AC-LON-2023-002572 - [2025] EWHC 2324 (Admin)

The initial charges related to conduct by the appellant as a nurse at the Fulford Nursing Home near York, where she was employed as an agency nurse. She had no previous disciplinary actions against her.

On 8 April 2019 an agency nurse failed to arrive for a nightshift at Fulford. The Deputy Home Manger made alternative arrangements, through an agency. for a replacement. The appellant attended for the shift. During the shift she administered medication to two residents. Resident A complained that she was woken up by a tablet being pushed into her mouth and that the appellant did not identify herself. Resident B reported that she was woken up around 05:00 by the appellant pushing a tablet into her mouth and without being told what it was.

Resident C died unexpectedly during the night. The appellant is alleged to have failed to act with urgency when she was told about the death. The appellant did not document Resident C’s death in their notes, including at what the time she was informed of the death, who informed her and. the instructions that she gave to the person informing her.

Following concerns about her conduct at Fulford, an ISO was imposed on the appellant on 10 May 2019. At a review on 7 November 2019, a conditions of the order was imposed which included conditions that Ms Tsolo should not work as a registered nurse and not work without supervision.

At the substantive hearing in 2023, the following findings of fact were made by the Panel:

“That you, a registered nurse:

On the nightshift of 8-9 April 2019 at Fulford Nursing Home (the “Home”)

5)

Failed to carry out appropriate medication administration, in that you;

a)

Failed to introduce yourself to residents prior to administering medication to them; (proved)

c)

Tried to administer medication to Resident B by putting the medication into their mouth whilst they were sleeping; (proved)

6)

Failed to follow correct procedure on or around the occasion of the death of Resident C, in that you failed to;

c)

Document the death; (proved)

d)

Provide the necessary details to the 111 operator; (proved)

9)

On 28 July 2019, whilst your registration was subject to an interim suspension order, worked as a registered nurse; (proved)

10)

Between 5 December 2019 and 12 April 2020, whilst your registration was subject to an interim conditions of practice order, breached the conditions of said order, in that you; (proved in its entirety)

a)

Worked as the only registered nurse on duty, and so were;

i)

The Designated Nurse in Charge, contrary to condition 1 of the order;

ii)

Not supervised by a registered nurse, contrary to condition 2 of the order;

iii)

Not supervised when administering medication, contrary to condition 3 of the order;

b)

Failed to create a personal development plan with your line manager, contrary to condition 4 of the order;

c)

Failed to inform the NMC of your employment within 7 days, contrary to condition 5 of the order;

d)

Failed to provide a copy of these conditions to an organisation or person you worked for an/or an agency with which you were registered for work, contrary to condition 7 of the order;

11)

On 23 April 2020, informed an interim order panel of the NMC, that; (proved in its entirety)

a)

There were always two nurses on shift when you were working, when you were the only nurse on duty;

b)

You were always supervised when administering medication, when you were not;

12)

Your conduct at charge 11a and/or 11b was dishonest, in that you intended for the panel to believe you were working in compliance with your conditions of practice order; (proved)”