Angela Vanessa Brown v Nursing and Midwifery Council

The appellant is a nurse. She appeals under arts.29(9) and 38(1) Nursing and Midwifery Order 2001 (2002/253) from a decision of the respondent’s Fitness to Practise Panel (the Panel) of 5 August 2025, in which it upheld charges of misconduct, found that her fitness to practise was impaired and concluded that it should impose the sanction of striking off.

At the hearing before the Panel the appellant was represented by a friend, Mr Loggenberg, and the respondent by Ms Da Costa of counsel. The appellant has pursued her appeal acting in person. At the hearing before me the respondent was represented by in-house counsel, Ms Whawell. The appellant represented herself, and was accompanied by Mr Loggenberg. I had written skeleton arguments from both parties. I heard oral submissions and argument from the appellant and Ms Whawell. Without objection from Ms Whawell, I permitted Ms Loggenberg also to speak at points on the appellant’s behalf.

The appellant has been registered as a nurse since 1999. Starting in 2013 she worked for HCA Healthcare Limited (HCA) as a Band 5 Bank Nurse. In August 2021 a number of concerns arose in relation to the appellant which led to an investigation being conducted by HCA. In the course of that investigation further concerns arose that the appellant may have removed medication in excess of the amounts required for patients. Arising from these matters the appellant was dismissed by HCA on 19 November 2021.

In the meantime, on 3 September 2021 the respondent received a referral from HCA relating to these matters. On 1 October 2021 the appellant was subject to an interim conditions on practice order (ICOPO). After HCA she worked for another employer, but subject to the conditions of the ICOPO. On 6 September 2023 the ICOPO was revoked. She continued to work as a nurse thereafter.

The charges which came before the Panel in July 2025 were that the appellant, as a registered nurse employed by HCA:

“1.

On or around 20 August 2021, while working at the Lister Hospital, failed to administer Amoxicillin to Patient 1;

2.

On 21 August 2021, while working at the Lister Hospital:

a.

failed to take blood from Patient 1 to monitor gentamicin levels;

b.

failed to administer paracetamol and/or ibuprofen to Patient 2.

c.

documented that paracetamol and/or ibuprofen had been administered, to Patient 2, when it had not.

3.

On 28 August 2021, while working at London Bridge Hospital, failed to adequately prepare an intravenous saline drip for Patient 3 in that you added an unknown substance to it.

4.

On one or more occasions outlined in Schedule A, you removed medication in excess of the amount to be administered to each patient, which you documented on the Omnicell system was removed to be administered to that patient.

5.

Your actions in charge 4, above, were dishonest in that you recorded the purpose for taking any or all of the medication was to administer it to the patients, when it was not.

6.

You stole any or all of the medication referred to in charge 4, above.”

Schedule A, which accompanied those charges, was a table that had entries for 31 alleged incidents. For each there was a column giving the date, the type of medication, the excess quantity withdrawn and the patient (each of whom was identified by a unique letter). The 31 incidents occurred during a period from December 2018 to August 2021.

The Panel hearing took place between 21 July and 1 August 2025. At the outset Mr Loggenberg informed the Panel that the appellant made “full admissions” in relation to charges 1, 2 and 3. The hearing then proceeded in stages.

Following some initial matters of application and case management that are not relevant to this appeal, the Panel heard and considered the witness and documentary evidence about what was said, factually, to have occurred, including live evidence from the appellant and three witnesses for the respondent. After that there were submissions. The Panel then considered its factual findings. It gave its decision in relation to the facts on 30 July 2025. Mr Loggenberg then sought an adjournment in order to obtain a transcript of the evidence of one of the respondent’s witnesses and further documentary evidence. That application was declined.

The Panel then heard submissions on whether the facts found amounted to misconduct, and, if so, whether the appellant’s fitness to practise was currently impaired. It then came to a further decision answering both questions in the affirmative. The Panel then heard submissions on sanctions before coming to its decision that the appellant should be struck off the register. The Panel went on to make an interim suspension order to allow for the possibility of an appeal.

The respondent wrote to the appellant on 5 August 2025 confirming the outcome. The enclosures included the Panel’s compendious written decision in respect of all stages. There were public and private versions. In the public version of the decision references to certain matters which the Panel had agreed to hear in private were redacted. The redacted material is extremely limited, and, it was common ground before me, has no bearing on this appeal. For obvious good reason patients were anonymised in the Panel’s decision. Witnesses were also referred to by number in the Panel’s decision, rather than by name, but their identities were known to everyone and were confirmed in a schedule.

The Panel’s decision should be read for its full content. The following is a summary.

After setting out the charges, including the Schedule A table, the Panel described the background, to which I have already referred. After discussing various applications and the decisions on them the Panel then set out its decision and reasons on the facts, noting, first, the full admission given on charges 1, 2 and 3, which were found factually proved on that basis.

After reminding itself of the burden and standard of proof, the Panel summarised the sources of evidence. As to the live witnesses, the Panel heard from the appellant. One of the live witnesses, Witness 1, was the Deputy Head of Pharmacy at the HCA London Bridge Hospital. It used the Omnicell system to monitor and track the usage and administration of medications. During the course of an investigation Witness 1 had conducted a review of Omnicell reports from that hospital. Witness 2 was the Matron at that hospital at the relevant time. Witness 3 was a Ward Sister at that hospital at the time.

The Panel opened its findings in relation to charges 4, 5 and 6 in this way.

