Nurses under investigation by the Nursing and Midwifery Council (NMC) are being left isolated, confused and struggling to afford legal support, a not-for-profit law firm has warned.
A nurse and senior case lawyer behind Sequentus Law have spoken to Nursing Times about some of the ongoing challenges facing nurses under investigation by the regulator.
“We’ve seen what happens when it goes wrong and it’s not fair”
Khaled Hussain-Dupré
Sequentus Law, established in 2022, is a not-for-profit organisation which focuses on providing pro-bono and affordable legal assistance to nurses, midwives and other healthcare workers going through the fitness to practise (FtP) process.
It offers a range of services, including legal advice, case preparation and representation at hearings, as well as free mental health support for registrants.
Samantha Wilson, a registered nurse and programme director at Sequentus Law, told Nursing Times that many nurses and midwives found the FtP process “really hard” to navigate.
“It’s really hard for them to understand what’s happening to them,” she explained.
“And if you’re not legally inclined you are not going to make your way through these processes at all,” she said.
Sequentus Law was established by Ms Wilson and solicitor Khaled Hussain-Dupré, to provide affordable legal advice and representation to registrants who would otherwise be unrepresented.
The organisation receives around one enquiry per day and is currently managing between 60 and 70 active cases.
Ms Wilson said: “I have had big dreams and goals for this programme, because I do want it to be accessible to everybody.
“Nurses are coming to us, and other healthcare staff, but I want them to know that it exists from day dot.”
One of Sequentus Law’s first clients was suspended and had conditions of practise imposed which resulted in her being unable to afford to live.
This prompted the organisation to focus on pro-bono and affordable representation.
“She couldn’t even afford to buy a weekly shop [or] pay her rent, so there was no way that she could afford to pay for any representation,” Ms Wilson explained.
“So it’s things like that [where] I want to make sure that we’ve got these people covered.”
Samantha Wilson.
Ms Wilson also raised concerns about registrants being charged excessive fees by other organisations.
She said: “It is the elephant in the room for us. We don’t want to be criticising other organisations who are trying to come in and assist, but there are huge, glaring examples [of it].
“They shouldn’t be doing that. I would go as far as to strongly say it’s at the level where it could be considered being taken advantage of.”
Overall, Ms Wilson said the FtP process could be “one of the loneliest times in the world” for nurses.
She said: “It has such a massive further impact on the nurse’s mental health.
“I am not surprised that people, without being too graphic here, just think, ‘you know what, I’d rather be dead than continue to go through this’, because of how this process makes them feel.
“This is where I think support, right from the start, [and] people being aware of places like us, the clinic, what we can do, what we can offer, [can help].
“We go out of our way to be a full support to them,” she noted.
This was echoed by Mr Hussain-Dupré, who works in the capacity of senior case lawyer at Sequentus.
He said: “I speak to each and every potential client and all express a massive sense of relief at being able to find an organisation that is finally able to help, not turn them away.”
For many registrants, legal support is “completely and utterly inaccessible”, as they are not members of a union, Mr Hussain-Dupré warned.
“If you’re not a member of the [Royal College of Nursing] or the [Royal College of Midwives], or Unison or Unite… then you are pretty much on your own,” he added.
“And legal fees, if you went to a high-street law firm, or if you went to a barrister, would be in the tens of thousands for serious cases.”
Sequentus does some pro-bono work for registrants most in need but otherwise charges around £60 an hour for casework.
It offers an initial review of cases, legal advice and support with preparation and representation at hearings.
The organisation has also partnered with UK universities to enable law students to work on live cases under supervision, creating a “circular economy”.
“We know that being referred to our fitness to practise process can be distressing, particularly for those without legal or union representation”
Lesley Maslen
“What we wanted to do is try and marry that up really – law students looking for experience and clients who actually needed resource for their case,” Mr Hussain-Dupré explained.
“It works really, really well. The universities get a programme delivered, students get experience, and we can deliver the service that’s absolutely needed.”
Since its inception, Sequentus has expanded its legal team to meet rising demand, including hiring a second qualified solicitor, additional case lawyers, and two full-time legal support staff.
The organisation has also broadened its remit to represent registrants across other healthcare regulators in England.
