Reporting a Nurse Or Midwife to the NMC: Patients and Public

Referring a nurse or midwife to the NMC:

For patients and the public

We need accurate information to assess your referral and, if appropriate, dosomething about it. Ensuring referrals are appropriate for us and contain all information required means we can act and respond quickly. Please read information on “Concerns, complaints, referrals” pages on our website:

If you are not a patient or member of the public please use a different referral form available on

If you have any questions or if you would like this form in a different format or in Welsh language or you require assistance with completing this form, please phone 020 7681 5248 or email us at

How to complete this form electronically

• To fill in each section, click on a grey field and start typing, or double-click a grey box to mark it checked.

How to complete this form by hand

• Write your responses using BLOCK CAPITALS or in clear, legible handwriting.
• If you need more space for further information, write a summary in each box, attach additional information separately and reference the additional information in each box on this form. Please do not simply write ‘see attached’.

Checklist before submitting this form

1. Read our information on “Concerns, complaints, referrals” pages on our website:
   
2. Complete all sections of the form
3. Provide all required information, documents and evidence.

How to submit a referral

By email

Type your full name in the signature box, save and email this form and electronic copies of supporting evidence . Please note: attachments are limited to 25MB, so please send larger files separately.

By fax

Fax this form and copies of supporting evidence to 020 7580 3410.

By email and post

Email this form and evidence as above, but send hard copies of the supporting evidence and a signed, printed copy of this form to the address below.

By post

• Write your responses using BLOCK CAPITALS or in clear, legible handwriting.
• Sign your name, seal this form in an envelope with copies of the supporting evidence, and send it to:
  

Nursing and Midwifery Council

Screening Manager

Fitness to Practise

1 Kemble Street

London, WC2B 4AN

We will write to let you know we have received your referral and that we are considering it. We will then keep you informed about what is happening.

Confidentiality

If you wish to remain anonymous you can still make a referral. However, in most cases this means we are unable to use this referral form and any information provided to start or progress the investigation. Moreover, you will not receive any updates on this referral.You can find out more about this on our website:

Although the nurse or midwife needs to be aware of the identity of a complainant, we respect patient confidentiality. At hearings, identities are usually kept anonymous. In cases where a complaint of a sensitive nature is made against a nurse or midwife (for example, sexual impropriety) and the patient is the sole witness, we try to make the hearing as easy as possible.

For more details on how we handle your information, please visit “Concerns, complaints and referrals” pages on our website.

Section 1: About you

To complete the information in this form, click on the relevant grey box andtype.

Reasonable adjustments

We are committed to making adjustments to make sure that our processes are accessible for everyone. Please tell us if there is anything we can do to make this process more accessible and easier for you to engage with.

Are you completing this form on behalf of someone else? If so, please provide their details and a brief explanation aboutthe nature of your relationship with them and whether they require us to do anything to make the process more accessible and easier for them to engage with.

Section 2: About the incident

Who was the nurse or midwife involved?

Please give the name of anyone involved. If you don’t know their name, please provide us with as much information as possible to help us find out who they are, as we cannot undertake our investigation if we can’t identify them.

If you know their NMC Pin, please provide this so we can progress your referral quickly.

Do not write ‘see attached’ – please provide a brief summary.

When did the incident(s) take place?

Please give exact dates and times, if possible.

Do not write ‘see attached’ – please provide a brief summary.

Where did the incident(s) take place?

Please provide the name and address of the hospital, nursing home or place where the incident(s) occurred. It will also be helpful if you can provide the name of the specific ward, department or unit. If incidents occurred in more than one place, please provide the name and address, or location,where each incident took place.

Do not write ‘see attached’ – please provide a brief summary.

What happened?

Please describe what happened. There may not have been one major incident, but rather a series of small events over time. Provide as much information as you can.

Do not write ‘see attached’ – please provide a brief summary.

Section 3: Witnesses

Did anyone else see what happened?

Were there any other witnesses? Do you know their details? If known, provide their names and contact details, including home and/or work address and mobile/landline numbers.

Do not write ‘see attached’ – please provide a brief summary.

Section 4: Your actions

Have you made a complaint to anyone else about this?

You may have told someone else or another organisation about your concerns. There are independent complaints systems available locally. If you have contacted any of these people or bodies, please provide us with their names and addresses or phone numbers.

Do not write ‘see attached’ – please provide a brief summary.

Are you raising a concernabout patient safety or the wider healthcare system?

For assistance in answering this question, please see our Policy on whistleblowing and our Raising concerns guidance for nurses and midwives

Yes No

If yes, please explain below.

Section 5: Signature and agreementto disclose

We will use your information in accordance with our privacy notice and our Fitness to Practise information handling guidance. You can find out more about these on our website:

By signing (or typing your nameif sending this form by email) and dating below, you give us your agreementto disclose this referral form, any supporting information and any other information you provide during the course of our investigation. We may disclose this information to the nurse or midwife, their employer and any other relevant party we identify.

You can make a referral without providing your agreement to disclosure but wemay still need to act on the informationthat you have provided and disclose information as a result. We will explain this to you if this is the case.

We can consider anonymous referrals where you don’t provide your name or agreement to disclosure. However, this may make it more difficult for us to consider the referral and may mean we cannot take any action. You will not receive any information from us about our enquiries or the outcome.

I have read the NMC’s information on referrals, and confirm this is an appropriate referral containing all required information.

Section 6: Document checklist

Please complete this document checklist. It will help us to make sure that we have received the documents you have sent us.

Be sure to include how many of each of the listed documents you have supplied, and list any other types of documents you have supplied and state how many in each case.

Type of document

How many?

Other types of documents (please specify)

How many?

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