Referring a Nurse Or Midwife to the NMC: Lsamos

Referring a Midwife to the NMC:
For Local Supervising Authority Midwifery Officers

We need accurate information to assess your referral and, if appropriate, dosomething about it. Ensuring referrals are appropriate and contain all information required means we can act and respond quickly.Please read information on , refer to Advice and information for employers of nurses and midwives (NMC, 2011) or call 020 7637 7181.

If you are not a LSAMO referring a registered midwifeplease 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, please phone 020 7637 5688 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

Read our information on “Concerns, complaints, referrals” pages on our website:
Complete all sections of the form
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 to . 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.

Although the 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 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

Your name
Your designation
Your LSA Region
Organisation name
Correspondence address
Your daytime phone number
Your email address

Please provide details for an alternative point of contact

If you are unavailable we may need to make contact with your LSA Office, please ensure that the person named below is aware of this referral.

Name
Designation
Daytime phone number
Email address

Section 2: About the midwife

Please complete one form for each midwifethat you refer to the NMC and provide as much detail as you can.

Which part of the register is the midwife on? Tick all that apply.

MidwifeNurse Specialist community public health nurse

Is the midwife currently suspended from practice by the LSAMO? Yes No

Name / Pin / DOB / Address
1
How long has this midwifebeen working within your Local Supervising Authority?
Who is the midwife’s current Supervisor of Midwives?
Which organisation is the midwife employed by?
What is their current employment status?
Which role were they employed in?
Please provide a contact name and contact details for the employer.

Section 3: About the incident(s)

In which country did the incident(s) take place? Tick all that apply

England

Scotland

Wales

Northern Ireland

Overseas or other (please specify):

In what type of place was(or is) the midwife concerned employed?

NHS Trust

PCT

GP practice

Independent midwifery

Private hospital or unit

Other (please specify):

Chronology of Incident(s)

Incident 1:

Date(s) and time(s) of incident
Address where incident occurred (include location details e.g. ward)

Description of incident (please provide a brief summary and include attachments if applicable)

NOTE: CONTINUATIONPAGES ARE LOCATED AT THE END OF THIS FORM FOR USE IFREQUIRED

Was a Supervisory Investigation conducted? Yes No

(space is provided below to detail a specific employer investigation)

Named Supervisor of Midwives who conducted the investigation
Designation
Organisation name
Correspondence address
Daytime phone number
Email address

Please provide a brief summary of thesupervisory investigationand provide relevant reports.

Outcome of supervisory investigation (please enclose relevant material).

Recommendations of this supervisory investigation:

Local Action

Local Action including Developmental Support

Local Supervising Authority Practice Programme

Please provide a chronological summary of the support provided to the midwife. If a practice programme was recommended, please provide details as to why it was deemed necessary, where it took place, who was involved and the relevant dates. Please enclose relevant supporting material.

Was the Programme successfully completed?

Yes

Date of completion…………………………………

If no, please provide a brief summary of onward actions:

Was this incident referred to the NMC?

Yes No

Has/was the midwife been suspended from practice by the Local Supervising Authority

YesDate of Suspension…………………………………….

Please provide correspondence sent by the LSA to the midwife with regard to their Suspension from Practice and referral to the NMC in your attached information.

Was an investigation conducted by the employer in addition to the Supervisory investigation?

Yes

Named of staff member who conducted investigation
Designation
Organisation name
Correspondence address
Daytime phone number
Email address

Please provide a brief summary of the investigation and provide relevant reports.

Outcome of investigation (please enclose relevant material).

Were any other investigations conducted in respect of this incident(s) in addition to the Supervisory investigation and/or employer investigation?

Yes

If yes, please provide detail here

Continuation pages are included at the end of this form if FURTHER INCIDENTS ARE TO BE REPORTED

Section 4: Background to referral

Are you aware of any previous concerns, complaints or incidents that relate to this midwife?

Yes

If yes, please provide a summary below and attach any supporting information.

Does the LSAMO feel all local options have been considered?

Yes

Why are you referring this matter to the NMC rather than dealing with the concerns at a local level?

What is the LSA’s view on the scope for further local action, including a practice programme (if not already undertaken)?

Section 5: Witnesses

Were there witnesses to the incident(s)?

If yes, please provide their details below and attach copies of witness statements or reports. You should tell the witnesses you are passing their statements to the NMC and that they may be called to give evidence.

Incident 1

Name and designation of witness / Contact details (address, email, telephone number) / Have they been informed of this referral / Are they willing to cooperate with this investigation?
Yes
No
Yes
No
Yes
No

Incident 2

CONTINUATIONPAGES ARE LOCATED AT THE END OF THIS FORM FOR USE IFREQUIRED

Section 6: Otheractions

Have thefamily/families involved in any of the incidents listed been informed of the referral of this midwife?

Yes

Have you contacted any other agency about this matter?

For example the police and other agencies. If so, please provide their contact details. If you contacted the police, please provide the name and contact details of the investigating officer.

Section 7: Signature and consent to disclose

To undertake our investigation, we require your consent to send a copy of your referral and associated information to the relevant midwife, their employer and any other relevant party as required. We also require your consent for any healthcare provider holding relevant information about your referral (including medical or nursing notes) to disclose that information to us as required for our investigation.

By signing (or typing your name if sending this form by email) and dating below, you give us consent to disclose this referral form and supporting information and any other information you provide during the course of our investigation. If you wish to remain anonymous, i.e. you don’t provide your consent, you can still make a referral. However, in most cases this means we will be 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.

Signed / Date

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

Section 8: 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.

You may attach your own index list if you wish.

Type of document

How many?

Evidence that the matter has been investigated locally
Copies of witness statements
Copies of relevant medical records
Consent to approach employer for further information to assist our investigation
LSA documentation

Other types of documents (please specify)

How many?

Continuation pages

Chronology of Incident(s)

Incident 2:

Date(s) and time(s) of incident
Address where incident occurred (include location details e.g. ward)

Description of incident (please provide a brief summary and include attachments if applicable)

Was a Supervisory Investigation conducted? Yes No

Named Supervisor of Midwives
Designation
Organisation name
Correspondence address
Daytime phone number
Email address

Please provide a brief summary of the investigation and provide relevant reports.

Outcome of investigation (please enclose relevant material).

Recommendations of this Investigation:

Local Action

Local Action including Developmental Support

Local Supervising Authority Practice Programme

Was the Programme successfully completed?

Yes Date of completion…………………………………

If no, please provide a brief summary of onward actions:

Was this incident referred to the NMC?

Yes No

Has/was the midwife been suspended from practice by the Local Supervising Authority

YesDate of Suspension…………………………………….

Please provide correspondence sent by the LSA to the midwife with regard to the Suspension from Practice and referral to the NMC in your attached information.

Continuation pages

Section 5: Witnesses

Incident 3

Incident 4

Page 1 of 18