Completing a referral form

Providing information to us

In order to raise a concern with us you will need to complete a referral form. When completing a referral form, please provide as much information as possible.

If information is unavailable and you are concerned about patient safety, you can still make a referral. Any information presented early in the process is better than full information presented late.

In urgent cases where you believe patient safety is at risk you should make a referral to us immediately.

Information to provide on our referral forms

We read and study all evidence and information submitted to us to ensure that outcomes of cases are fair, relevant and always based on fact. Referrals should be supported by documented evidence if appropriate.

The complaint
Please provide a clear summary and detailed account of the complaint.

Incidents relating to the complaint
Please provide clear details about any incidents relating to your referral, being sure to include:

  • when the incident(s) took place (including exact time and dates if possible)
  • where the incident(s) took place (including name and address of the organisation, and specific wards or departments where possible)
  • the type of place where the nurse or midwife was employed at the time of any incident (for example, hospital, nursing home or GP practice)
  • who was there (including patients, colleagues or any other witnesses), and
  • the context and circumstances of any incident(s) (for example, the number and types of patients for whom the nurse or midwife was responsible for and who else was on duty at the time)

Any witnesses
Please provide contact details for witnesses if available. They may be required to give evidence in person to a fitness to practise committee.