“In reaching a decision on each of the disputed charges, the panel was satisfied that the Omnicell system reports before it related to transactions made by you, and this included the entries for the medications set out in Schedule A, which you had accepted. It noted that the entries in Schedule A related to transactions within Omnicell which showed that medications had been removed in excess of the amount which had been prescribed for the named patients. There was nothing within the Omnicell reports to indicate that any of the medications set out in Schedule A had been returned through Omnicell or documented as destroyed.

The panel noted that none of the allegations preceding 2021 had been dealt with at the material time, and these matters only came to light after Witness 1 was asked to interrogate the Omnicell system in respect of your usage from 2018.”

The Panel made a number of reasoned findings about the Schedule A entries. There was no suggestion that what had happened was the result of inadequate training. The Omnicell system was robust. The entries were not the result of glitches or computer errors. The appellant had suggested that another nurse could access the medications drawer during her log-in period. But she had also told the Panel that she was conscientious and careful; and Witness 3 was clear in her evidence that such issues were very rare. Witness 1 also told the Panel that the Omnicell and patient medication records were not interfaced or linked at the time and that discrepancies were generated only when a countback tally conducted by the nurse did not match the Omnicell record of the medications in the system.

I will set out the next few paragraphs in full.

“The panel next considered Mr Loggenberg’s closing submissions that Witness 1 had made reference in his oral evidence to a report which showed that you had returned the medications set out in Schedule A, but this had not been provided by the NMC. The panel accepted Witness 1’s evidence that he carried out a six-month review of the Omnicell reports during Hospital B’s investigation, which included a number of other unrelated reports being generated. The panel was satisfied from Witness 1’s evidence that those entries as contained within Schedule A, did not include any instances where medications were documented as destroyed or returned. Further, the panel noted that the return of the medications set out in Schedule A had not been raised by you or put forward as part of your defence during the local investigation.

The panel accepted that Witness 1’s review of the Omnicell reports showed exactly what medications were taken by you, and there was no evidence to suggest that these medications had been returned or destroyed. Witness 1’s evidence was that you had demonstrated competence in the usage of the Omnicell system. The panel found Witness 1’s evidence credible and consistent in respect of the workings of the Omnicell system. In addition, his evidence was corroborated by the other NMC witnesses who were either in a managerial or Omnicell-user capacity.

Given the disputes within this case, the panel determined that it was necessary to consider the contemporaneous documentation, which included the local interviews and statements provided by you and the NMC witnesses, and compare it with the oral evidence provided in this hearing. The panel considered that the NMC witnesses remained consistent in their evidence, as opposed to your account which had changed and was inconsistent.”

The Panel went on to consider charge 4. It noted that Schedule A showed entries for medication removed at variance with, or in excess of, the patient prescriptions and which the patient records did not show as having been administered. There was no evidence that the medications had been destroyed or returned. The Panel had considered the Omnicell reports and patient records for each entry. It noted some common themes, and gave examples. It also noted that the majority of excess medications removed were for pain relief.

The Panel noted that, at the time of meetings with Witness 2 (who had begun the internal HCA investigation) in November 2021, the appellant had not offered any explanation for errors that had been identified then; but she had suggested to the Panel that the medications were either subsequently administered, returned or destroyed, or there may have been errors in the Omnicell system. It regarded these accounts as inconsistent and noted that no documentary evidence had been provided to support medications having been subsequently administered, returned or destroyed. It found charge 4, in respect of Schedule A, proved in its entirety.

Turning to charge 5, as to dishonesty, the Panel directed itself by reference to Ivey v Genting Casinos (UK) Ltd t/a Crockfords [2017] UK 67; [2018] AC 391. For reasons it went on to explain it concluded that medications had been recorded by the appellant as being taken for the purpose of administering to patients, knowing that this was not the case. Applying the Ivey v Genting Casinos test the Panel concluded that this was dishonest.

The Panel went on to find charge 6 proved. It found that the appellant had taken ownership of the medication in question. In the course of this section the Panel said:

“The panel was satisfied that by selecting on the Omnicell system that you were removing a particular quantity of medication, and then proceeding to remove that exact amount, no discrepancies would have appeared on that system. The panel noted that the Omnicell system worked independently from patient prescriptions and records, and the two systems did not interact. It took into account that it was only during the local audit of the records, that the Omnicell reports were reconciled with patient records, and the numerous instances of excess medication having been removed by you was identified. The panel noted that had this audit not taken place, the medication count in the Omnicell would have otherwise tallied, so no discrepancies or issues would been raised or DATIX created. It was of the view that had you identified an issue with the Omnicell system, it would have been your responsibility to escalate it, but there was no evidence of any such issues.”

The Panel went on to discuss the application by Mr Loggenberg, following the fact-finding decision, to adjourn to obtain the transcript of Witness 1’s evidence and obtain further documentary evidence. It set out its reasons for rejecting that application. I will return to this.

The Panel went on to consider whether the facts found proved amounted to misconduct, and, if so whether the appellant’s fitness to practise was impaired.

The Panel had regard to The Code Professional standards of practice and behaviour for nurses, midwives and nursing associates (2015). It considered that the appellant’s conduct breached a number of provisions, which it set out, but noted that breaches do not automatically result in a finding of misconduct. However, for reasons it set out, considering each in turn, it found that the omission at charge 1, and the conduct at charges 2a, 2b and 2c, and 3, all fell seriously short of expected standards and amounted to misconduct.

