Nursing and Midwifery Council determination — substantive hearing

Struck off the register

The regulator’s term: erasure

What does “struck off the register” mean?

Being struck off (the regulator calls this "erasure") removes the practitioner from the register. They are no longer permitted to practise this profession in the UK. Erasure can be reviewed after a minimum of five years, but is otherwise indefinite.

Concerning Naomi Kathlynne Amanda Butcher, nurse (Nursing and Midwifery Council 83Y1881E).

Decision date: 13 April 2026 · Hearing started 10 April 2026 and ended 13 April 2026

In plain English

The NMC's Fitness to Practise Committee found that Naomi Butcher, a hospice nurse, made multiple medication errors over a six-month period, including giving a terminally ill patient ten times the prescribed dose of midazolam and falsely recording the correct dose. She also made an unprofessional comment about a dying patient and made discriminatory remarks while refusing a deceased patient's family permission to visit. The panel found her fitness to practise impaired and ordered her to be struck off the register, with an 18-month interim suspension order.

Charges

While working as a Band 6 Team Leader at St Peter and St James Hospice, Mrs Butcher: failed to check 10mg morphine sulphate tablets into the controlled drugs cupboard; failed to administer paracetamol to Patient D; programmed an incorrect syringe model on a syringe driver pump (twice, on different occasions); failed to give Patient D his full dose of oxycodone; failed to give Patient D his promethazine; failed to check a syringe driver at 18:00; said about Patient E words to the effect that 'I make a bet with all of you that he will die on Christmas day'; administered 80mg of oxycodone to Patient B instead of 80mg morphine sulphate; administered 50mg of midazolam to Patient A over 24 hours instead of the prescribed 5mg and recorded that she had administered 5mg; refused Patient X's family's request to visit the sanctuary and made discriminatory comments about them being 'gypsies' who 'burn their bodies in caravans when they die'. The panel found her conduct in respect of Patient X's family was discriminatory by reason of ethnicity.

Findings

All charges were found proved, the majority by Mrs Butcher's admission and one (charge 11b(iii)) on the evidence. The panel found her actions amounted to misconduct, including multiple medication administration and management errors, inaccurate record-keeping, an unprofessional comment about a dying patient, and discriminatory conduct towards a patient's family. The panel concluded patients were placed at unwarranted risk of harm and actual harm was caused to Patients A and D. It found Mrs Butcher had shown limited insight, had not strengthened her practice and had deep-seated attitudinal concerns regarding discrimination. Her fitness to practise was found currently impaired on both public protection and public interest grounds.

Mitigating factors

Mrs Butcher had made admissions to the majority of the charges; she had shown some remorse and apologised for her actions; she stated she had not been in clinical practice for many years and that the level of support at the Hospice was questionable; she stated she was facing personal difficult circumstances at the time of the incidents.

Aggravating factors

Limited insight into her misconduct and its impact on patients, her colleagues, the nursing profession and the wider public; a pattern of misconduct over a period of time; discriminatory behaviour towards a patient's family; misconduct placed vulnerable patients at unwarranted risk of harm and caused actual harm to Patients A and D.

Source

All facts on this page are drawn from the publicly published Nursing and Midwifery Council determination linked below. MedicWatch does not editorialise the regulator’s findings.

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