Our findings of fact
Our findings of fact
First, we have some observations to make in relation to some associated employment tribunal (ET) proceedings (case 2602311/22). The Upper Tribunal hearing bundle included a copy of the grounds of complaint brought by OS in the ET against the care agency (pp.145-151) together with the employer’s response to that claim (pp.152-159). The bundle disclosed no further information as to the outcome of those proceedings. However, it emerged at the hearing before us that the ET case had gone to trial. Mr Atanda told us that he had a copy of the ET judgment but not with him. Mr Serr not unreasonably raised the question as to whether we should have sight of the ET decision.
However, we took the view that an adjournment, even a short adjournment to source an electronic copy of the ET decision, was not necessary and announced as much in the course of our hearing. The ET proceedings were concerned with a range of different issues, several of which (e.g. various contractual matters) had no direct or indirect bearing on the matters before us. We had to decide on the lawfulness of the DBS decision on the basis of the evidence before us, applying different legal tests under different legislation. We simply note our concern that this matter arose at such a late stage in the proceedings. It is true that there was no Upper Tribunal direction to file a copy of the final ET judgment. However, parties are under a duty to co-operate generally with the Upper Tribunal (see rule 2(4)). We consider that this includes a duty of candour, to ensure that all relevant documents are disclosed in good time so that the Upper Tribunal has a complete picture.
We now turn to the incident in question and the subsequent developments. It is not in dispute that OS had only recently been recruited by the care agency from his home country. OS’s letter of appointment is dated 1 February 2022 and provided for a start date of 28 February 2022 (p.96). In fact OS did not start working in the role of ‘senior care assistant’ until 16 April 2022 (p.80 and p.155 para 23). He had undertaken a range of training before taking up his appointment, but this had been done remotely, i.e. on-line.
The incident in question took place on 5 June 2022. For a while previously OS had been working solo on night shifts. At fairly short notice he was rostered to be part of a two-person team (with Kim) on the day shift assisting Edward with his personal care at home. Kim had been working with Edward for some time but this was OS’s first occasion with him. On their first visit of the day Kim and OS were washing Edward while he was lying in bed. They were standing on either side of the bed (to start with at least). OS then moved away to pick up a sheet or bedcover while the bed-guard was down. At the same time Kim, who was wetting a flannel, asked Edward to turn over – Edward did so but fell to the floor on OS’s side of the bed. The fact that this accident happened was not relied upon by the care agency as a reason for the subsequent dismissal of OS. It was accepted that accidents happen. Equally, the accident itself is not the reason or one of the reasons why the DBS has made its barring decision.
It is not in dispute that immediately after his fall OS and Kim then lifted Edward back into bed. It is also not in dispute that manual handling protocols stipulate that a person who has had such a fall should not be lifted – not least so as to avoid the risk of injury both to the service user and/or the carer(s) in attendance. This was made clear in the relevant training module undertaken by OS, as he himself recognised in his disciplinary hearing. We also accept as inherently credible Kim’s detailed account of the immediate aftermath of the fall (p.104):
OS said “lets help him up onto the bed” I completely forgot the training we underwent that tells us ‘in such a situation they should not pick someone up but wait for emergency services’. I unwisely agreed and we proceeded to support Edward up off the floor and put him on the bed. He used his weight to leverage on the bed while we used our shoulders as support (again not allowed in moving and handling).
It follows there is no mistake of fact in allegation 1, that OS assisted in lifting Edward from the floor following a fall contrary to moving and handling guidelines.
Kim’s account then continued as follows (p.104):
When I looked closely I discovered that as a result of the accident Edward had sustained bruises on his left arm and right foot. OS then appealed to me not to tell anyone. I asked OS to let the manager know what had happened and tried to convince him that Linda is very supportive and easy to talk to. But OS said he was scared that he would lose his job as he has only just been in the country on a carers visa for 2 months. He was scared that he would lose his visa. After the incident I could see he was visibly shaken. I again asked him to call Linda which he asked me for a bit off time to collect himself before he can go there and talk about it. He was in tears and was begging me not to ruin his livelihood that he has a wife and child depending on him. … I felt sorry for him and gave time for him to talk to Linda.