The Panel considered the conduct at charge 4 to be serious, and to be aggravated by the fact that it took place on multiple occasions between December 2018 and August 2021, and in respect of numerous patients. The appellant had unacceptably circumvented the correct procedures. Her actions fell “far below” the conduct and standards expected and amounted to misconduct. As to charge 5, the appellant’s dishonesty brought her integrity into question and was so serious as to amount to misconduct. As to charge 6, stealing the medications was serious and risked patient harm. This conduct fell seriously short and amounted to misconduct.

Turning to impairment, the Panel had regard to the Fitness to Practise Library and the guidance of Cox J in Council for Healthcare Regulatory Excellence v NMC and Grant [2011] EWHC 927. Cox J referred to the need to consider not only whether the practitioner continues to present a risk but whether the need to uphold standards and public confidence in the profession would be undermined if a finding of impairment were not made. The Panel found that all four elements of Dame Janet Smith’s test in the fifth Shipman report, discussed by Cox J in Grant, were engaged in this case: has put, or is liable to put, patients at risk; has brought or is liable to bring, the profession into disrepute; has breached, or is liable to breach, one of the fundamental tenets of the profession; has acted, or is liable to act, dishonestly.

In relation to charges 1, 2 and 3 the Panel considered that the conduct was capable of being addressed. As to whether it had been addressed, and the risk of repetition, there remained, despite the steps that had been taken (which the Panel identified), a “residual risk of repetition” due to the appellant’s limited insight.

As to whether the misconduct that was the subject of charges 4, 5 and 6 was capable of being addressed, and the risk of repetition, the Panel said:

“The panel considered, however, that the misconduct at charges 4, 5 and 6 was so inextricably linked that it would be difficult to separate the removal of medication in excess of the amount to be administered to patients, which you documented on the Omnicell system was removed to be administered to those patients, from the dishonesty and theft that had been found proved. It determined that your misconduct at these charges raised deep-seated attitudinal concerns which are more difficult to address. The panel was of the view that your misconduct at these charges was on the higher end of the scale of seriousness, as it involved multiple instances of theft and dishonesty in respect of medications over a sustained period of time.”

The Panel went on to say, in respect of these charges:

“Whilst the panel acknowledging that you are entitled to defend yourself in respect of the charges, the panel determined that your actions at these charges demonstrated a deep-seated attitudinal issue, in relation to your honesty and trustworthiness as a registered nurse.

The panel was also concerned that you were less than credible in your oral evidence, and evasive to questioning at both the local investigation stage and during your oral evidence at this hearing. The panel acknowledged your reflective account, in which you highlighted the need for nurses to be honest and trustworthy. Whilst the panel appreciated that you denied charges 4, 5 and 6, there was no evidence before it of any attempt of reflection or remediation in relation to your misconduct at these charges, in particular, the dishonesty and theft of excess medication identified. It therefore determined that there was a high risk of repetition in respect of charges 4, 5 and 6.”

The Panel went on to conclude that a finding of current impairment of fitness to practise was necessary on the grounds of public protection. It also concluded that public confidence would be undermined if a finding of impairment were not made in this case, and therefore also made such a finding on grounds of public interest.

Turning to sanction, the Panel identified both aggravating and mitigating features. It had regard to NMC guidance on “Sanctions for particularly serious cases” in respect of cases of dishonesty, which it set out. I will return to it. The Panel said:

“The panel was satisfied that your misconduct posed a direct risk to people receiving care, and that it was a systematic and longstanding deception. The panel did not identify any of the factors that could make your dishonest conduct less serious in this case. It therefore determined that your dishonesty was serious and more likely to call into question whether you should be allowed to remain on the register.”

Considering the available sanctions in escalating order, the Panel considered that it would be inappropriate to take no further action. A caution would also be inappropriate, as the misconduct was not at the lower end of the spectrum.

The Panel then considered the option of placing conditions on the appellant’s practice. It considered that the misconduct and charges 1, 2 and 3 could be addressed through retraining. It had regard to the fact that the last incident occurred in 2021, and the appellant had been practising as a nurse since then with no concerns raised. It continued:

“However, the panel considered the seriousness of your misconduct in respect of the dishonesty and theft of medications at charges 4, 5 and 6 and the deep-seated attitudinal issues identified. The panel determined there were no practical or workable conditions that could be formulated, given the nature and seriousness of your misconduct at those charges, and such misconduct was not something that could be addressed through retraining. Furthermore, the panel concluded that the placing of conditions on your registration would not adequately address the seriousness of this case and would not protect the public.”

The Panel next considered whether to make a suspension order. However, it noted that the appellant’s actions were not a single instance of misconduct and that there was evidence of a “deep-seated attitudinal problem” in relation to charges 4, 5 and 6. It took into account that there was no evidence of repetition, “however, your insight was not fully developed and it had found that you pose a significant risk of repeating your behaviour.” The appellant had abused her position of trust. This was a serious breach of the fundamental tenets of the profession which was “fundamentally incompatible with you remaining on the register.” Suspension would not be a sufficient, appropriate or proportionate sanction.

Turning to striking off, after citing from the Sanctions Guidance, the Panel said:

“The panel considered that the regulatory concerns in this case raise fundamental questions about your professionalism. The panel determined that public confidence in the profession would be undermined if you were not removed from the register. It was of the view that members of the public and other nurses would be most concerned to learn that you acted in the way that you did.

The panel concluded that a striking-off order is the only sanction which will be sufficient to protect patients, members of the public, and maintain professional standards because a lesser sanction would not reflect the seriousness of the misconduct in this case, nor address the ongoing risk of repetition identified by the panel.

