A “grossly incompetent or grossly negligent” Manitoba nurse has been stripped of her licence and fined $10,000 after admitting to wrongly administering fentanyl and another drug that caused a patient’s heart to stop last fall, a licensing body says.
Nipaben Patel pleaded guilty to four charges at a hearing in November before a College of Registered Nurses of Manitoba panel of inquiry, said a decision released Thursday. A fifth charge was withdrawn.
“The registrant’s admitted professional misconduct is egregious,” says the decision, dated Jan. 28.
“The registrant’s failure to understand their obligations, to recognize their own inexperience and limitations, and to communicate or collaborate demonstrated an astounding lack of judgment.”
Patel demonstrated an “incredibly serious, egregious” lack of skill and judgment in November 2024, when she administered fentanyl and succinylcholine to a patient in Lynn Lake, Man., without receiving prior consent from a doctor, the decision says.
The 55-year-old patient went into respiratory or cardiac arrest.
Patel failed to follow guidelines for administering the “high alert medications” and didn’t perform proper checks on the patient, the panel said in the decision.
“When the patient’s vital signs became unstable, they failed to intervene and failed to alert other members of the health-care team,” the decision says.
The committee asked the college to cancel Patel’s nursing licence, and issue a reprimand and $25,000 penalty. Patel asked for a suspension of 15 to 18 months, with credit for already not practising for 12 months, and to be put through a clinical competence assessment.
Patel worked from 2004-10 as a registered nurse and midwife in India before getting a job as a health-care aide in Canada in 2012, an agreed statement of facts said.
She completed English language proficiency testing in 2017 and was registered as a licensed practical nurse in Manitoba from 2017-23. Some of that time, she worked in long-term care facilities and for an agency in northern communities.
In 2023, she became licensed to practise as a registered nurse in New York, then became registered in Ontario and, through an endorsement portal, was able to bypass a clinical competency assessment and register in Manitoba, the college said.
She got her registered nurse licence in Manitoba in August 2023, after the National Nursing Assessment Service deemed her experience in India was sufficient.
In January 2024, she began getting contract work in Lynn Lake. Prior to that, Patel hadn’t practised as a registered nurse since her time in India 13 years earlier.
The patient was hospitalized after being found lying on the floor of his home. Patel was one of two nurses on staff, along with a clinical care assistant and physician.
The doctor determined the patient needed to be transported to Winnipeg via LifeFlight air ambulance. He also eventually needed to be intubated, the doctor said, but was in stable condition and OK receiving air through a mask for the time being.
Patel misinterpreted the situation and what the doctor said.
She removed fentanyl from a locked cupboard in the medication room without noting on the narcotic sign-out sheet who the drug was for, then pulled the paralytic medication succinylcholine from a fridge. She didn’t label either syringe properly and ignored other warnings.
She didn’t perform a double-check on either medication, which Shared Health — Manitoba’s provincial health-care body — requires under safety controls for high-alert medications.
Patel administered the succinylcholine. She watched as the patient’s oxygen levels dropped over the next four minutes, and then gave the patient fentanyl — all without notifying her peers and without the doctor present.
Within six minutes, the patient went into respiratory and cardiac arrest. A code blue was called and CPR was started by a member of the emergency medical team.
The physician took over and the patient started breathing again.
Patel incorrectly assumed she got verbal permission from the physician to administer the drugs, the decision said, but later admitted she didn’t get an order from the doctor or anyone else.
After the code blue, Patel asked the doctor to fill out a written order stating she gave her permission to administer the succinylcholine and fentanyl. The doctor refused to do that retroactively.
The next day, Patel quit.
About a week later, the physician filed a complaint that was reviewed as an urgent matter by the nursing college CEO and registrar.
Patel’s licence was temporarily suspended. An investigation ensued and found, in part, Patel hadn’t previously administered succinylcholine and “did not know what the medication was for.”
The panel ordered that Patel’s licence be cancelled, and that she be reprimanded and pay a $10,000 penalty.
Her misconduct was described as “shocking,” and the college said the decision was important for maintaining public trust and to “keep people safe.”
“The fact that the registrant sidestepped or ignored multiple safety steps would have resulted in the death of the patient if a paramedic had not been present in the trauma bay,” the decision said.
“Had the registrant been subject to a [clinical competence assessment] before being endorsed as a registrant with the college in 2023, these tragic events … might have been avoided.”
Manitoba’s college — like other regulators — has to honour registration decisions made elsewhere in Canada.
Deb Elias, CEO and registrar with the college, said in a statement that easing requirements for labour mobility applicants registered in other Canadian jurisdictions is at “the core of the college’s concerns regarding the Manitoba government’s continuing directive that the college may not require or set a standard for currency of practice for labour mobility applicants seeking registration in Manitoba.”
That concern extends to both internationally and Canadian-trained nurses, the college says.
The college is now seeking a meeting with provincial officials to review that directive.