In sworn testimony before us OS, on at least two occasions, denied having appealed to Kim not to tell anyone about Edward’s fall. We were unable to accept that evidence. This account by Kim was in effect corroborated by OS himself in his disciplinary hearing, when he said “I did not record it because I was really scared that I would be sent back to my country because I’m on a sponsorship visa and that’s my livelihood of feeding my family. So I didn’t report it in the continuation sheets of the notebook I didn’t report it, what happened, at all” (audio file 08:00-08.18). He also agreed that he had noticed the cut on Edward’s elbow (but not the injury to his toe) (audio file 13:55). In addition, he accepted that his record in the notes that there were no concerns was not true (audio file 15:03). Those admissions provide support for allegations 2, 3 and 6.
At the hearing before us an objection was raised as to the record of OS’s statement in the disciplinary investigation. OS denied having ever made the statements in the last four sentences of his version of events (at the foot of p.105), namely: “I begged Kim not to say anything and that if asked I would speak. We maintained this even on our second visit. When NOK asked why we did not report. In hindsight I know it was a very silly lie and we should have followed proper procedure.” The suggestion was that this passage had been fabricated by the employer. OS showed Mr Serr a WhatsApp entry containing his statement which purportedly did not include this passage. We do not believe the passage in question has been fabricated. In part at least, the contents are demonstrably true, in that the pretence that nothing untoward had happened was maintained on the second visit (see below). We note that the text is described as being part of OS’s ‘version of events’, rather than his ‘statement’ as such, and we consider it most likely that the disputed passage is simply the investigator’s summary of an admission made orally by OS.
We also interpose here that it was alleged on behalf of OS in the ET proceedings that Kim “had told the claimant not to report the incident or log it, otherwise there would be trouble. The claimant was the junior colleague who had just been sponsored into the UK and regrettably went ahead with the plan devised by [Kim]” (p.148 para 26). However, that account is completely inconsistent with the version of events that OS gave in the disciplinary investigation. Although part of that statement as recorded was disputed ( see above), this specific passage was not (p.105):
The management at the care agency is very keen on safeguarding clients avoiding incidents. Because of this I panicked with the fear of losing my job as this is my only source of income to feed my family. I’m on a skilled work visa of which I do not want anything to happen to my visa I didn’t record the incident in our continuation sheet and I didn’t tell Edward’s wife what had happened.
As we will see, we would add it was not simply a case of not telling NOK what had happened but rather actively seeking to deceive her as to what had happened, e.g. by denying that a fall had happened in their presence. That finding supports allegation 4. For all the reasons identified above, we entirely reject the false account as alleged in the ET proceedings that Kim was the instigator of the attempted cover-up.
The next developments were recorded by Linda, the line manager, as follows in her statement to the subsequent investigation (p.106):
10:46: OS called to report that on the morning visit they noticed a tear on Edward’s skin but were not sure how it happened. I advised him to do an incident report on returning to office and also notify the team to be careful. He made it sound like his skin integrity was compromised by his condition which is not uncommon in our client type.
10:54 OS put a message on the team handover group saying ‘Please note Edward’s skin is very tender so we need to be gentle with him during wash time’.
The disclosure by OS at 10:46 was incomplete and positively misleading. OS knew how the tear had happened but was denying he had any such knowledge. This finding of fact supports allegations 2, 3 and 5.
