What happened
A psychiatric staff nurse worked on an acute mental health ward for patients with organic mental health problems at Betsi Cadwaladr University Health Board in Denbighshire. Between 2012 and 2013 he faced three sets of allegations, heard together by a Nursing and Midwifery Council panel in April 2024.
The first concerned how he moved a patient into a wheelchair, using unnecessary force to manipulate the patient’s right knee. The second was that he kicked another patient repeatedly to move them out of the nurse’s office.
The third is the one this case is here for. A patient was physically resisting medication. He tilted the chair the patient was sitting on, which restrained them, and emptied the syringe into their mouth while they were tilted back.
The outcome
The panel found the charges proved: the force used on the knee, the kicking, and the three particulars concerning the forced medication. It found his fitness to practise impaired.
No criminal proceedings are recorded in the decision. The referral to the regulator came from the health board in July 2014, after a series of events on the ward.
What went wrong
Each of the three incidents is a different failure with the same root: the patient’s body was treated as the obstacle to the task.
Tipping a chair is a restraint. It takes the person’s balance away, fixes them in place, and gives the staff member control of their head and airway while they are supine and unable to protect themselves. It is not a way of administering medicine; it is a hold performed with furniture.
The panel heard all three together, which is how these cases surface: not one act, but a pattern colleagues noticed and took eighteen months to escalate.
What it teaches
Covert restraint is the theme. None of these three acts would appear in a restraint log as a restraint. A knee manipulated during a transfer is recorded as moving and handling. A kick to move someone out of an office is recorded as nothing at all. A tilted chair is recorded as medication administration. A service can have a restraint policy, training and a reporting form, and still miss all three.
That matters for auditing. If the only restraints counted are the ones written down as restraints, the count is not a measure of what is happening on the ward.
The second lesson is time. The events ran from 2012 to 2013, the referral was in 2014, and the hearing was in 2024. A decade is long enough for the same practice to continue elsewhere.
Questions for the room
- Which of your restraints are recorded as something else: moving and handling, medication, behaviour management?
- A colleague kicks a patient to move them. What happens in the next ten minutes, and who is told?
- Tipping a chair is not in any restraint policy. How would your service find out that it was happening?
- The board took 18 months to refer. What would have shortened that?
Evidence and limits
Confidence: confirmed. The Nursing and Midwifery Council’s reasons document of 22 April 2024 was read, and the findings above are taken from it.
The person is not named on this page. He was not convicted of any offence, and the standing rule for this casebook is that a member of staff is named only where a criminal conviction exists. The decision itself is public and cited below, so a reader can identify him; the page simply does not do it for them.
The record does not state a sanction. The panel found impairment, and this page does not say what order followed.
Sources
If your service needs help recognising restraint that is not being recorded as restraint, our physical interventions training starts with an audit of what is actually happening.
Reviewed 20 October 2026.