Whilst the panel noted the hardship such an order would have on you, it was of the view that the findings in this particular case demonstrate that your actions were serious and to allow you to continue practising would undermine public confidence in the profession and in the NMC as a regulatory body.

Balancing all of these factors and after taking into account all the evidence before it during this case, the panel determined that the appropriate and proportionate sanction is that of a striking-off order. Having regard to the effect of your actions in bringing the profession into disrepute by adversely affecting the public’s view of how a registered nurse should conduct herself, the panel has concluded that nothing short of this would be sufficient in this case.

The panel considered that this order was necessary to mark the importance of maintaining public confidence in the profession, and to send to the public and the profession a clear message about the standard of behaviour required of a registered nurse.”

An appeal of this type is by way of a rehearing: CPR PD 52D para. 19.1(1)(h) and (2). It will be allowed where the decision appealed was (a) wrong; or (b) unjust because of a serious procedural or other irregularity in the proceedings below: CPR Rule 52.21(3).

Ms Whawell referred me to the summary of guiding principles given in the decision of the Divisional Court (the then Sharp LJ and Dingemans J) in General Medical Council v Jagjivan [2017] EWHC 1247; [2017] 1 WLR 4438 at [40] (albeit, I note, in the context of an appeal by the GMC, not the practitioner). This included at [40]:

“ii)

It is not appropriate to add any qualification to the test in CPR Part 52 that decisions are 'clearly wrong': see Fatnani at paragraph 21 and Meadow at paragraphs 125 to 128.

iii)

The court will correct material errors of fact and of law: see Fatnani at paragraph 20. Any appeal court must however be extremely cautious about upsetting a conclusion of primary fact, particularly where the findings depend upon the assessment of the credibility of the witnesses, who the Tribunal, unlike the appellate court, has had the advantage of seeing and hearing (see Assicurazioni Generali SpA v Arab Insurance Group (Practice Note), [2002] EWCA Civ 1462; [2003] 1 WLR 577, at paragraphs 15 to 17, cited with approval in Datec Electronics Holdings Ltd v United Parcels Service Ltd [2007] UKHL 23, [2007] 1 WLR 1325 at paragraph 46, and Southall at paragraph 47).

iv)

When the question is what inferences are to be drawn from specific facts, an appellate court is under less of a disadvantage. The court may draw any inferences of fact which it considers are justified on the evidence: see CPR Part 52.11(4).

v)

In regulatory proceedings the appellate court will not have the professional expertise of the Tribunal of fact. As a consequence, the appellate court will approach Tribunal determinations about whether conduct is serious misconduct or impairs a person's fitness to practise, and what is necessary to maintain public confidence and proper standards in the profession and sanctions, with diffidence: see Fatnani at paragraph 16; and Khan v General Pharmaceutical Council, [2016] UKSC 64; [2017] 1 WLR 169 at paragraph 36.

vi)

However there may be matters, such as dishonesty or sexual misconduct, where the court "is likely to feel that it can assess what is needed to protect the public or maintain the reputation of the profession more easily for itself and thus attach less weight to the expertise of the Tribunal …": see Council for the Regulation of Healthcare Professionals v GMC and Southall [2005] EWHC 579 (Admin); [2005] Lloyd’s Rep Med 365 at paragraph 11, and Khan at paragraph 36(c). As Lord Millett observed in Ghosh v GMC [2001] UKPC 29; [2001] 1 WLR 1915 and 1923G, the appellate court "will afford an appropriate measure of respect of the judgment in the committee … but the [appellate court] will not defer to the committee's judgment more than is warranted by the circumstances".

vii)

Matters of mitigation are likely to be of considerably less significance in regulatory proceedings than to a court imposing retributive justice, because the overarching concern of the professional regulator is the protection of the public.

viii)

A failure to provide adequate reasons may constitute a serious procedural irregularity which renders the Tribunal's decision unjust (see Southall at paragraphs 55 to 56).”

In Bawa-Garba v General Medical Council [2018] EWCA Civ 1879; [2019] 1 WLR 1929 the Court of Appeal observed at [61] that the decision on sanction in that case:

“…was an evaluative decision based on many factors, a type of decision sometimes referred to as "a multi-factorial decision". This type of decision, a mixture of fact and law, has been described as "a kind of jury question" about which reasonable people may reasonably disagree…”

At [67] the court in that case added:

“An appeal court should only interfere with such an evaluative decision if (1) there was an error of principle in carrying out the evaluation, or (2) for any other reason, the evaluation was wrong, that is to say it was an evaluative decision which fell outside the bounds of what the adjudicative body could properly and reasonably decide.”

In Sastry and Okpara v General Medical Council [2021] EWCA Civ 623; [2021] 1 WLR 5029 the Court of Appeal, at [113], reflecting on what was said in Jagjivan at [40(vi)] and in Bawa-Garba, said: “We agree that in matters such as dishonesty or sexual misconduct, the court is well placed to assess what is needed to protect the public or maintain the reputation of the profession and is less dependent upon the expertise of the Tribunal.”

In her notice of appeal at section 5 the appellant identified five numbered grounds, which she described as follows:

“(1)

Procedural Unfairness – Failure to Disclose and Consider Material Evidence

(2)

Irrational and Unsupported Findings

(3)

Improper Reversal of Burden of Proof

(4)

Failure to Consider Alternative Explanations and Public Interest

(5)

False statement by NMC denying that their witness gave oral evidence about existence of another report showing resolution of discrepancies.”

