Upper Tribunal Administrative Appeals Chamber

[2025] UKUT 302 (AAC)

Fecha: 10-Jul-2025

Were DBS’s mistakes in findings of fact material, given DBS’s other (unchallenged) factual findings?

Were DBS’s mistakes in findings of fact material, given DBS’s other (unchallenged) factual findings?

27.

It seems to us that DBS relied on all its factual findings in coming to its decisions; this can be seen in its identification of a “pattern of behaviour” (see [8b] above). To put it another way, we see nothing in DBS’s decision letters, or in its “barring summary document, to indicate that the factual finding at [8a ii.] above, and/or that at [8a iii.] above in relation to JS’s daily outgoing, was alone sufficient to justify its decisions.

28.

Furthermore, we are able on the basis of the evidence before us to make further contextual findings about the incidents in DBS’s “unchallenged” factual findings, namely

as regards the incident in DBS’s finding at [8a ii.] above, we find that

PEO assumed at the time, on the basis of what he had been told by the day staff in the “handover” on the evening before, that all the residents were on site and in their beds; this turned out to be a false assumption, in the case of JS;

ii.

PEO failed to go into JS’s room (or indeed the rooms of any other of the ground floor residents he was looking after that night) during the course of the night to check that they were alright; he assumed they were sleeping safely, unless something alerted him to the contrary;

iii.

when PEO wrote in the electronic record that JS was “in his bed settled” on the morning of Sunday 2 April, this was not because PEO was knowingly recording something false, but rather the outcome of points i. and ii. above; and

as regards DBS’ finding at [8a iii.] above in relation to JS’s daily outgoing, we find that

PEO did not in fact know that JS had to be prepared for a daily outgoing that day;

ii.

PEO had not been told about this duty in the handover from the day staff;

iii.

PEO had not, in fact, consulted JS’s care plan on this matter; but if he had, he would have read that due to covid guidelines, JS was not attending any day services at the present time (see [11g i.] above).

29.

In making these contextual findings, we have (again) found PEO’s evidence on these matters to be coherent, plausible and believable. We note that PEO did not try to diminish his failure to check on JS during the course of the night; or that he should have prepared JS for his daily outgoing.

30.

These contextual findings about DBS’s “unchallenged” factual findings reinforce us in the view that DBS’s mistakes in its findings at [8a i.] and [8a iii.] above were material to its decisions.