At about 2 pm NOK telephoned the care agency to report that Edward had told her he had fallen out of bed during his morning wash. NOK was obviously concerned for her husband but was also concerned because the fall had not been documented in the client folder. Moreover, “she asked the carers about the fall and OS denied that they witnessed a fall” (p.101). Kim’s account of what happened at lunch-time was as follows (pp.104-105):
At lunch time when we both went back for the afternoon call with Edward his NOK asked us why we hadn’t reported the incident of her husband falling off the bed? OS immediately jumped in and said Edward had not fallen and denied the accident. As we were leaving the afternoon call I reminded OS that he needed to call and inform management of the incident especially after getting Linda’s call. I explained to him that the lie was getting out of control. I finally called Linda to tell her what had happened and sent her a text that I wanted to open up about what had happened.
The failure to be frank with NOK was admitted by OS at his disciplinary hearing: “The second time I was still not composed… I was still scared of telling her what had happened. .. On my mind I was still thinking about my family, how will I feed them? How will I feed them?” (audio file 09:20-09:45).
The further developments in the early afternoon were reported by Linda as follows (p.106):
13:52 – Call from OS stating that Edward’s wife was accusing them of dropping Edward but not documenting. OS maintained when queried that Edward had not had a fall in their presence. I asked if they had left bed rails up on leaving and he confirmed they had. At that point I said to him the story does not add up. Why would NOK say he fell if he didn’t? and I asked him if I could speak to Kim. Call was put on loud speaker as she was driving and she said she would call me back.
13:58 – I called NOK to get more information about the incident. She explained she had been told by Edward that he had a fall and that on checking the notes the incident had not been recorded. I apologized and asked to attend their home to talk to her and Edward about the incident.
The exchange noted on the telephone call at 13:52 was likewise misleading on the part of OS, in that he was again denying to his manager that Edward had had a fall in their presence. This finding provides further support for allegations 3 and 5.
At 14:23 pm, according to the care agency’s response in the ET proceedings, “as Linda was heading to the client’s home to discuss the incident, Kim sent a message to Linda stating, ‘please pick up my call I will tell you the truth,’ which was followed by several missed calls and finally a call to the Director, where she [i.e. Kim] explained that OS had asked her to lie about the incident that took place” (p.157, para 38). This corroborates Kim’s own evidence as above.
At 15:00 pm Linda asked OS and Kim to attend a brief meeting later that day at the end of their shift, when they were each asked to prepare a statement detailing what had happened (p.157, paras 38 and 39).
OS (and indeed Kim) was suspended on the same day pending a disciplinary investigation (p.97). The disciplinary hearing for OS took place on 14 June 2022, conducted by Linda and Clive, a Deputy Manager – there is both a (non-verbatim) transcript of the hearing (pp.111-114) and an audio file recording, which we have had the opportunity to listen to. The report of the care agency’s investigation into the NOK’s complaint is at pp.101-110.
On 15 June 2022, i.e. the day after the disciplinary hearing, and according to the employer’s ET response, an ‘in-house reflective practise meeting’ took place, attended by Linda, Kim and OS “at which Linda gave both OS and Kim an opportunity to be truthful and give accurate information. However, OS continued to give an inconsistent narrative according to what the client’s next of kin had explained. This caused a lot of shouting and aggressive behaviour between OS and Kim” (p.157, para 42).
The complaint investigation report concluded as follows:
When we employ our carers we trust that they will work in a manner that will safeguard and put our clients wellbeing first. It is clear that both individuals acted unprofessionally and put our client health and our company’s reputation at risk. Their behaviour and actions as a result of this accident went against all company protocol and guidelines that they were taught during their induction and training with us. Accidents happen but the individuals in this case chose to lie and hide the fact from both the NOK and the company. Had they been upfront and honest from the beginning, the matter would have been dealt with differently and the client NOK would not have been put through the distress of this whole situation. OS one of the carers was found to still be lying on investigation and making stories up to implicate his colleague. He had made claims that his colleague knew he had moved as he was looking for bed sheets but was not able to give rationale why he would be looking for bed covers while still giving a client a wash. He then stated that actually they had finished with the wash and they in fact looking for bedcovers and even NOK was looking for it too. He then said when asked why Kim would need to ask Edward to turn if they had finished with the wash and were just left with coving him. He then said he did not know. He did not show proper remorse for his actions even though he claimed to understand where he had gone wrong. We only managed to get a true statement from him after we informed him client has a camera in the room and we will need to go and check what happened. We concluded that OS was more concerned about his families’ livelihood than his duty of care.
Following the meeting on 15 June 2022 and the disciplinary investigation, OS was dismissed for gross misconduct. The letter of dismissal (p.99) gave the following reasons:
You have been dismissed for the following reasons:
Failure to comply with company incident reporting processes.
Entering a false record in the client's file
Deceiving the Manager on call about the circumstances leading to client injury.
Making a member of your team to lie on your behalf so as to further deceive the company about the incident that happened on the 5/6/2022.
Further investigation shows that after the client had a fall on the morning call on Sunday the 5th of June you and your colleague did not record in the notes what had happened. You met the NOK before leaving and still did not inform her that her husband had a fall. This put the clients health and safety at risk as you did not follow protocol to ring emergency services and NOK immediately before moving the client.
You further coerced a member of the team to not report the incident citing that you were worried that you would lose your sponsorship as an international candidate.
You further lied on returning to the client for lunch call and declined any knowledge of the incident in the presence of the client and NOK.
The investigation has found that the fall was a result of an accident and due mainly to lack of proper communication between you and your colleague during the procedure. This on its own is considered an accident that could have happened to any other carer regardless of their experience. However, the main failing was of falsifying records, attempting to deceive the client and failing to contact your manager on call proper incident management and to safeguard the client's wellbeing.
The care agency referred OS to the DBS with the following summary of the circumstances (p.81):
It was determined that the incident itself and the fall is an accident; that this on its own would not have been considered a safeguarding concern had the right protocol been followed in reporting it. The fact that OS continued to lie, and even faced the patient and confirmed that he had not had a fall regardless of the evidence of injuries makes his actions neglectful. He did not consider the detriment to the client's health and was more concerned about safeguarding his job that he was about his duty of care. The fact that even after being reassured by management that accidents happen and while attending another session of induction, OS maintained a lie that would have resulted in his colleague losing her job. He knew he had instigated the whole process and emotionally blackmailed her to not speak a word of the incident and yet at the meeting he had fabricated another fake story to make her the one in the wrong. This made it that we as an employer could not trust his integrity and ability to serve the best interest of the team and clients. This resulted in the ultimate dismissal from the service.
Finally, so far as the facts are concerned, our attention was drawn to the differing outcomes of the two disciplinary cases. In the course of the ET proceedings the care agency gave four reasons to justify its differential treatment of the two carers involved in the incident with Edward and its aftermath (p.158, para 49):
Kim was not on probation, OS was.
Kim whistle-blowed, OS did not.
Kim had an 18-month excellent record with the agency, OS does not.
Kim was remorseful and able to reflect on what she did wrong; OS was and is still not able to reflect on what he did wrong, which is the lying and dishonesty which led to putting a client and the agency at a detriment.
Although she was not dismissed, Kim was in fact subject to a raft of disciplinary sanctions – she was suspended for 2 weeks without pay, demoted in her staff grade and required to re-do certain induction and training courses, as well as shadowing a senior carer for 3 months and being subject to spot checks for 6 months (p.109).
- Heading
- The decision of the Upper Tribunal is to dismiss the appeal. The decision of the Disclosure and Barring Service dated 4 May 2023 did not involve an error of law or material mistake of fact
- Introduction
- The Upper Tribunal oral hearing
- The legal framework
- The people involved in this case
- The DBS decision
- The grounds of appeal
- Our findings of fact
- Discussion of the ‘error of law’ grounds of appeal
- Discussion of the ‘mistake of fact’ grounds of appeal
- Conclusions
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