Mr Hussain-Dupré said: “The demand has absolutely come through the roof. We’ve taken up our time to upscale things so that we do it properly, so that we can actually deliver the service that’s actually required.”
“There are similar levels of demand across all those professions: people in the same situation, not members of the union [and] they can’t afford representation.”
As well as providing legal advice, the organisation wants to provide “moral support” for registrants who may have been going through the process for a prolonged period.
Mr Hussain-Dupré said: “We’ve seen what happens when it goes wrong and it’s not fair.
“If people are already in a situation where it is the difference between whether they can practise or not, when it’s been going on for four, five [or] six years, I don’t think it’s fair to play with people’s lives or to leave them in any kind of uncertainty whatsoever.”
Last year’s independent review into the NMC’s internal culture found that delays in FtP investigations were having a serious impact on registrants’ wellbeing.
The report warned of good nurses being investigated for years over minor issues, while serious concerns were left unresolved.
It also revealed that six nurses had died by suicide while under investigation in the preceding year.
More recently, the regulator has been pushed by campaigners to publish lessons learned from the deaths by suicide of nurses under FtP investigation in recent years.
Mr Hussain-Dupré said he was “not surprised at the number of suicides” mentioned in the independent culture review and would “venture that there are probably hundreds and hundreds more who are on the verge”.
In response, Sequentus has established a team of independent counsellors to provide free mental health support to all clients.
“We provide the counsellors with in-depth training in relation to the fitness to practise process and what we know to be the particularly stressful aspects, such as finances, stigma, professional identity, self-confidence and legal anxiety,” said Mr Hussain-Dupré.
“Our team uses a solution-focused model to help registrants develop the coping strategies and resilience to be able to handle whatever comes next in their case.”
The NMC has recently reported “major strides” in improving its FtP processes over the past year.
More on fitness to practise
In an update to its governing council in July, the regulator said around 70.4% of FtP cases were being resolved within 15 months, representing an increase of around 10 percentage points on July 2023.
It had also seen a record number of screening decisions being made, with 809 decisions being made in May alone.
To reduce the stress and uncertainty for people involved in the NMC’s FtP process, the regulator said it had focused efforts on making quicker decisions and resolving cases earlier.
In the 12 months to June, the regulator reached an average of 928 decisions a month across the FtP process, meaning cases were either closed or progressed to an investigation.
This is an increase on the average of 777 decisions in the previous 12-month period.
The progress follows momentum by the NMC to turn FtP around, which includes a Fitness to Practise Plan underpinned by £30m investment.
In a separate update, the regulator said it had completed 24 of 37 recommendations from last year’s culture review, including the establishment of a safeguarding hub to identify and support vulnerable registrants earlier in the FtP process.
However, the NMC has acknowledged that challenges remain, with high numbers of new referrals continuing to place pressure on the system.
Lesley Maslen, executive director of professional regulation at the NMC, told Nursing Times: “We know that being referred to our fitness to practise process can be distressing, particularly for those without legal or union representation.
“Professionals who have support are more likely to experience better outcomes, and we encourage them to seek advice and support throughout the process.”
Ms Maslen said a key part of the NMC’s FtP plan was about “improving people’s experience” and, as part of this, the regulator had updated its website to signpost professionals to organisations that can advise them on the process, including Sequentus.
She added: “We’ve also added information about organisations offering wellbeing support. We will continue to develop our website-based information for professionals.
“Additionally, we recently co-hosted a webinar with unions to provide clear, practical information, and we’re planning further sessions in the future.
“We also recognise that the longer someone is involved in FtP, the more difficult it can be,” she said.
“That’s why improving the timeliness of decision-making is so important,” said Ms Maslen.
“There’s more to do, but we’re making progress – including a record number of screening decisions and continued improvement in the time it takes to complete cases end-to-end within 15 months.”
The NMC also highlighted several recent measures aimed at improving safeguarding and emotional support for registrants.
Since October 2019, it has provided an independent Careline, run by specially trained counsellors, which offers confidential emotional and practical support to professionals involved in the FtP process.
In addition, a safeguarding hub has been introduced to ensure that all new FtP referrals are reviewed at the outset to identify any safeguarding or wellbeing risks.
The NMC has also made substantial investment in its internal safeguarding team, expanding the number of advisers available to provide direct support and guidance to staff when safeguarding or wellbeing issues are identified.
