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Referring a nurse or midwife to the NMC:

For patients and the public

If you feel that the actions of a nurse or midwife may be putting the safety of patients or
the public at risk, you can use this form to refer them to us. We need the information
requested so we can consider your referral and, if appropriate, do something about it.

If you have any questions or if you would like this form in a different format or in
another language, please contact either by phoning 020 7681 5999 or email us at

If you are an employer, please refer to the employer section of our website at and complete our referral form for employers.

To complete this form electronically

Save the form to your desktop before completing it. To fill in each section, click on the
grey fields and start typing or tick the relevant grey box.

To complete this form by hand

Print it and write your responses in the spaces provided using BLOCK CAPITALS or in
clear, legible handwriting. If you require more space for further information, write a
summary in each box (please do not simply write see attached), attach additional
information separately and reference the additional information in each box on this form.

Section 1: About you

To complete the information in this form, click on the relevant grey box and type.

Your name Peter M. Heimlich

Correspondence 3630 River Hollow Run

address Peachtree Corners, Gerogia 30096

Daytime phone number 208-474-7283

Email address

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Are you completing this form on behalf of someone else? If so, please provide
their details and a brief explanation about the nature of your relationship with


Section 2: About the incident

Who was the nurse or midwife involved?
Please give the name of anyone involved. If you dont know their name, please provide
us with as much information as possible to help us find out who they are, as we cannot
undertake our investigation if we cant identify them.

If you know their NMC Pin, please provide this so we can progress your referral quickly.

Do not write see attached please provide a brief summary.

Jacqueline Ricketts - Mid and West Wales

Registered Nurse - Adult (Level 2)
Start date 01/06/1984
Expiry date 30/06/2017

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When did the incident(s) take place?
Please give exact dates and times, if possible.

Do not write see attached please provide a brief summary.

On or about May 29, 2016 reportedly at dinner time.

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Where did the incident(s) take place?
Please provide the name and address of the hospital, nursing home or place where the
incident(s) occurred. It will also be helpful if you can provide the name of the specific
ward, department or unit. If incidents occurred in more than one place, please provide
the name and address, or location, where each incident took place.

Do not write see attached please provide a brief summary.

Allt-Y-Mynydd Care Home

Llanybydder, SA40 9RF
Tel: 01570 480208 / 01570 480595
Fax: 01570 481070

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What happened?
Please describe what happened. There may not have been one major incident, but
rather a series of small events over time. Provide as much information as you can.

Do not write see attached please provide a brief summary.

Via Life Vac anti-choking device designed in North Devon has just saved its first life by Laura
Brainwood, North Devon Journal, June 14, 2016:

A North Devon family-owned anti-choking business has saved its first life - only a day after a
care home purchased the device.

...And they recently heard the news that one of their devices had saved the life of an elderly
woman at Allt-Y-Mynydd Care Home in Llanybydder, Wales.

Deputy Manager at the Ashbury Ltd Car Home Jackie Ricketts said: "I don't want to think
about what would have happened if we didn't have it."

She described how during dinner one of the residents began to choke on her food
prompting staff to begin the "usual back slapping" and subsequently used Life Vac.

Miss Ricketts said the device was used only one day after it arrived having been ordered
online to help the same resident, who has an ongoing problem with swallowing food.

She said: "I would like to see maybe a pocket one that is more mobile. I have been
recommending it to all my colleagues - I would highly recommend it to people who work with
children and other people."

Via the attached June 9, 2016 press release issued by Help Save Lives Medical & Training

Allt-Mynydd Care Home in Dyfed lost a resident in January of this year due to choking. Only
two days after owning a LifeVac it prevented another casualty after a resident choked on
their food during lunch time. The on duty nurse Jackie Ricketts applied the LifeVac which
dislodged the food without causing any injury to the resident.


It is unclear if the LifeVac device has been properly tested and approved. Therefore, this
is to request that your agency obtain the following information and determine if Ms.
Ricketts was in compliance with all applicable standards and guidelines, and to provide
me with the results of your determination.

1) Has the LifeVac device been approved for use on care home residents in Wales?

2) Did nurse Jacqueline Ricketts receive approval to use the LifeVac device on a
resident? If so, what is the name and job title of the employee who provided that

3) What training if any did Ms. Ricketts receive before using the LifeVac device on the
elderly female resident of the care home?

4) What other medical professionals reviewed and approved the use of the LifeVac
device prior to its use the elderly female care home resident?

