sincerely 

Chief Nursing Officer 
England 

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