We need accurate information to assess all the concerns that are raised with us and do something about them if we deem them serious. Making sure referrals are appropriate for us and contain all information required means we can act and respond quickly.
This referral form is to be used by healthcare professionals who want to refer another nurse, midwife or nursing associate to us.
If you’re a member of the public or colleague, please use our other referral forms
If you have any questions or if you need this form in a different format or you need assistance raising your concern, please call us on 020 3307 6802.
You’ll be able to upload information when you fill in this form. This could include:
During our fitness to practise process, you might need to give us more details in writing, talk through your experience with a member of our team or receive written information from us.
We know that these things can be difficult for some people, and we want to provide you with the best support possible. For example, some people might want to only talk to us over the phone or have someone to support them through our process, like an advocate.
We've got lots of information on our website about the process that we'd recommend looking at before submitting your concerns. It'll help give you an idea of what to expect and what support you might need.
What support might you need from us during the fitness to practise process?
Please note: By law, we can only to investigate concerns about nurses, midwives or nursing associates.
If your concern is about another type of health professional you could:
Please provide details for an alternative point of contact within your organisation
This could be your manager or a colleague. Please let this person know that we may contact them about the referral if we can’t contact you.
* Required fields
Please provide as much detail as possible, including your contact with the individual you’re referring and any dates in question.
If yes, please tell us why below
Please give us a summary and attach any supporting information.
Please note: you can only upload the following file types - pdf, doc, docx, jpg and jpeg.
There is a 10MB limit to each file, you must select and upload all of your files in one go. You'll need to upload all your files in one go, if you upload the wrong file you can delete and upload again.
If yes, please let us know who you informed, when you did so and how the they responded.
If you didn’t feel able to involve their place of work, please let us know us why.
If yes, please let us know
Please name the specific wards, departments or units where the incident or incidents took place. If this was across different locations, please include all below.
Please use the following format (day/month/year)
Please describe what happened in as much detail as possible.
If there wasn’t one incident but smaller incidents over time, please describe all these incidents in as much detail as possible.
Telling us about anyone else who was there will help us investigate what happened.
Please note that where you provide contact information for witnesses, we may contact them without first telling you.
For example, if you contacted the police, please let us know the name of the officer you contacted, their details and any responses they’ve made.
We’ll use the information you’ve provided in this form in accordance with our our privacy notice and our Fitness to Practise information handling guidance.
By agreeing and submitting your concern, you give us permission to share this referral form, any supporting information and any other information you provide during the course of our investigation.
It might be necessary for us to share this information to the nurse, midwife or nursing associate, their employer and any other relevant party we identify.
You can make a referral without providing giving us permission to share the information in this referral, but we might still need to act on the information that you have provided and share this information as a result.
We’ll explain this to you if this is the case.
