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On the evening of 20 December 2019, Nurse Ndiweni commenced what was only his second shift at SummitCare Wallsend. He had accepted an offer from Caring for You Nursing Agency to work at the aged care and nursing home facility. At handover, one of the evening nurses asked if he could change the indwelling catheter of an 82-year-old male resident, who was due his six weekly change, and he replied that he could. At about 2.00 am the next morning he began to change the catheter with the help of an Assistant in Nursing. When removing the catheter he injured the patient’s urethra, leading to bleeding.
About a half hour later Nurse Ndiweni attempted to insert a new indwelling catheter, but without success, and there was further bleeding. Nurse Ndiweni did not seek any guidance or assistance until he called the Executive of the facility about an hour later who advised him to call for an ambulance. When handing over to the ambulance officers Nurse Ndiweni provided limited and incomplete information. The clinical notes he made that evening were also limited and incomplete.
Since first becoming registered as a nurse in Australia on 18 December 2012 Nurse Ndiweni has practiced almost exclusively as a mental health nurse, as he does to the present day. Nurse Ndiweni has only been responsible for inserting a catheter twice before, the last time being about three or four years previously.
In agreeing to work that shift, deciding to remove the indwelling catheter, proceeding to do so, attempting to insert a new catheter, handing over to the ambulance officers, and recording his clinical notes, Nurse Ndiweni is guilty of unsatisfactory professional conduct. We have decided to reprimand Nurse Ndiweni. We also restrict his practice so that when he is working outside of a mental healthcare setting, he is not the sole registered nurse on shift, and he is not the nurse in charge.
Before reviewing the evidence, setting out our findings, and giving our reasons it is useful to review the scope of our inquiry and the matters in dispute.
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