An important part of nursing is recognizing that situations can go wrong—often due to human error. However, understanding, acknowledging, and escalating problems early enough can help prevent devastating outcomes. Unfortunately, when situations cannot be rectified, they may end up being brought to a court hearing at the Nursing and Midwifery Council (NMC). These hearings involve various cases that nurses and midwives have been part of, which can span from a couple of days to several weeks, depending on the severity and complexity. I was curious to learn more, so I decided to visit the council and observe a hearing as an observer. Read on to find out more about my experience.
My Experience
I spent a few days in London attending Nursing and Midwifery Council (NMC) court hearings. I wanted to explore the legal side of healthcare and understand how the system handles consequences when bad practice occurs. To prepare, I researched previous court cases and reviewed their outcomes, which gave me helpful context. After reviewing past cases, I searched the NMC website for upcoming hearings. The list included various nurses and midwives facing different charges. It highlighted how even the smallest of errors can escalate to the severity of a court hearing and result in formal charges. It was also striking to see the seriousness of some prosecutions. This was what motivated me to attend the hearings as an observer and witness these situations in real life.
The NMC Building
Arriving at the NMC building, I didn’t know what to expect, as I had never visited a court before. I imagined it would look different and grander—more like the courts seen on the news. However, the NMC operated out of a block of flats, with hearings held in office rooms. The receptionists welcomed us and, after I checked in, explained they would call us when the hearings were ready.This gave me the opportunity to observe my surroundings and take note of the different rooms available. It appeared to be a very professional and initially well-organised place.
The side rooms next to reception were for defendants to meet with their representatives and discuss the case. Several rooms along the hallway were already set up for hearings. I didn’t know how long the wait would be, but I definitely didn’t expect to spend nearly two hours waiting before someone invited me into a hearing.
Five minutes after sitting down in the first hearing, the panel decided to adjourn. So I sat back in the reception area and waited. I struggled to understand what was happening because no one had given me any background information about the case I was observing. After waiting another half hour, staff finally called me into the next hearing. This time, I was able to understand more of what was going on, as I managed to observe for an hour and a half.
The hearing room seated observers directly behind the accused, giving them a clear view of everyone involved. Three independent members made up the panel: a Chairperson, a nurse or midwife, and a layperson from outside the healthcare sector. Supporting the process were a legal assessor, a case presenter representing the NMC, a panel secretary, and a shorthand writer. When required, witnesses were called to give evidence. The nurse or midwife facing allegations also attended with their legal representative.
The Case
It was quite overwhelming at first, as I had never experienced anything like it before. The case I observed involved an adult nurse who had been the registered manager of a care home. The panel charged her with misconduct and scheduled the hearing over seven days.
A legal representative defended the accused, while the case presenter, the panel, and the representative cross-examined the witnesses. The questions focused on problems that had occurred at the care home involving patients A, B, C, D, E, and F. It was difficult to follow certain parts of the case. Because I missed the start of the hearing and the panel withheld some details from observers, I struggled to follow everything. Still, it quickly became clear that staff had failed to meet a patient’s hygiene needs and had missed medication doses. Staff failed to implement food and fluid charts, causing a patient to lose a significant amount of weight without being referred to a GP.
Over the next few days, the hearing continued, which I was fortunate to observe still. More issues emerged regarding what had been happening in the care home. Staff relocated 75% of the residents, and authorities eventually closed the care home. The investigation by the Care Quality Commission (CQC) had started following a report that identified several areas requiring improvement. The CQC stated they would return within a few months for a follow-up visit. However, staff still hadn’t resolved some of the issues by the time of the follow-up visit.
I didn’t manage to see the end of the case, so I researched online the outcome. What I discovered revealed a much more serious situation than I had initially realised. A news article reported that a resident at the care home had died after choking on food. He had known swallowing difficulties and should not have been given solid food. This tragic death led to an inquest into the running of the care home. Resulting in further investigation into the registered manager’s failure to carry out her responsibilities properly.
My Thoughts
From observing the court case and researching the CQC report, it became clear that there were several problems in different areas.
First Category: Treating people with respect and involving them in their care.
