Fitness to Practise RO referral form
This form is for Responsible Officers, Suitable Persons, employers, their nominated representatives, and those acting on behalf of organisations to send fitness to practise concerns to the GMC.
General Medical Council
DC9092-Fitness-to-Practise-Referral-Form pdf-66764382 Fitness to practise referral form
This form is for Responsible Officers, Suitable Persons, employers, their nominated representatives, and those acting on behalf of organisations to send fitness to practise concerns to us.
Getting help
Guidance for completing this form is available in the referral guidance. The guidance provides assistance on making fair and accurate referrals based on GMC thresholds.
Responsible Officers, Suitable Persons and their designates can seek advice and discussion about concerns and whether they meet our threshold for investigation. For details about the employer liaison adviser for your region, please visit our website.
If you are a professional raising concerns in your individual capacity or a member of the public, please visit our website to fill in our online form.
Returning the form
Please return this form to us, using practise@gmc-uk.org. You should also copy in your employer liaison adviser into the email.
If the concerns are of a serious and urgent nature and completing the form could cause a delay, please e-mail practise@gmc-uk.org straight away with as much detail about the concern as possible.
Details about the doctor
Doctor's full name
Doctor's specialty
Doctor's job title
Doctor's grade
The doctor's work details
Organisation the doctor was working for, or contracted to, or providing services for at the time the concerns arose.
GMC number
How long have they worked here?
Other organisations where the doctor is known to work or contract with (eg independent hospital, locum agencies)
Your relationship to the doctor
Are you the doctor's Responsible Officer?
If no, please specify your connection to the doctor.
If no, and you have been able to identify the doctor's RO or Suitable Person, have you shared your concerns with that individual?
Have you shared your concerns with the doctor?
If yes, when did you do so?
Yes
No
Yes
No
Yes
No
Is the doctor aware that you are making a referral to the GMC?
Yes
No
Please note: If the referral is about multiple doctors please use the pages at the end of the form to add their details.
Summary of concerns
RO referrals relating to a doctor's fitness to practise should be discussed with a GMC ELA prior to submitting the referral form.
* Please note if the concerns you are raising indicate an immediate patient safety risk or are of an urgent or high-profile nature then do not delay in referring but inform your ELA as soon as possible. *
Have you discussed your concerns with an employer liaison adviser?
Yes
No
If yes, did the ELA advise you to make a referral to us?
Yes
No
(The ELA is a source of advice/support to you but as a Responsible Officer it is still ultimately your decision whether you make a referral to the GMC or not).
Please use the box below to provide the following details:
summary of the concern(s) including location and who else was involved
a chronology of events
details of risk to patient safety (if applicable)
summary of all local action taken and on-going investigations (if any)
please indicate where you have been unable to verify information contained within this referral
(eg where the information is from a source outside of your remit, where a local process is on-
going or where you believe there is an evidential conflict)
details of any other relevant concerns or previous complaints you are aware of at this time (and local
actions and outcomes). This will help us assess whether this incident is part of a pattern of behaviour.
Local restrictions
Please provide details of any restrictions on the doctor's practise at a local level:
Supporting documentation
Please list in the box below any available supporting information and mark which items are included with this form. Please forward to us any further supporting information which subsequently becomes available as soon as possible and, if possible, indicate in the box below which information you expect to be able to send at a later stage.
Supporting documentation (where available) could include:
notes, reports and transcripts of internal investigations or disciplinary documentation
on this matter or related previous concerns
complaint letter
anonymised / redacted medical records
Where supporting information contains patient identifiable details, we may ask you to seek consent from those individuals, where you have not done so already.
expert report(s)
relevant Royal College reviews
relevant audit findings
NCAS assessment reports and other relevant NCAS correspondence
conviction / caution cases: criminal records check or certificate of conviction
health cases: (1) details of any relevant sickness absence; (2) medical records
and (3) notes of any meetings where the doctor's health has been discussed
where the incident being referred is part of a pattern of behaviour - all supporting
documentation relating to the other concerns.
Other sources of information
Please use the box below to detail any organisations and bodies (eg regulatory bodies, coroners, ombudsman, the police) that may be able to assist with providing relevant information to us. Where possible, please include the contact details of a named person within that organisation.
Patient safety concerns
To your knowledge, has the doctor whom you are referring raised concerns about patient safety with your or any other organisation that patient safety or care is being compromised by the practice of colleagues, the system, policies, procedures in the organisations in which they work?
Yes
No
Explanatory guidance on patient safety concerns can be found in the referral guidance.
If yes, when did the doctor raise their concern? Also, please indicate the nature of the concern.
Have the concerns been investigated?
Yes
No
Please list any supporting information available in regard to the investigation and the patient safety issues raised. If the concern was not investigated, please provide an explanation below.
Supporting documentation (where available) could include:
Reports or notes of internal / external enquiries or investigations
Declaration
In accordance with my duty to raise concerns about the fitness to practise of doctors, I refer the named medical practitioner(s) to the GMC. In so doing, I confirm that:
the referral is made in good faith, based on all the information that is available
to me at the present time
I have taken reasonable steps to ensure that the referral is fair and accurate.
Signature
Date
Your full name
Your role
Organisation
Where you are a nominated delegate, please provide the name and role of the person you are acting on behalf of, if applicable: Acting on behalf and with the knowledge of
Role (eg Responsible Officer, Suitable Person, Medical Director, or Chief Executive)
Organisation
Additional doctor 1: Details about the doctor
Doctor's full name
Doctor's specialty
Doctor's job title
Doctor's grade
The doctor's work details
Organisation the doctor was working for, or contracted to, or providing services for at the time the concerns arose.
GMC number
How long have they worked here?
Other organisations where the doctor is known to work or contract with (eg independent hospital, locum agencies)
Your relationship to the doctor
Are you the doctor's Responsible Officer?
If no, please specify your connection to the doctor.
If no, and you have been able to identify the doctor's RO or Suitable Person, have you shared your concerns with that individual? Have you shared your concerns with the doctor? If yes, when did you do so?
Is the doctor aware that you are making a referral to the GMC?
Yes
No
Yes
No
Yes
No
Yes
No
Additional doctor 2: Details about the doctor
Doctor's full name
Doctor's specialty
Doctor's job title
Doctor's grade
The doctor's work details
Organisation the doctor was working for, or contracted to, or providing services for at the time the concerns arose.
GMC number
How long have they worked here?
Other organisations where the doctor is known to work or contract with (eg independent hospital, locum agencies)
Your relationship to the doctor
Are you the doctor's Responsible Officer?
If no, please specify your connection to the doctor.
If no, and you have been able to identify the doctor's RO or Suitable Person, have you shared your concerns with that individual? Have you shared your concerns with the doctor? If yes, when did you do so?
Is the doctor aware that you are making a referral to the GMC?
Yes
No
Yes
No
Yes
No
Yes
No
Additional doctor 3: Details about the doctor
Doctor's full name
Doctor's specialty
Doctor's job title
Doctor's grade
The doctor's work details
Organisation the doctor was working for, or contracted to, or providing services for at the time the concerns arose.
GMC number
How long have they worked here?
Other organisations where the doctor is known to work or contract with (eg independent hospital, locum agencies)
Your relationship to the doctor
Are you the doctor's Responsible Officer?
If no, please specify your connection to the doctor.
If no, and you have been able to identify the doctor's RO or Suitable Person, have you shared your concerns with that individual? Have you shared your concerns with the doctor? If yes, when did you do so?
Is the doctor aware that you are making a referral to the GMC?
Yes
No
Yes
No
Yes
No
Yes
No
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