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Section 3: Witnesses
Did anyone else see what happened?
Were there any other witnesses? Do you know their details?

Do not write see attached please provide a brief summary.

According to correspondence I received (copies on request), Allt-Y-Mynydd Care Home

administrator Elaine Richards was aware of the choking incident.

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Section 4: Your actions
Have you made a complaint to anyone else about this?
You may have told someone else or another organisation about your concerns. There
are independent complaints systems available locally. If you have contacted any of
these people or bodies, please provide us with their names and addresses or phone

Do not write see attached please provide a brief summary.


Section 5: Consent to disclose

To undertake our investigation, we require your consent to send a copy of your referral
and associated information to the relevant nurse or 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.

An important aspect of our work is to protect the public. Because of this, we can
sometimes share someones personal data with others in order to progress an
investigation or to report safeguarding concerns.

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By signing (or typing your name) 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. We will be unable to use this referral form and attached
documents without your consent.

Signed Date July 4, 2016

Please type your name if sending this form by email.

Section 6: 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 in
the space provided list any other types of documents you have supplied and state how
many in each case.

Type of document How many?

Evidence that the matter has been investigated locally
Copies of witness statements
Copies of relevant medical records
Other types of documents (please specify) How many?
June 9, 2016 press release issued by Help Save Lives Medical & Training 1

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Type of document How many?

Section 7: Next steps

Thank you for completing this form. There are four ways to send the completed
information to us.

1 By email: Type your full name in the signature box, save this form and attach the
file to an email, together with electronic copies of supporting evidence, to

2 By email and post: Send this form as in option 1 above, but send hard copies of
the supporting evidence and a signed, printed copy of this form to the address

3 By fax: Send this form and faxed copies of supporting evidence to 020 7580 3410

4 By post. Please seal it in an envelope, along with copies of the supporting

evidence, and send it to:

Nursing and Midwifery Council

Screening Manager
Fitness to Practise
1 Kemble Street

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.

If the nature of your referral falls outside the NMC's remit, we will put you in contact with
the appropriate body.

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LifeVac Saves its First Life

LifeVac Anti-Choking Device Saves the Life of a Care Home Resident in Swansea

LifeVac is a new single suction anti-choking device has saved the life of an elderly care home resident
in Swansea. After supplying Ashberry Healthcare Limited in May with a LifeVac it saved a residents life!

Allt-Mynydd Care Home in Dyfed lost a resident in January of this year due to choking. Only two days
after owning a LifeVac it prevented another casualty after a resident choked on their food during lunch
time. The on duty nurse Jackie Rickett applied the LifeVac which dislodged the food without causing
any injury to the resident. LifeVac saved the residents life on the FIRST application! Help Save Lives &
LifeVac is proud to say we have saved our first of many lives!The LifeVac device has been proven safer
and more effective than conventional abdominal thrusts and back slaps in a peer reviewed journal

After seeing a demonstration of the device at the Elderly Care: Leading the Way conference in Blackpool,
a care home matron commented: this should be in every establishment, just like fire extinguishers are.
LifeVac has received a great response since the New Year, and is being supplied to many different
industries including: schools, restaurants and the care sector in particular. Over 200 care homes in the UK
are now equipped with the LifeVac device. In testing the LifeVac has had a 99.9% success rate in
comparison to the 80% success rate of conventional choking first aid methods and only requires one
person to aid the choking victim. This relieves the panic and fear of choking away from vulnerable people
and their carers.
The incredible benefit of the LifeVac is that there is zero risk of injury to the casualty. The device has a
one way patented valve, when applied it only sucks up and does not push air down the throat when
pulled, creating three times more pressure than the abdominal thrust. If the patient is elderly, disabled,
frail, bariatric or not built to take the abdominal thrust the LifeVac is ideal.

The number of establishments equipped with the LifeVac is growing daily, but we need this to continue
to increase to ensure that lives are saved in the future. Death by choking is avoidable with the LifeVac
device. LifeVac is available from Help Save Lives Medical & Training Supplies - - 0208 127 0210 or

Editors Note:

The success of the LifeVac has been proven in independent papers and published with the
American Journal of Emergency Medicine.
The LifeVac is FDA approved, MHRA approved as a class one medical device, Canadian Health
service approved and CE accredited.
LifeVac costs 59.95 + VAT.

Help Save Lives Medical & Training Supplies

Tel: 0208 127 0210 - Email: - Web: