Key Points
- Anthony J B D P Andrews, a South London mental health nurse, has been struck off the Nursing and Midwifery Council (NMC) register following serious misconduct.
- On September 8, 2023, Mr Andrews administered incorrect medication to a patient via their tracheostomy—an opening in the throat—despite the patient not being under his care and not prescribed that drug.
- The patient’s family attempted to intervene and stop Mr Andrews, but he ignored their pleas and proceeded with “considerable force,” causing the patient to cough and exhibit signs of respiratory distress before stabilisation.
- Mr Andrews mistook the patient for another individual and failed to check their records prior to administration.
- On the same day, September 8, 2023, he administered medication to a second patient without verifying their records.
- The NMC misconduct panel ruled that Mr Andrews acted dangerously and dishonestly, impairing his fitness to practise as a nurse.
- Hearings occurred in December (year unspecified in reports), which Mr Andrews did not attend.
- A report detailing the findings was released this month (contextually January 2026).
- Mr Andrews worked as an agency nurse for Care Staff Solutions and Pulse Nursing.
- Placements included The Royal Hospital for Neuro-disability in Putney, South West London; St George’s Mental Health NHS Trust; and the NHS Talking Therapies team at West London NHS Trust.
- The panel determined his actions put patients at risk.
Putney, South West London (MyLondon News) January 16, 2026 – A mental health nurse employed by agencies in South West London has been permanently removed from the professional register after forcing incorrect medication through a patient’s tracheostomy, ignoring desperate pleas from the patient’s family to stop.
What Happened on September 8, 2023?
The incident unfolded on September 8, 2023, at a healthcare facility linked to Mr Andrews’ agency placements. As detailed in the NMC report, Mr Andrews administered medication to a patient via their tracheostomy—a surgical opening in the throat—despite the patient not being under his direct care and not prescribed that specific drug. The panel noted that this method required “considerable force,” highlighting the physical nature of the error.
The patient’s family witnessed the event and actively tried to intervene. According to the NMC findings, they pleaded with Mr Andrews to halt, but he disregarded their concerns and continued. Immediately after, the patient began coughing violently and displayed clear signs of respiratory distress, necessitating urgent stabilisation. This sequence underscores the immediate danger posed, as respiratory complications from tracheostomy misuse can be life-threatening.
Compounding the error, the panel established that Mr Andrews had confused the patient with another, failing entirely to consult their medical records—a basic safeguard in nursing protocol.
Why Did the Nurse Ignore the Family?
Family intervention forms a critical aspect of the case, raising questions about patient safety protocols. The NMC panel explicitly found that Mr Andrews ignored the family’s attempts to stop him, proceeding despite their visible distress and objections. No direct quote from the family appears in the report, but the panel’s determination paints a picture of deliberate override, labelling his actions as dishonest.
This disregard breached fundamental duties of care, particularly in mental health settings where patients may have heightened vulnerabilities. The panel’s ruling emphasises that such conduct not only endangered the immediate patient but eroded trust in agency nursing practices.
In similar past cases, family voices have proven vital; here, their ignored warnings amplified the risk, leading directly to the respiratory episode.
What Was the Second Incident That Day?
Remarkably, September 8, 2023, saw a second breach by Mr Andrews. He administered medication to another patient without checking their records, mirroring the initial lapse in due diligence. The NMC panel viewed this as part of a pattern, further evidencing impaired professional judgement.
Details on this second patient’s outcome remain limited in the report, with no mention of adverse effects. However, the repetition within hours prompted the panel to classify both events as interconnected misconduct, heightening concerns over systemic checks in agency staffing.
This dual failure on one shift illustrates how unchecked errors can cascade, potentially affecting multiple lives in rapid succession.
Which Agencies Employed the Nurse?
Mr Andrews operated as an agency nurse through two providers: Care Staff Solutions and Pulse Nursing. These firms placed him at key South West London sites, including The Royal Hospital for Neuro-disability in Putney—a specialist facility for complex neuro-disabilities.
Additional placements encompassed St George’s Mental Health NHS Trust and the NHS Talking Therapies team at West London NHS Trust. Agency nursing often fills staffing gaps in the NHS, but this case spotlights vetting and supervision rigours. Neither agency has publicly commented in available reports, leaving questions on their internal protocols unanswered.
The diversity of settings—from neuro-disability care to mental health therapies—underscores Mr Andrews’ broad exposure, making his lapses particularly alarming across varied patient needs.
What Did the NMC Panel Rule?
A Nursing and Midwifery Council (NMC) misconduct panel conducted hearings in December, which Mr Andrews chose not to attend. Their determination: his fitness to practise was impaired due to dangerous and dishonest actions that risked patient safety.
The report, released this month, catalogues these findings exhaustively, striking Mr Andrews from the register—a career-ending sanction. The panel stressed the potential for harm, noting the tracheostomy administration’s force and the unchecked second dosing.
This ruling aligns with NMC standards, prioritising public protection. No appeal details emerge from the document, cementing the decision’s finality.
How Does This Affect Mental Health Care in London?
Mental health nursing demands precision, especially with tracheostomies common in long-term cases. Mr Andrews’ role in such units amplifies the incident’s gravity, as patients often lack capacity to self-advocate. Putney’s Royal Hospital for Neuro-disability, a beacon for specialised care, now faces scrutiny over agency oversight.
St George’s and West London NHS Trusts, integral to London’s mental health infrastructure, rely on agencies like Pulse Nursing and Care Staff Solutions amid chronic shortages. This event may prompt audits, though no official responses are recorded yet.
Broader implications include eroded family confidence and calls for enhanced record-checking mandates in transient staffing.
What Broader Lessons Emerge for Agency Nursing?
Agency models offer flexibility but expose vulnerabilities, as seen here. Mr Andrews’ dual errors on one day reveal gaps in real-time verification, particularly ignoring family input—a red flag in ethical care.
The NMC’s dishonesty finding suggests possible awareness of the mistake, urging regulators to refine training for locums. Comparable cases have led to protocol overhauls; this could follow suit.
Ultimately, the panel’s report serves as a stark reminder: patient records are non-negotiable, and force in medication delivery demands utmost caution.
Patient Safety Measures Post-Incident
Following the respiratory distress, the patient stabilised, per the NMC account—no long-term harm specified. Yet, the “considerable force” required flags technique flaws, potentially exacerbating tracheostomy risks like infection or obstruction.
NHS trusts emphasise double-checks, but agency shifts challenge continuity. This case bolsters arguments for electronic record mandates pre-administration.
Families’ roles gain prominence, with advocacy training possibly expanding in response.