The appellant also attached to the Notice of Appeal a longer document headed Grounds of Appeal. She also produced a skeleton argument. These documents expand upon, and clarify, the tenor and substantive bases of the challenges advanced.

Underpinning a number of the more particular challenges is the contention that the Panel hearing, and the substantive factual findings in relation to the Schedule A incidents, were unfair and flawed, because the Panel did not have all the relevant documentary evidence before it, and did not take the steps that it should have taken to obtain it. The effect is said to have been, wrongly, to place the burden of proof on the appellant. Without that evidence the Panel’s conclusions are said to have been irrational and unsupported. I will consider this aspect first.

In submissions to the Panel on the facts, Mr Loggenberg postulated that there would be discrepancy reports on the Datix system, relating to one or more of the Schedule A incidents, showing how discrepancies were resolved. He contended that Witness 1 had indicated during the course of his oral evidence that such reports would exist. The onus was on the respondent to produce that evidence, but it had not done so. Mr Loggenberg specifically contended that it would cast light on whether the appellant had returned excess medications taken out in error. In response Ms Da Costa gave the Panel an assurance that the NMC was not withholding any report that supported the appellant’s case or indeed the respondent’s case. She hadn’t noted a suggestion in Witness 1’s evidence that there was another report that had not been disclosed, but “it may be that I have missed that”, but she had checked and there did not appear to be any.

I have set out the Panel’s relevant conclusions, including that it “accepted that Witness 1’s review of the Omnicell reports showed exactly what medications were taken by you, and there was no evidence to suggest that these medications had been returned or destroyed.”

As I have earlier noted, following the giving of that decision, Mr Loggenberg applied for an adjournment so that a transcript of Witness 1’s evidence, and the documents he sought, could be obtained, being Datix reports relating to the appellant for the relevant period and/or other audit reports carried out by hospital staff. The Panel decision noted that, in the course of her response, Ms Da Costa had explained that the production process meant that obtaining the transcript would take some time, but her own notes of Witness 1’s evidence were “in line” with those of the Panel; and were not as Mr Loggenberg had put it in his closing submissions.

After deliberation, the Panel refused the application. It had referred to its notes of evidence and “did not find any evidence of the report referred to by Mr Loggenberg.” It noted that the concerns about the removal of excess medications were only discovered in 2021 as a result of Witness 1’s audit investigation, not at the time of removal, and “hence no DATIXES would have been in existence. This evidence was already before the panel.” The Panel concluded that it had “no concerns of any gaps in the evidence presented.”

I had the benefit of having in my bundle an evidence pack, including a transcript of the oral evidence of Witness 1 to the Panel. At the hearing before me the appellant relied upon the following exchange in the course of his cross-examination by Mr Loggenberg:

“Q. So looking at these 2018 things, when was the first time these issues were brought, to your knowledge, to your attention, or to – I know you probably can’t answer for your predecessor, but at least let’s say to your attention, when was the first time the 2018 ones were brought to your attention?

A. When I was made aware of this investigation, I think it was in 2021. What I would say is the reports you’re looking at, the majority of them are transactions by user, so any fixes or any resolution of discrepancies on the system would not show on these reports because they relate to a user.

Q. Yes.

A.

So there will be, and there is an audit trail of all transactions in the system, so there are other reports that can be produced to show when discrepancies are resolved, keeping in mind that a busy hospital with humans involved, there will always be some discrepancies along the way that happen, that’s understood. I think what was obvious or inherent from the investigation here was that there were anomalies in relation to certain drugs over time.”

The appellant also referred to evidence given by Witness 3 to the effect that where a discrepancy was identified on the Omnicell system a “receipt” would be printed, triggering an investigation by way of a manual count, and a report in the Datix system. She also sought to rely on an email from HCA of 20 August 2015 to which I will come.

In his statement to the Panel Witness 1 explained that he had reviewed the Omnicell reports. He explained how the Omnicell system worked. To obtain medicines, a nurse would have to log in by fingerprint identification, and input particulars of the patient, what medicine was required and in what quantity. He had cross-checked Omnicell reports against the corresponding medication charts for each of the patients concerned. His statement went through the records in relation to each instance where he had identified a discrepancy between what medicine, or amount, was taken and what the patient had been prescribed or received.

In the course of his oral evidence Witness 1 further explained aspects of how the system works and took the Panel through a number of particular examples in the specific records that he had exhibited in this case. He explained that the system maintains a record of the numbers of tablets held of a given medicine. When the pharmacist replenishes the stock they check that record against what is actually there and update it to reflect the replenished stock. As an extra safeguard, or reminder, there would be a countback on some drugs whereby, when removing a quantity, the nurse would also need to count, and input, the number remaining. If the system registered a discrepancy that would be flagged to the pharmacy for investigation.

When discussing a particular example, Witness 1 explained that, if a nurse erroneously took more than they had recorded having taken, they could correct the error. Otherwise the discrepancy would be identified at the next restock “but in this instance, there wasn’t any information given to the system that these were in error, that they were cancelled transactions or that the patient had refused”. Further on he confirmed in relation to other examples that, if there had been a removal in error, there would have been an opportunity to correct that in the Omnicell record which would have recorded it. He also explained that if a countback input indicated a discrepancy, the system would flag it up by generating a specific code.