This was definitely lacking. The report revealed that staff failed to ask residents for their consent before providing care. The NMC Code highlights the importance of obtaining and documenting informed consent before carrying out any action. Staff must inform residents of what is about to happen out of respect and offer them a choice—if they have the capacity to make that decision.
Second category: Providing care, treatment, and support that meets people’s needs.
During the hearing, it became clear that staff failed to treat residents as individuals. They provided generalised care, neglected hygiene needs, ignored the need for food and fluid charts, and failed to update resident care plans. For example, risk assessments were out of date, highlighting a significant lack of management and staff training.
It is essential to provide the highest quality of care that residents deserve. Hygiene is crucial for preventing infection, reducing dental decay, and supporting overall well-being. Staff must use food and fluid charts to monitor residents at risk of malnutrition or dehydration and refer them to the appropriate health professionals, such as a dietitian or GP. Maintaining a healthy diet is key to ensuring the body functions efficiently.
Staff must regularly update care plans to reflect changes in residents’ conditions and needs over time. For instance, changes in mobility require updated risk assessments to ensure safe assistance, protecting both residents and staff. Every resident is an individual, and their care plans should reflect that. Regular monitoring and weekly updates are necessary to ensure care remains person-centred and appropriate.
Third category: Caring for people safely and protecting them from harm.
The case revealed serious failures in how staff handled medication. Nurses must administer medication on time—if it’s prescribed for the morning, they need to give it in the morning. Delays or missed doses can put patients at significant risk. In this case, the registered manager allegedly delayed administering a resident’s medication until they returned from being out during the day.
Staff needed to create and clearly document a proper plan—either explain why they missed the medication or outline an alternative, such as giving it before the resident left. Failure to administer medication as prescribed can lead to serious consequences, depending on the type of medication. For example, missing a dose of anticoagulant medication can put a resident at risk of developing a life-threatening blood clot.
Fourth category: Staffing.
Although staffing is a widespread issue across the healthcare sector, all healthcare settings must remain aware of and responsive to low staffing levels. Managers must consistently monitor staffing levels and recruit additional staff when needed to maintain safe and effective care.
In this case, unregistered nurses were reportedly caring for residents in situations that legally required a registered nurse. This is extremely dangerous. Allowing someone who is not qualified to provide care that falls under a registered nurse’s responsibility is illegal. Major mistakes and errors become far more likely, as untrained staff may not recognise clinical risks or know how to respond appropriately.
It was deeply concerning to hear that the registered manager allowed this to happen. The manager clearly failed to prioritise resident safety—an unacceptable breach of responsibility and professional standards.
Fifth category: Quality and suitability of management.
It was evident throughout the entire court hearing that the quality and suitability of the care home’s management were inadequate. A registered manager must run the care home to the highest possible standard. This includes ensuring that there are sufficient nursing and support staff on duty each day.
When complaints arise, it is the manager’s duty to investigate, address the issues, and implement necessary changes. Managers must ensure staff receive proper training before allowing them to work independently. They also need to keep all resident documentation up to date and actively monitor how senior staff perform.
The manager plays a vital role in the team and must actively engage with both staff and residents. It is essential for the manager to build relationships with residents and ensure they are consistently receiving the best possible quality of care.
Final reflections
Visiting the NMC court hearings truly opened my eyes to the serious consequences that can result from poor nursing care. It has made me more aware—and admittedly a little anxious—about the constant responsibilities I face as a registered nurse. Mistakes can happen easily, and the consequences can be catastrophic.
However, I’ve also learned that even the best nurses can make mistakes. What matters most is how nurses respond to mistakes—by being honest, documenting them properly, and notifying senior staff immediately, they can resolve issues faster and reduce potential harm.
Make it a priority to take your time when administering medication—this is an area a lot of newly qualified nurses feel most nervous about—and do not hesitate to ask for help when needed. Always provide a high standard of care and obtain informed consent before starting any procedure.
Building a strong rapport with patients, I believe, is one of the best ways to recognise early signs of deterioration. Commit yourself to doing your best for every patient you care for and upholding the values and standards of the nursing profession to the best of your ability.
Have you ever observed a professional hearing or had an experience that changed your perspective on nursing?
I’d love to hear your thoughts or reflections—whether you’re a student, a newly qualified nurse, or someone further along in your career. Share your insights in the comments below or contact me through my page.
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