Upper Tribunal Administrative Appeals Chamber

[2025] UKUT 219 (AAC)

Fecha: 12-Jun-2025

Finding 4

55.

It is not in dispute that (a) James was due to have his morning medication between 9 a.m. and 10 a.m.; and (b) the Appellant did not administer his medication within that window or at all.

56.

The Appellant’s explanation (both at the time of the investigatory meeting and subsequently) for the failure to administer James’s medication was that she had been locked out of the mobizio system (the on-line software package used to record care actions taken) and so could not sign in. She said she knew she was not allowed to administer medication without a record being made of that action. She said that she waited until the next carer (Karen) arrived at about 11 a.m. so she could tell her about the medication and instruct the new carer to administer the medication.

57.

The Appellant was asked at the investigatory meeting why she had not phoned the on-call number at the agency for advice. He response was that she did not call anyone as it was handover day and a new live-in carer was due to arrive in any event. We have to say we find that to be an unsatisfactory response. The Appellant was also asked at the investigatory meeting whether she understood that missing medication was a form of neglect and comes under abuse to the client. We find her response to be telling:

The Appellant told me that this is not abuse, that it is a matter of being locked out of mobizio. The Appellant got very angry towards me. I ask the Appellant to calm down so I could explain that medication not being administered at the correct time can have some serious consequences which is why missed medication is a safeguarding matter under neglect and abuse.

I explained that it was The appellant's responsibility to administer the morning medication between 9 and 10am. The Appellant repeatedly said that 11am is still morning and she handed it over to the other carer. The Appellant should have been working until 1pm so would still have been responsible at 11am. The Appellant did not agree with this. At one point I did have to stop the Appellant from talking about the other Carer by pointing out to her that this meeting was about the Appellant not administering medication.

The Appellant and I discussed that she should have called the office if she could not see her activities to get advice and that she could have administered medication and written on her visit notes what medication was administered, the dose and the time. The Appellant would have found all this information on the original boxes. The Appellant felt that as she had handed over the medication to the other Carer it absolved her from any wrongdoing.

When speaking to the other Carer she said that she had to ask the Appellant for a handover as the Appellant had her coat on and ready to leave the placement at 11am. The Appellant did not handover morning medication to other Carer. This was only noticed because the other Carer found James’s breakfast in the microwave which made her question whether medication had been administered.

58.

We find this to be an accurate account of their conversation. It is virtually contemporaneous (being drafted following a meeting just four days later) and detailed. The Appellant’s answers reflect the attitude we noticed in relation to her oral evidence, namely her almost unshakeable conviction that, whatever the circumstances, she knew best. However, her responses do not bear out that degree of self-confidence. It is no answer to say that 11 a.m. is still morning when medication is due to be administered between 9 and 10 a.m. The failure to ring the on-call office – the default advice in any such situation – was again symptomatic of the attitude that the Appellant knew best.

59.

We identified just one factual mistake in the DBS’s findings which relates to Ground 5. The DBS referred to the Appellant having been given a written warning by her employer. As noted above, there is some ambiguity about that but on the balance of probabilities we find that it was an oral warning (albeit referred to unhelpfully as a ‘verbal’ warning). However, we do not consider that error to be material in all the circumstances. The simple fact of the matter is that the Appellant failed to provide James with his morning medication on 2 February 2020.

60.

We therefore find no material mistake of fact or error of law in relation to Finding 4.