Witness 1 also told the Panel that, over a six-month period, he had gone through every Omnicell report for the appellant; and he confirmed that he had found correct removal of other medicines. In the course of cross-examination he explained the process that the pharmacy would follow if a discrepancy report was flagged for investigation, and how the outcome would be followed up, and a report of what was flagged, and the outcome, logged on to Omnicell. The passage in his oral evidence, which I have set out, to which Mr Loggenberg and the appellant attached significance, came a little further on in the cross-examination from that discussion.

Witness 1 also explained that the patient prescriptions did not populate into Omnicell. But, if, for example, the patient declined to take the medicine, that could be recorded in the system and would appear on their medication chart as well. He also explained that if, in error, too great a quantity was taken, and the excess, where possible, was returned to the cabinet, then an entry would be recorded on the Omnicell system of that return.

Having reviewed the relevant aspects of the evidence before the Panel, I am satisfied that its conclusion that there was no other relevant evidence that was not before it was sound. That is, in summary, for the following reasons.

First, and foremost, the incidents relied upon in Schedule A were instances where the medicines recorded as requested by the appellant when logging on to Omnicell, did not tally with the patient records of what medicine or quantity that patient had in fact been given on that occasion, and/or in some cases, what had been prescribed. The problem was not that there was a difference between what the appellant had recorded she had taken, and what she had actually taken. As there was no discrepancy of that sort, it followed from Witness 1’s evidence, that there would be no such discrepancy detected by the Omnicell system, which was not linked to the patient medicines records, hence no discrepancy report or flag generated by Omnicell, no investigation and no follow-up report following such a flag.

Secondly, it is clear from Witness 1’s evidence that the Panel did not have all of the Omnicell reports that he looked at over the course of his six-month investigation. But the reports that it did not have related to other occasions, which he did not find to be of concern. It also appears to me that, in the passage relied upon by Mr Loggenberg, Witness 1 was, following on from the earlier explanation he had given when asked about discrepancy reports, explaining that, if there were discrepancy reports relating to incidents in which the appellant had been involved, they would not be before the Panel (because they were not made by user). But this related to reports on cases where a discrepancy between the quantity recorded as taken, and the quantity identified as remaining, had been “flagged”. To repeat, the cases with which the Panel were concerned, however, were not of that kind. The witness was not saying that there was further documentary evidence relevant to those cases that was not before the Panel.

Finally, Witness 1’s evidence indicated that, had the appellant on some occasion erroneously taken more than she needed, realised after, and returned the excess to the cabinet, there was a process for recording that on Omnicell, but no such returns had been recorded. Further, the appellant’s contention, and the basis of Mr Loggenberg’s submission and application to the Panel, was that the limitation of the exercise conducted by Witness 1 was that he only looked at the Omnicell reports and the patient medication records, and that relevant Datix or other discrepancy reports must exist, but were not before the Panel.

I turn to the email of 20 August 2025 from HCA to the appellant, obtained following the outcome of the Panel decision, and on which she sought to rely in this appeal. It was by way of a reply to a number of questions that the appellant had asked of HCA. It set out the questions and added highlighted answers. In particular she had asked whether a Datix had been raised in each of 2018, 2019, 2020 against herself in respect of medications suspected of having been stolen, and, if so, for a copy. The answer for each year to the first question was “no”. She also asked about the frequency of medication stock auditing on Omnicell on the wards on which she had worked for those years, and the answer provided that information.

Ms Whawell submitted that I should not consider this evidence because what lawyers refer to as the Ladd v Marshall [1954] EWCA Civ 1; [1954] 1 WLR 1489 tests for the admission of new evidence were not satisfied. In particular, the appellant could have obtained this information prior to the Panel hearing and presented it to the Panel; and, in any event, it would not have had any bearing on the outcome. The appellant contended that it supported her case, as it showed that there had been no contemporaneous concerns raised, nor contemporaneous investigation or report flagging a potential concern about her conduct or honesty. She told me that she had not requested this information sooner, because she had not anticipated that she would be struck off, nor that she needed to prove something which she did not do.

I conclude that there is no real possibility that this email, had it been obtained sooner and put before the Panel, would have made any difference to the Panel outcome. In any event it does not assist the appellant in this appeal. The evidence before the Panel was that HCA only became aware of the potential issue after August 2021. That was, as I have discussed, because there was no discrepancy between what the appellant recorded taking on each occasion and what she actually took, and because the discrepancy between that and what the patient had been given, would not have been detected by the Omnicell system at the time. Nor, logically, I would add, would it have been picked up by a stock audit of the Omnicell system, to which the further question and answer set out in that email referred.

I can turn now to the specific criticisms levelled at the Panel’s decision by reference to this aspect, in the summary and/or detailed grounds of appeal. My conclusions in relation to them flow from the analysis and conclusions I have set out thus far, and so I can state them fairly shortly.

First, I conclude that there was no procedural unfairness by the respondent failing to disclose material documentary evidence, nor by the Panel declining Mr Loggenberg’s application to adjourn so that such evidence could be obtained and/or to check the transcript of Witness 1’s evidence. That evidence was not to the effect that there was documentary evidence relevant to the Schedule A charges, that was not before the Panel. Nor had Ms Da Costa made a “false statement” to it with regard to the evidence given by Witness 1. It is clear that what she was saying was that she had no note of him suggesting that there was some undisclosed report that would assist the appellant; and the position had in any event been checked, and this was not the case. Nor did the Panel wrongly put the burden on the appellant to obtain, or produce, relevant evidence that ought to have been produced and put before the Panel by the respondent, by way, as the detailed grounds put it, of Datix reports or discrepancy resolutions.

