What happened
On the night shift of 30 to 31 August 2023, at a mental health ward in London run by Central and North West London NHS Foundation Trust, a patient was taken to her bedroom.
A bank mental health nurse, the most senior member of staff on duty that night, took over the restraint. The patient was placed prone on the bed. The panel found he held her head face down on the bed, allowed colleagues to hold her by the neck, slapped her, and threw a cup of liquid over her.
He documented none of it and gave a dishonest account intended to conceal what had happened. Bruising to her face, neck and arm was recorded.
The outcome
At a hearing on 21 April 2026 the Nursing and Midwifery Council found the charges proved, including holding her head face down, allowing the neck holds, the slap, the liquid, the failure to document, and the dishonest account. The charge that he himself held her by the neck was not proved.
The panel found his fitness to practise impaired and concluded the only appropriate sanction was removal from the register.
No criminal proceedings are recorded in the decision.
What went wrong
The trust’s own use-of-force policy, which the panel recorded, states that physical restraint must never involve compression of the neck and that neck holds must never be used. That prohibition is not a preference. Compression of the neck can stop blood flow to the brain within seconds and is one of the recognised routes to death in restraint.
So the finding that matters most is not the slap. It is that the most senior nurse on duty stood in a bedroom where colleagues had their hands on a patient’s neck and did nothing. The panel found he allowed it.
Face down on a bed is the second mechanism: a mattress gives way under a chest that needs to expand, and the head is turned away from anyone monitoring it.
Then the paperwork: no record and a false account. That is how an incident disappears, because the next shift, the reviewing manager and the safeguarding lead all read that nothing happened.
What it teaches
Rank is not protection. The most senior person present is the one who sets what is permitted in the room, and here the senior person was part of it.
A banned technique in use tells you the policy is not enforced at the bedside. The test is not whether staff can recite the rule but whether anyone has ever stopped a colleague mid-restraint, and been backed.
And the record is part of the intervention: a restraint not written down accurately cannot be reviewed, learned from, or seen by the family.
Questions for the room
- Your policy bans neck holds. What happens the first time someone uses one in front of a more senior colleague?
- Who in that bedroom had the authority to stop it, and did they know it?
Evidence and limits
Confidence: confirmed. The Nursing and Midwifery Council’s reasons document of 21 April 2026 was read, and the findings above are taken from it.
Two distinctions are kept deliberately. The panel did not find that he held her by the neck himself; it found he allowed colleagues to do so. And this is a regulatory finding, not a criminal one.
The nurse is not named. He was not convicted of an offence, and the standing rule for this casebook is that staff are named only where a conviction exists. The patient is not named and is described only as a patient on an inpatient mental health ward.
Sources
Our vulnerable and volatile persons training deals with exactly this: what a senior person does when a restraint in front of them has gone wrong.
Reviewed 20 October 2026.