It is also contended that the Panel’s conclusion that the appellant stole medication was wrongly reached without: (a) an audit trail; (b) contemporaneous allegations; (c) any unresolved discrepancy data; or (d) an investigation in 2018 – 2020. That conclusion was, for those reasons, contended to be irrational or unsupported in the Wednesbury sense, citing Associated Provincial Picture Houses Ltd v Wednesbury Corp [1947] EWCA Civ 1; [1948] 1 KB 223.

As to that, the reason why there had been no contemporaneous allegations or investigation was apparent. The evidence was that the respondent’s ordinary systems would not have picked up what the appellant had done. They would not have generated “unresolved discrepancy data” in relation to this type of activity. The evidence that the Panel did have was that Witness 1 had carried out a systematic review and analysis of the contemporary Omnicell and patient medication records. That exercise itself could fairly be described as an audit. It was comprehensive and analysed primary records. The fact that it had not been carried out sooner, and went back as far as 2018, was not a reason why the Panel should have doubted what it showed. Witness 1 also gave extensive evidence about the robustness of Omnicell. For reasons I have addressed, the Panel was right to conclude that there would be no “unresolved discrepancy data” relevant to the Schedule A incidents and which it did not have.

That evidence, together with the other evidence that the Panel had, including from the appellant herself, and in relation to such matters as whether she lacked training on the Omnicell system, and what she had said when first asked about these matters in November 2021, and the overall picture of the number of incidents and the extended period over which they had occurred, together supported the Panel’s conclusion that these incidents were not the result of error, but of the appellant deliberately taking more medication than was required, and having retained, and not returned, the excess. The Panel’s conclusion that this conduct was dishonest was properly reached, drawing upon its factual findings, and applying the correct legal test; as was its conclusion (albeit not in the context of a criminal process) that it amounted to stealing.

I therefore do not agree that these conclusions were Wednesbury unreasonable.

I turn to other aspects of the challenges advanced by this appeal. In summary, the appellant contends that even if (contrary to her primary case) the Panel’s findings of fact about her conduct in relation to the Schedule A incidents stand, the tribunal erred in concluding that her fitness to practise was currently impaired; and, relatedly, in its decision to impose the sanction of striking off, as, she argues, that sanction was unnecessary and disproportionate.

In summary, first, the appellant relies upon the following features of the facts and evidence before the Panel. The misconduct found was in the period from 2018 to 2021. The Panel was coming to its decision in July 2025. The appellant had practiced safely since, with no further misconduct, both during the period of restrictions on her practice, and a further period without restrictions. She had a number of positive references. Further, she had, during that period, taken remedial steps, in particular completing further medication training; and she had made “full admissions” and engaged positively with the Fitness to Practise process.

Secondly, the appellant says that the Panel wrongly reached, and relied upon, its conclusion that she lacked insight and/or that there remained “deep-seated attitudinal issues”. There was no expert or psychiatric evidence of any such deep-seated psychological problem, and the appellant’s good record in the last four years pointed in the other direction. The appellant submitted that the Panel had also wrongly treated lack of insight as an “absolute bar” to continued registration, citing Yusuff v General Medical Council [2018] EWHC 13 (Admin). The Panel is also said to have misapplied the NMC’s Sanctions Guidance rigidly, and without regard to the foregoing context, when concluding that this was a “particularly serious” case.

My conclusions on these aspects follow.

First, when considering fitness to practise, the Panel directed itself (citing an authority relied upon by the appellant in this appeal – Cohen v General Medical Council [2008] EWHC 581 (Admin)) to whether the conduct was capable of being addressed, had been addressed, and was likely to be repeated. As noted, it concluded that the conduct at charges 1, 2 and 3 was capable of being addressed. In considering whether it had been addressed, the Panel specifically noted the “training, remediation, and strengthened practice that you have undertaken”, mentioning in particular a certificate of continuing professional development in medicines management of June 2022. It also expressly noted that the appellant was currently working as a registered nurse practitioner, and the references which “attested to your safe administration of medication and pain relief.”

On the question of the appellant’s insight in relation to charges 1, 2 and 3, the Panel specifically considered her reflective statement, which “demonstrated an understanding of where you went wrong and how you would do things differently in future”, and also noted the admissions of these charges at the outset, which also demonstrated some understanding. However, the Panel found that the appellant had “not yet developed full insight” as she still appeared to seek to blame others and deflect responsibility, leading to its conclusion that there remained a residual risk of repetition.

These were reasoned conclusions that the Panel was entitled to reach on the evidence; and they show that it did consider, with care, the evidence of the appellant’s clean track record since 2021, positive testimonials and steps taken by way of training and remediation of her practice, in particular regarding the administration of medicines.

As to charges 4, 5 and 6, I have already set out the relevant passages from the Panel decision. Although this was listed as three charges, they all related to the same conduct and the Panel was plainly right to treat them as “inextricably linked”. As to the possibility of addressing the conduct the Panel flagged that it raised “deep-seated attitudinal concerns which are more difficult to address”, and was on the higher end of the seriousness scale “as it involved multiple instances of theft and dishonesty in respect of medications over a sustained period of time.”

The Panel went on, as I have set out, to take account of the fact the appellant denied charges 4, 5 and 6, and her reflective account, in which she “highlighted the need for nurses to be honest and trustworthy.” But there was no evidence before it of any “attempt of reflection or remediation” in relation to these specific charges of dishonesty and theft of medication, leading to the conclusion that there was a high risk of repetition. As I have noted, its conclusion of current impairment was based both on the principle of public protection and on the need to maintain public confidence in the profession.

The Panel went on to specifically set out the following passage from the Sanctions Guidance relating to sanctions for particularly serious cases involving dishonesty:

“Generally, the forms of dishonesty which are most likely to require consideration of striking-off will involve (but are not limited to):

•

deliberately breaching the professional duty of candour by covering up when things have gone wrong, especially if this could cause harm to people receiving care

•

misuse of power

•

personal or financial gain from a breach of trust

•

direct risk to people receiving care

•

premeditated, systematic or longstanding deception.

Dishonest conduct will generally be less serious in cases of:

•

one-off incidents

•

spontaneous conduct

•

no direct personal gain

•

incidents outside professional practice.”

The Panel considered that the conduct posed a direct risk to people receiving care and was a “systematic and longstanding deception”. That made it serious and more likely to call into question whether the appellant should remain on the register. As I have set out, it worked through the available sanctions in escalating order, highlighting that this was not a case of a single instance, and that there was evidence of a “deep-seated attitudinal problem”. It took into account that there was no evidence of repetition; but the appellant’s insight “was not fully developed” and she posed a significant risk of repetition. It expressly referred to the hardship which striking off would involve, but considered the appellant’s actions so serious that not to strike off would undermine public confidence in the profession and the NMC.

I note that the relevant section of the Sanctions Guidance begins in this way:

“Honesty is of central importance to a professional’s practice because of the large degree of trust placed in them. Therefore, allegations of dishonesty will almost always put the public at risk of the professional not being trustworthy; because of this a professional who has acted dishonestly will always be at risk of strike-off. However, in every case the Committee must carefully consider the kind of dishonest conduct that has taken place. Not all dishonesty is equally serious.”

This section of the Guidance also comments that “dishonesty is an attitudinal concern which cannot easily be mitigated by conditions”. It also states:

“The Committee should be careful when it finds allegations of dishonesty proved after the professional denied them. This is known as a rejected defence of dishonesty. Professionals should have a proper opportunity to resist very serious allegations. This must be balanced against the necessity of protecting people receiving care and the public from professionals whose honesty and integrity cannot be relied on.”

Standing back, and in light of all the foregoing, I consider that the Panel properly regarded the appellant’s found dishonest conduct to be, in its nature, inherently conduct which raised a potential attitudinal problem, particularly in this case, where it involved not a one-off incident, but conduct that was repeated many times over a period of years. The Panel did not, on these facts, err in characterising it as involving a “systematic and longstanding deception” nor in its approach to the Sanctions Guidelines.

The Panel also plainly had in mind the appellant’s evidence of remediation and retraining, to which it referred in relation to charges 1, 2 and 3. But charges 4, 5 and 6, unlike charges 1, 2 and 3, did not relate to matters to do with incidents concerning errors relating to the administration of medication or of care to patients; and the Panel properly concluded that this conduct was not amenable to, for example, the imposition of fresh conditions on her practice, which was the sanction that the appellant particularly urged. The Panel also weighed in to its assessment the appellant’s general statements in her reflective account, but was entitled to consider that there was lack of evidence of reflective insight into this particular conduct.

As to other points raised in the appeal, the “full admissions” that the appellant had made related only to charges 1, 2 and 3. The grounds refer to the lack of financial gain on her part, but personal benefit is not necessarily confined to financial gain; and what the Panel properly found, was that the appellant had assumed ownership of the medication in question. It made no assumption, or finding, about what was done with it by her beyond that. The Panel did not make any finding that there had been any specific harm to patients by these incidents; but it was entitled to conclude that the removal of excessive quantities of medication, particularly on this scale, posed such a risk. Finally, reliance is placed in the grounds on the lack of Datix /audit reports; but, as I have explained, the factual findings, and the associated characterisation of the conduct as deliberate and dishonest, were not unfairly reached, and were sound.

The Panel was also alive to the fact that the appellant denied having taken and kept the medicines in question, and dishonesty, and that she had the right to defend herself – Mr Loggenberg specifically submitted to it that she should not be penalised for doing so. But the Panel was also entitled, when it came to consider impairment, and then sanction, to have regard to the nature of the deliberate dishonest conduct it had found proved. I note also that the appellant had the benefit of knowing the facts found, before submissions were made on misconduct and impairment, and the outcome of those stages, before submissions on sanction. The Panel was, in my judgment, entitled, at the sanction stage, to conclude that there remained a lack of insight, and a deep-seated attitudinal problem, and a high risk of repetition. In any event it properly concluded that the need to maintain public confidence in the NMC and the profession supported the conclusion that the sanction of strike-off was necessary in this case.

This being an allegation of dishonesty, and given its nature, it might be said that this was a case in which the court, while showing due deference to the Panel’s decision, is itself in a position to make some assessment of what was needed to protect the public or maintain the reputation of the profession. But, I do not, in any event, consider the Panel’s judgment in this regard to have been wrong. It was not wrong to consider that, as it had found that there had been deliberate and dishonest removal of medications on 31 occasions over a period of several years, and having regard to all of the other features that were identified, this was a case of serious abuse of trust. It was not wrong to consider that the need to maintain public confidence in the profession and the NMC pointed to the conclusions that the appellant’s fitness to practise was currently impaired, and that strike off was necessary and proportionate in this case.

For all the foregoing reasons, I will order that this appeal is dismissed.

I will give directions to enable the parties to seek to agree the terms of a draft costs order and/or to make further written submissions about that, before I make a further order as to costs.